I don’t get writings from my beloved brother Rev. Jim Norton very often. When I do, I read them very closely because whether I agree with Jim or not, he has a gift for speaking forcefully yet kindly and always logically.
I got an e-mail today which he sent to his voluminous e-mail list. It had a letter to him from “our” Congressional Representative, David McKinley, and Jim’s thoughtful reply.
The subject: The Affordable Care Act. I will not call it JonesCare, SmithCare, or even YouKnowWhoCare. Let’s show a little dignity for a change.
Rep. McKinley’s letter starts out:
“Thank you for contacting me about the Affordable Care Act, also known as *****care. I appreciate hearing from you on this important issue.”
Fortunately, we can be fairly confident that the Representative never saw the letter and has never heard of Jim. I also sincerely hope that the Representative had little or no part in writing the policy statements in the letter. It doesn’t bother me what he was saying, since he’s a Republican and toes the party line. It’s just it was so damn dull.
Well, Norton is a regular reader of these Dispatches and perhaps he will choose to tag them with his text. It is not for me to quote him and besides I’m heading off on a slightly different tangent.
The Affordable Care Act is a massive tax scheme which no Representative actually read before voting on it. The ACA was a dream come true for lobbyists, the insurance industry, consultants, lawyers, accountants, actuaries and lots of other people who make their way in the world in the non-care aspects of the medical industry. I hardly blame the consultants, accountants, actuaries or most of the lawyers – They have been handed an impossible mess with instructions to make it work.
No system of healthcare will work until we can answer the following questions. If we cannot answer these questions, we do not have a system of healthcare. We have a system of commercial transactions where some people happen to get medical care.
The questions are:
1 - Who gets care?
2 - What care does what patient get?
3 - Who pays for that care?
4 - How much does the provider of the care get paid for the care?
Until you can answer those questions, this is a meaningless discussion. Moreover, these questions are apolitical. You can design a system that is very “conservative,” or very “liberal,” or even very innovative.
(Incidentally, the terms “conservative” and “liberal” historically are economic categories that have now been made into cartoons.)
So let’s look at some scenarios:
A - Grandma is 85. She has had a stroke and is in an ICU. She is on a vent. She has some minimal response to external stimuli such as following things with her eyes and feebly squeezing on command with one hand. Every physician who has looked at her believes that she has about a month to live, but will never come off the vent. The current sticker price for an ICU bed is about $3000 a day. With the negotiating power of some sort of huge payors, let’s dial that back to $2,000. Grandma has left no advance directives.
Does she get the $60,000 worth of care?
B - John is an undocumented visitor/illegal alien from North Elbonia. He has been in the United States for 20 years working under the table. He has no savings and no health insurance. He shows up at emergency department with symptoms that are typical of a heart attack. The cost of hospital care is all over the map, but $15,000 is a reasonable price for a modest little hospital.
Decide. Is John in or out? It’s no longer a political question, it’s a guy.
C - Edna has cancer of the funny bone. It’s a real bad thing to have and statistically 5 in 100 patients survive more than one year. Wegottumgooddrug Labs develops the Supercalifragelistic injection. One injection increases the one-year survival rate to 10 in 100 patients. It cost $250,000. Edna is 75. Does she get it?
Okay, Edna is 60. What now?
Oh my God, rationing healthcare!
Oopsie, we’ve been doing that since the first Medicine Woman found the first medicinal root. Why do you think Dick Cheney is about the only 70-year-old who have gotten a heart transplant in the last decade? (I like Dick Cheney, by the way.)
D - Mary is a really great specialized surgeon. Unionburg General Hospital wants to hire her. In her field, the “market” price is $600,000 per year. Because she is exceptional, the hospital wants to pay her a cool million. Then, they will use that to justify a rate increase request that somebody has to pay for. UGH is a not-for-profit hospital with a self-perpetuating Board of Directors.
Does “Government” interfere with the hiring decision by holding back the money?
I have opinions about these things. For today’s discussion, they are not relevant.
What is relevant is that we need to find the courage to have the discussion.