Ethical Health Care Reform

Recently I heard a Christian TV personality refer to Obamacare as “iniquitous.” This started me thinking, What would make a health care funding reform scheme “iniquitous”? Or, although the words aren’t synonymous, what would make such a scheme unethical? What should go into ethical health care reform?

The answers to these questions are legion and conflicting. There are some who see government intervention as inherently wrong; for them, the free market is the key to ethical health care reform. There are others who distrust the free market, and consider some degree of governmental control to be the only ethical option. Some see personal mandates to buy insurance as unethical; others understand the mandates as ethical solidarity with our neighbor. Some ardently believe justice means everyone gets exactly the coverage or treatment they pay for; others just as ardently believe justice means everyone gets the same coverage and treatment.

What is ethical health care reform? There are many possible answers. I am not sure that Obamacare is any more or less ethical than the versions of Trumpcare that have been put forward. I am not sophisticated or smart enough to pontificate about the free market or theories of justice.

One thing I am certain of, however: Whether the system relies on markets or government regulations, whether there are more or fewer mandates or taxes, whether everyone gets the same coverage or not, one final measure of whether or not a health care system is ethical is how it treats those who are the poorest and most disadvantaged among us. If those who are least able to provide for themselves are not provided for and granted access to the system, then it is an unethical system.

More about Charlie Gard

Dr. Robert Truog, the bioethicist and transplant physician who has pushed the envelope on the definition of death, has weighed in on the Charlie Gard case in a “Perspectives” piece that is generally available (i.e., without a subscription) from the Journal of the American Medical Association (JAMA).   By all means read it.

Dr. Truog approaches the case from the standpoint of limiting medical research—indeed, that’s in the title of his article.  He says the case is about “the best interest of the patient, financial interest, and scientific validity.”  On the first point, he is cautious about the British courts’ assertions that it can assess how much pain and suffering Charlie is experiencing, and whether the courts know this better than the baby’s patients.  This caution seems wise.  As I have reflected further on this case it strikes me that I may be missing a legal distinction between Britain and the US; frankly, I am not well-versed on British law in these cases.  I do tend to think of the Gard case in terms of substituted decision-making in the case of severe or terminal illness.  My thought process runs through the checkpoints.  First, the patient’s wishes are paramount.  In this case, the patient cannot express wishes and may not be able to form them.  In that case, second, a surrogate decision-maker should speak for the patient using “substituted judgment” or “substituted perspective” to express how the patient might have approached the case if able to express wishes.  Here, the parents are available to speak for the patient.  It would be only in the absence of a decision surrogate that “the best interests of the patient,” as judged by the physicians or the courts, would control.  Apparently British law grants rather more primacy to third parties, other than the patient and any surrogate decision-maker.  Under the rubric I’m used to, the parent’s wishes would control.  Here, the British authorities argue, they do not.

The columnist William McGurn took exception to this attitude in The Wall Street Journal earlier this week.  “This is our call, [the doctors and courts] say,” he writes.  And this is the necessary attitude of single-payer healthcare, he claims: “at the heart of single payer is single authority.”  The hospital, McGurn charges, “even wants the last word on love: ‘In one respect, Charlie is immensely fortunate” to have such loving parents, but that respect apparently has nothing to do with this decision, for which their love apparently disqualifies them.  (BTW, perhaps you have seen the report that the court-appointed “guardian” for Charlie chairs an organization that is a sister organization to one that promotes doctor-assisted suicide.)

Dr. Truog’s second point is that distributive justice trumps (my word, no political pun intended, honest) the money Charlie’s parents have raised for his experimental care.  In fact, justice demands we disqualify that fundraising effort, because to allow them to pay is to elevate their ability to pay over others who may be in need of scarce resources.  He says that public funds have stood up the hospital and British health system overall, so the Gard family does not, as it were, “own” it or lay privileged claim to access.  I find this argument of Dr. Truog’s specious.  There is no certainty at all that Charlie would block other needed care—unless, I suppose, it is allowed that Britian’s National Health Service already rations care to the point of extreme scarcity!—and they harm no one by possibly paying for experimental care.

