Health Policy Priorities

Crossposted in part from the Home of the Brave [1] blog.

Maggie Mahar wrote a post [2] in her always excellent Health Beat blog which finally got me to begin to articulate my dissatisfaction with both Obama and McCain's health platforms. She has been pondering the questions around health being considered a right versus a moral obligation on her blog for awhile. I happen to think that it's both a right and a moral obligation, but so far, the question has been posed as oppositional and mutually exclusive.

As regular readers know, I prefer to view healthcare as a civilized society’s moral obligation to everyone in that society—a shared, collective obligation based on the Golden Rule: “Do unto others. . .” But this is because I view our moral obligations as humans as even more important than individual rights under the law.

For one, if you call healthcare a legal “right,” it seems to me that you could pass laws limiting that right: to people who are full-fledged citizens (not just legal immigrants); to people who are not overweight; to people who haven’t spent too much time in the sun; to people who don’t engage in risky Xtreme sports; to people under 85 . . .Well, you get the picture. But for all practical purposes, Merrill and I are in agreement: everyone should have access [3] to effective care.

[snip]

Bloggers disagree on which candidate has a better plan. On the Health Affairs Blog , Paduda notes, “Harvard economist David Cutler and Obama advisor calls the McCain plan "out of touch [4]", while AEI economist Tom Miller and unpaid McCain advisor defends [5] McCain's plan.Over on the Huffington Post, Michael Millenson doesn't like [6] the McCain reform plan one bit. “

Bloggers also are split on whether the economic meltdown will stall reform. Paduda reports that “Bill Scher at the Campaign for America's Future is, calling for us to stop worrying abut short term budget issues and focus on bigger issues.

Paduda himself isn’t so sure. But he believes that “We can do a lot [7] to help people get coverage, with no impact on the Federal budget or taxes.”

I agree; we should start with those structural reforms that either won’t cost money or will save money, both because money will be very tight, and because there is no point in pouring hundreds millions into a broken system. Begin fixing it in the next two years, improve access for Medicaid patients, children on SCHIP and patients with pre-existing condtions--- and then expand the whole system.

Paduda also recommends taking a look at Bob Laszewksi’s “post on the disconnect between political reality and wishful thinking . . . especially if you disagree.”

He adds “Those who actually work on the front lines -- selling health insurance and servicing their customers, have a reality-based perspective that is vitally important. Louise at Colorado Health Insurance believes that"in order for health care reform to work . . . We need a solution that spreads the cost of health care evenly across the entire population (adjusted for income, just as taxes are) and doesn't leave large groups (like people with pre-existing conditions) to fend for themselves.”

My first reaction, which I did not include in my comment on Maggie's Health Beat post, is that Paduda is so infuriating when he refers to insurance agents as front line health care workers. They don't do a single thing that is directly related to alleviating suffering, to providing health care, and that lead to anyone's health. They sell - for profit - the ability to submit a claim for possible reimbursement. They are userers and money changers and profiteers. What gall!

Three Card Monte

My second reaction is that he is wrong when he refers to spreading the costs of health CARE. He's actually referring to spreading the costs of commercial health insurance, again, which does absolutely nothing related to providing actual health CARE. The two are entirely separate and unrelated concepts. This is such a three card monte, dishonest tactic.

I really hate that the terms are conflated or are even allowed to be used in the same arena. Insurance must be kept separate from health policy and health care discussions, as any mention of it taints and poisons those topics.

OK, I've settled down enough

As long as healthcare system reform resources go to the parasitic insurance industry, reform will not occur. Nor will the health indicators trend upward.

Since both McCain and Obama are committed to perpetuating insurance support instead of directing resources into healthcare infrastructure, services, provider education and support, etc., I don't foresee fundamental change.

What I would advocate, instead, is to refocus on the public health infrastructure and take a two-pronged approach.

One of the approaches should be to purge the public health-related agencies of partisan appointments from the Bush administration unless their track records have demonstrated solid support for science and overall competence and qualification for the position held. Many agencies, such as the FDA and CDC, have suffered catastrophic losses of qualified scientists and researchers. Those ranks must be replenished pronto.Robust oversight by Congress is needed to make sure that those agencies have the resources and are performing adequately by well-defined benchmarks to adequately protect the safety of food, drugs, water, air and soil.

The second approach should be to replenish the resources of community-based health services including bolstering the numbers of qualified school, community and public health nurses, ramping up disease surveillance, prevention and containment, assuring adequate nutrition, clean water, clean air, adequate housing and adequate safe public transportation - the infrastructure for Americans to attain and maintain basic health.

Without a framework to provide universal health CARE, public health measures are the sole extant infrastructure from which to build.

If, in the future, the US chooses to expand Medicare as a single payer vehicle or to expand the VA system to be the rough equivalent of Britain's NHS, then we can move forward with real system reform.

But just like the economy bail out, if we inject more government funding into the commercial health insurance industry, not only will the overall health of the US citizenry not be greatly affected, but the only people profiting will be investors, while the sick will be paying more out of pocket and using scarce dollars to pay for a commercial policy that only allows then to submit claims, but does not assure access, quality, service or even reimbursement.

Both plans to me are akin to shoving money at the wrong target.

And when cost containment and savings are targeted, I believe those targets are largely wrong, as well. When's the last time that profit margins of commercial insurers were looked at as targets of cost savings or cost reductions?

Instead, the "savings" are coming from the ever-more squeezed physicians and nurses who spend less and less time with patients, don't develop long-standing therapeutic relationships, which are integral parts of professional practice and which directly affect patients' ability to manage their own health successfully.

Insurers are buttinsky middlemen, in my view. They interfere with professional practice, strip reimbursement from practitioners, reward for assembly line treatment which is a huge dissatisfier for physicians, nurses and patients, and are profiting at the direct expense of preventable suffering and deaths of patients by refusing to insure for pre-existing conditions, for denying claims and for delaying claims.

And then they hide. It's not them actually doing the denying of care. The face that the patient sees is a nurse or rarely, a physician who comes out of hiding in an exam room or a physician's lounge. More likely, though, is that the patient doesn't even have direct contact with anyone. The denial comes by letter, email or an impersonal phone call.

That's not only not right, but it's as immoral as the day is long.

Just as Americans are entitled to an education and to fire protection, so, too are Americans entitled to basic health care. No one exists in total isolation from others. It's in the collective interest of everyone to help each other to remain healthy.

We got rid of private fire insurance long ago because the for-profit private model didn't serve the common good. What is different about health protection?

Under what moral code is it acceptable to ignore a person who is suffering or dying when healthcare would alleviate suffering or restore health and productivity? Which people should be allowed to die preventable deaths?

When health care is available only to those who can afford it, does that mean that those who choose or can only find work with low salaries or no benefits are not worthy of health care?

Does that mean those who choose to work in the lower-paid not-for-profit sector or academia are not as worthy of healthcare as their private sector CEO neighbors?

What morality mandates that physicians run their practices as competitive for-profit businesses instead of professional practices?

In moving to the free market capitalism model, professionalism is being degraded and debased. Is that what we want?

That seems to be what we are demanding. But fewer and fewer people are entering and staying in primary care and in front line patient care because of it being such a dissatisfying model.

To that end we are actively worsening an already critical shortage of primary care physicians and baccalaureate prepared nurses.