That leaves the third issue—is treatment, admittedly experimental in this case, ethical?  Dr. Truog says no, because the chance of success is so low and “does not meet a threshold of scientific plausibility.”  He argues that the rationale is theoretical only, and complains that the proposed experimental treatment has not been tested in animals or humans before.  But again, this is at least partially specious.  Charlie suffers from an extremely rare condition, animal models may be lacking or entirely unpredictive (medical researchers operate with this general conceit that animal studies DO predict—boy can I tell you how often we are wrong about that!), and when a condition is rare, EVERY individual case provides the opportunity to learn something.  Medical history is replete with work based on the careful observation of clinicians, even apart from the randomized clinical trial, which could never be done in such a rare condition as Charlie’s.

It is of course possible to object that the risk-benefit ratio for giving Charlie the experimental treatment is a judgment call that should be made against treatment.  If the doctor is truly being reckless with the proposed treatment, is profiteering, or if there is no reasonable possibility, at acceptable risk, for direct benefit to Charlie or for useful knowledge to be gained, then the proposed treatment should be deemed unethical.  In the U.S., that would be a call for an IRB and the FDA.  And again, they might say “no,” in which they would be speaking more to the doctor than the patient’s parents.

But in this case I think the British courts should defer to the parents and allow them to pursue that question in the U.S.

Healthcare Insurance vs. Healthcare coverage?

Kimberly Strassel wrote an interesting piece in the WSJ entitled “The Simplicity of a Health Deal” (Link here – subscription required). I don’t think she was saying that crafting legislation to resolve all of America’a healthcare issues was easy, she was making the political point to Senate Republicans that, like it or not, no future legislation will be possible unless they agree to continue the ObamaCare provision of eliminating insurance proscriptions for pre-existing conditions. She cited a YouGov poll that showed 77% supported protections for those with pre-existing conditions as an example of the public support for this provision.

The problem with pre-existing conditions is that they cost more money to insure than not-yet-existing conditions. This fact is the primary reason for the unpopular provision of Obamacare – The Mandate (or tax, if you like). If you delay buying insurance until your not-yet-existing condition becomes an exiting condition, what exactly are you insuring? This “gaming the system” is illegal and for good reason. Without the mandate (that everyone buy some minimal level of insurance), insuring pre-existing conditions is very expensive. Insuring pre-existing conditions has turned out to be more expensive than anticipated, even with the weak mandate/tax, and insurance providers have been and are continuing to leave Obamacare, further reducing insurance options in many states. Failure to make significant changes in the present law (i.e. leaving Obamacare as is) would likely result in further reduction in the number of insurers and the cost of their products.

I find it odd that we continue to refer to ObamaCare or whatever the new Republican iteration will be as health insurance. Wikipedia describes insurance as a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Life insurance and car insurance are good examples. Premiums charged for these types of insurance policies are based upon one’s risk or lack thereof, as well as how much risk an individual wished to mitigate. Essentially, these are catastrophic risks we are taking about. Healthcare insurance has morphed into healthcare coverage. We expect our health insurance to pay for everything that has to do with accessing a healthcare provider: routine office visits, medications, emergency/trauma care and end-of-life support, to name but a few. That would akin to asking our car insurance to not only handle major accidents but also gas and oil purchases.Of course, taking the car insurance analogy to its logical conclusion suggests that just as there are some people that have such a terrible driving history that they simply are not insurable, there are similar people who are not insurable based upon their terrible health history. Eliminating pre-existing condition proscriptions effectively turns the insurance model on its head as a means for risk mitigation.

If we are going to eliminate pre-existing conditions, we are essentially agreeing healthcare insurance isn’t the way to pay for healthcare, at least the essential aspects, whatever those are. We are also agreeing that those essential aspects are basic rights, without an open and honest agreement on exactly how to pay for those rights. We need to have the discussion of what exactly constitutes basic or minimal healthcare rights and then we need to have the discussion about how to obligate those providing those rights (required as part of licensure, reforming malpractice, adjusting reimbursement, etc..).

My “Happy Fourth of July” daydream is that Congress would have such a debate, aided perhaps by many bioethicists from many persuasions. Tomorrow, I will wake up and go back to work.

Two Random Thoughts about Health Care Policy and Justice

I haven’t yet read the Senate Republicans’ draft health care bill, just out today.  Until I do I’m not going to comment about it directly.

The matter is a bioethics concern solely from the perspective of justice, really.  What is the wisest, most just policy?  And here one is forced, I think, into a fairly utilitarian assessment of what approach provides the best outcome for the country overall?  In that, we can allow for a “priority concern” for pool or relatively poor folks, allowing a weighting of factors in their favor.  In fact, I’m all for that.

But two thoughts.  First, I and others tend to argue that we should reform Medicare and Medicaid and not just leave them as they are, because to do so is to ratify their demise into bankruptcy or unaffordability.  That argument is open to two charges: that it assumes that forecasts of rapid demise are reliable, and that preserving the programs, in a sustainable form, favors future generations at the expense of the current ones.  On the latter, to wit:  Most people would agree that “my” (i.e., someone’s in general) duty to people close to them (like spouse, children) is greater than to a stranger.  But can we not say the same thing about generations?  Isn’t our duty to people already among us greater than, say, our envisioned duty to our grandchildren and great-grandchildren, even if they are ours and not someone else’s?  I suppose that one might argue that.  Then my longer-term argument would lose force.

Second, we hear so much about people who will be harmed if the Affordable Care Act is significantly touched, much less repealed.  (I don’t think any minimally serious observer of the political scene would suggest that true “repeal” of the ACA is even a remote possibility.)  But ANY change is called disastrous, mean, evil—pick your pejorative.  On the other side of the leger are working-class or middle-class people who can’t afford insurance and don’t qualify for subsidies now.  An accurate calculation of the two groups and what they stand to lose seems impossible.  Which group to favor?

Then again, maybe single-payer would conquer all.  As I have written 2 weeks ago and in the past, I’m not so sure.

In the meantime, I am at the annual meeting of the Multidisciplinary Association for Supportive Care in Cancer (MASCC) this week.  Discussions today centered on “financial toxicity”—the negative effects of high drug prices—and on the coming changes in how doctors are paid.  Bottom line: it all has to cost less.  The outcome may not be that public health will be worse—I’m not at all sure it will—or that rich doctors or industry executives will make less money (they will, but they’ll be OK).  But we don’t have a purchase on how many people of more modest current income will be out of work as a result—e.g., the chemists, regulatory folks, administrative assistants in industry.  I have no idea what that effect will be.  Maybe significant, maybe not so much.

But we are about to “conduct the experiment.”  One way or another, we have to.

Single-Payer in California?

I’m not sure that even advocates of single-payer health care will find the spectacularly overreaching “Healthy California Act” (California Senate Bill 562) a good idea.  Follow the link and read the text yourself—I link, you decide.

While the bill appears at points to read like a re-assertion of current federal programs, and perhaps some related private insurance (e.g., Medicare Advantage), in fact it looks to me like it would replace all current public and private health insurance for California residents, whether citizens or not, with a state run, state financed (how is yet to be determined) single plan called “Healthy California.”  This is how it is described in the general press.

Under it, no California resident would have to pay a dime for any aspect of health care.

As I read it, no other insurance plans would be allowed to pay for anything that Healthy California covers.  Just about anything and everything health-care related—including, it appears, skilled nursing and long-term care—would be “covered.”  Of course, any extra billings outside the coverage would be illegal.  Practitioners could opt out of the program but that means they couldn’t get paid—except, I suppose, on some sort of black market. 

Healthy California would be run by an independent 9-person board with no clear accountability.  This board would set coverage range and payment rates; certify doctors, hospitals, and other providers (including out of state, in case a Californian gets sick while traveling); oversee the collection and management of not only claims payments but also health and health-payment statistics, and do just about everything else that Medicare or your (evil?) insurance company currently does.  It would be advised by a separate 22-person advisory panel.

The legislation calls for any and all federal payments that otherwise would come into California for health care to be made to Healthy California.  It is argued that additional monies would be needed to pay for everything.  The bill says only that the legislature will come up with a plan for funding, and that the program would not go live until the funding is in place.  News reports have estimated the costs at up to twice the current total California state budget.  Estimates for how it would be paid for include things like a 15% payroll tax on everyone, and other measures.

I can accept that access to medical care should be a duty of human society.  I don’t think that means first-dollar coverage for everything, for all.  I also fail to see why reforms can’t be made within the overall structures of a market economy.  I read that Britain is having trouble with its National Health Service, and that people there try to “go private.”  And I don’t know whether anything will come out of the current Congress, or what it will look like.  I AM fairly sure that without substantial reform of Medicare and Medicaid, the money for them will start running out in my likely lifetime.  I don’t think the Affordable Care Act put us on a stable path.

But I also must say that I have wearied of trying to figure it all out, and I think the nation is on something of a ratcheting path toward national single-payer.  So we will carry out the experiment, as it were, perhaps before long.  (Then we’ll all “have coverage.”  I hope we will all be able to get in to see a doctor.) 

While we wait for that, the “Healthy California Act” looks to me like childish fantasy.  Any readers of this blog who read the bill and can explain how it will be workable are invited to do so in the comments section.

For my part, my wife is on Medicare, which is working reasonably well for her, and I like my current employer-sponsored insurance.  I would like the choice to stay with those, not have them replaced by fiat by the single-party California government.

The California bill passed the state Senate, and awaits action in the Assembly.  If it passes there, my guess is the current governor will veto it.  The likely next governor probably will not.

Health care disparities: a pro-life issue

This month’s Health Affairs carries an article examining the correlation between one’s income and one’s perceptions about one’s own health and health care. Worldwide, those with the lowest incomes feel that their health is worse than those with the highest incomes do. They also are more likely than those with higher incomes to skip necessary treatment because they can’t afford it, and are more concerned that if they become seriously ill, they won’t get the best treatment their country has to offer. Perhaps not unsurprisingly, the United States has one of the greatest disparities between those with the lowest and highest incomes. But at least Americans are also the most aware of this disparity: 67% of US respondents, the highest number of any in the world, agree that “many” people in the US do not have access to the health care that they need. This is a good thing: awareness of a problem is the first step towards fixing it.

But what if we are aware of the problem, yet don’t really think it’s a problem? Only 54% of us in the US think it’s unfair that people with higher incomes can afford better health care than those with lower incomes. What if we see unfairness, but don’t recognize it as unfair?

In his post to this blog on June 6th, Mark McQuain asked what our number one bioethical issues are. As a physician who is privileged to care for a wide diversity of patients — from higher-ups in large corporations to those struggling to support a family by working two jobs and driving Uber — I see daily the very real differences between those who are granted full access to all our health care system has to offer, and those who get only the scraps from the health-care table: differences not just between healthy and sick but between life and death. The ones on the lower end are disproportionately the poor, the widows and single mothers, the aliens among us. I am pro-life; since access to health care can be a life-and-death issue, it is part of my pro-life identity to advocate for access to health care for all. The disconnect between recognizing inequity in access to health care and recognizing that we should try to do something about it is deeply disturbing to me. At this time and place, the injustice (and the recognition that it is injustice) in the inequity of access to health care based on income is the number one bioethical issue on my list.

Euthanasia in Canada: Early Returns

Last week’s New England Journal of Medicine carried a report from physicians in Toronto about early results implementing “Medical Assistance in Dying,” or “MAiD,” the preferred euphemism for doctor-assisted suicide or euthanasia, in Canada.

“MAiD” became legally sanctioned throughout Canada in 2016.  It includes not only assisted suicide—where a doctor provides a patient with a drug prescription intended to be lethal if taken as directed—but also euthanasia, in which a doctor actively kills a patient, at the latter’s request (at least for now).  The recounts provisions in Canadian law intended to limit “MAiD” to people whose medical condition is deteriorating from a serious, incurable disorder, and to ensure that people who receive “MAiD” do so after freely requesting it, and affirming that request after 10 days to think it over.

To keep things “controlled,” the Toronto program is entirely hospital based, limited to lethal IV injection for which recipients are evaluated and ultimately killed by dedicated physicians who have freely agreed to participate.  The specific hospital ward where a patient is euthanized is rotated, so that no ward gets the title of the “MAiD ward,” but the medical team is set.

Some noteworthy points:

  • MAiD was assigned to the Department of Supportive Care. Other clinical departments demurred out of concerns like “conscientious objections of staff” and “obscuring their specialty’s role in protecting life.”
  • As reported elsewhere, patients receiving MAiD sought it because of loss of autonomy, as well as inability to enjoy life, not because of uncontrolled physical symptoms. These people “tended to be white and relatively affluent.”
  • From March 2016 to March 2017:

o   74 MAiD inquiries in the region served by the Toronto investigators.

o   29 went from request to formal assessment for eligibility, under the terms of the law, by the physicians.

o   19 actually received the injection (i.e., were killed by their doctors at their request).

  • In all cases, death occurred within minutes.

o   People who were not assessed or who were but were not injected did not progress because they died too quickly, changed their minds, or lost decision-making capacity.

o   Some patients refused symptom-controlling treatment—notably, opioids—in an attempt to stay clear-headed enough to be deemed to have a valid request for euthanasia.  That is, they requested compromise of their palliative care to keep the “MAiD” option live.

The authors believe that the MAiD decision process should be moved earlier in care—to the point at which end-of-life care and advance directives are discussed more generally—to prevent discussions or decisions about MAiD from being rushed at the very end of life.

They conclude,

“Just as advocacy from outside mainstream medicine brought palliative care ‘from the margin to the center,’ so has it brought MAiD into the mainstream of medicine.  It is now clear that MAiD education must be included in undergraduate medical education curricula…and in the training for a variety of specialties…[It remains to be seen] whether the legalization of MAiD…this ‘brave new world’ will ultimately be regarded as enlightened or dystopian.”

I cast a Huxleyan vote for “dystopian.”

Mailbag

Brief comments on four short articles from this week, on disparate topics:

James Capretta of the American Enterprise Institute (meaning he is politically right of center) pleads in the Journal of the American Medical Association (JAMA) for compromise between Republicans and Democrats on further healthcare policy reform.  Arguing that the House-passed American Health Care Act (AHCA) may never pass, he believes that a better result politically and for public policy would be if legislators could, in essence, split the difference between the AHCA and current law, the Affordable Care Act (ACA, aka “Obamacare”) on some points where he sees some agreements in principle.  He proposes: 1) a hybrid approach between the ACA’s income-based tax credits for health insurance purchase and the AHCA’s age-based approach; 2) ensuring continuous insurance coverage for people with pre-existing conditions by modifying the ACA’s penalties for not being insured to fall more heavily on higher-income people; 3) setting limits on the favorable tax treatment of employer-paid health insurance premiums; 4) automatically enrolling uninsured people into a bare-bones, no-premium plan from which they could opt out in favor of re-enrollment in a different plan (a proposal that sounds to me a lot like the Democrats’ “public option” with a guaranteed fight over scope of coverage); and 5) limiting Medicaid expansion to tie it to reform of the program (something that sounds to me a lot like what I understand is currently in the AHCA).  Mr. Capretta knows a lot more about health policy than I, and has been at it a lot longer.  His ideas seem reasonable.  But he admits that bipartisan compromise “may be wishful thinking,” and I must confess that my reaction to his article is, “when pigs fly.”

The editors of Nature smile on Pope Francis’s meeting with Huntington’s disease researchers and patients.  Many of the latter group, they note, are poor Venezuelan (who there is not poor—and oppressed—these days?) Catholics who greatly aided research with tissue donations “with little tangible reward.”  The editors further cite the Pope’s encyclical Laudato si, with its acceptance of the existence of anthropogenic climate change, as a hopeful sign that the Catholic Church will one day use its considerable influence to compromise on “sensitive issues” such as sanctity of human life from conception, and embryo selection.  Still, “there is a chasm between religion and science that cannot be bridged.  For all its apparent science-friendliness, Laudato si sticks to the traditional Vatican philosophy that the scientific method cannot deliver the full truth about the world.”  The editors call for “fresh dialogue” between science and religion—by which they mean capitulation of the latter to the flawed-on-its-face epistemology of the naturalist.  I’m not buying.

Another provocative piece in JAMA tackles ethical concerns about drug company marketing of treatments for rare diseases.  The specific concern is “disease awareness” campaigns.  The authors cite a collaboration between Incyte, the manufacturer of the only FDA-approved treatment for a rare disease (there are older, “grandfathered,” treatments of modest effectiveness), and the producers of the soap opera General Hospital, in which a character has said rare disease and (not quite like Huey Lewis) wants a new drug.  The authors ask:  Is disease awareness marketing in disguise?  Do disease awareness campaigns promote sales of specific drugs?  Does awareness of rare diseases really help, when, unlike common diseases, more aware people can get effective treatment at an earlier point in the disease history, but with rare diseases, they might only be overdiagnosed, overtested, and overtreated.  Hmmm.  The authors allow that the courts have protected direct-to-consumer drug advertising as free speech, but assert a duty of the medical profession to ensure that information to the public is not only true in a narrow sense but also not misleading.  They conclude with a bit of an overreach: “[D]irect-to-consumer advertising is a massive medical intervention with unproven public health benefit, dubious plausibility, and suggestive evidence of harm.”  The suggestion is that “disease awareness” campaigns ought to be regulated by the FDA.  I have to say I’d find it amusing, to say the least, for the FDA to be regulating soap operas—a candidate for Mad magazine’s “Scenes We’d Like to See.”

Wesley Smith blogs that Ontario is moving toward creating mandatory policies regarding assisted suicide that have the strong possibility, if not likelihood or certainty, that doctors will be required to help provide aid in dying or refer “in good faith” to other doctors who will—essentially steamrolling any conscience exemptions.  He sees in this a deliberate, tyrannical program to destroy the soul of medicine, extinguish thoughts of the sanctity of life, and cleanse the medical profession of religious or Hippocratic practitioners.  So do I.  Follow the link and read his post.

Undermining the USPSTF: The most important stakeholders are the patients

A strange “health care” drama plays out daily in our clinics and hospitals. A healthy person has a medical test done (even though he or she is healthy): a blood test, a chest x-ray or mammogram, maybe an ultrasound of some body part. The test comes back abnormal. The patient (for she has now gone from being a healthy person to being a patient) is struck with worry, and undergoes a further round of testing to determine whether the initial, “screening” test was accurate. This more invasive, risky definitive testing causes the patient pain, complications, infections, further procedures to fix the complications. But the testing shows that the original screening test was wrong, and the patient is relieved of their worry and overcome with a sense of gratitude: “Yes, the follow-up surgery was painful, but at least it’s not cancer.” However, notice what caused the worry in the first place: not some symptom that they were experiencing, but a test that was performed on a healthy person. What a marvelous bit of sorcery: we take a happy patient, create unnecessary worry, then win their undying gratitude by performing risk-laden procedures on them to remove their worry!

There is something very intuitive about the concept that detecting a disease (especially cancer) early leads to better outcomes, that screening tests are inherently good. Yet when one studies the actual outcomes of implementing mass screening programs in a population of people who have no signs or symptoms of a particular disease, one finds to one’s surprise that, not infrequently, more people are harmed by our screening test than are helped (See: PSA testing, carotid ultrasounds, annual stress tests, etc). This harm may take many forms: worry, invasive procedures with all the risk they bring, radiation exposure, disfiguring treatments, stroke, even death. Yet there is no shortage of promoters of various tests that capitalize on our intuition that “More testing is better.”

In steps the United States Preventive Services Task Force (or USPSTF), a group of experts in preventive medicine and primary care (since it is mostly primary care providers who order screening tests). Their task is to examine the scientific evidence of the potential risks and harms of preventive strategies like screening tests, and to make recommendations based solely on that evidence. They strive to use the best scientific data available to benefit the most people possible. Even when their recommendations are unpopular (because they go against our intuition that more screening is better), they have a large effect on what tests are performed — and what tests insurance will pay for.

This week the USPSTF recommended against screening for thyroid cancer in people without symptoms. The data show that screening has found lots of thyroid cancer that never would have been found otherwise. The data also show that screening has not produced a reduction in death from thyroid cancer or an increase in quality of life. What it has produced is an increase in harms, such as injuries to vital nerves from the increase in thyroid surgery. Who knew?

Now there is legislation pending in Congress proposing that “stakeholders” — that is, specialists and industry representatives — be included in the membership of the USPSTF. This is a very bad idea. Consider: What do specialists like thyroid surgeons (who are not experts in screening for thyroid cancer; rather, their livelihood is tied to operating for it) or drug and device manufacturers (who sell the tests and ultrasound machines used to screen for thyroid cancer) add to the USPSTF’s process?  The main thing “stakeholders” (that is, people with a financial interest in seeing the test done) add is a conflict of interest. Whatever difference such “stakeholders” make would be tilted to the advantage of the few who stand to profit from the screening, and to the detriment of the many in the population who would be harmed from the screening. The USPSTF’s work must not be transformed from a transparent procedure that seeks to minimize harm into a get-rich-quick scheme.

But at least we don’t have socialized medicine

I just read T. R. Teid’s 2009 book The Healing of America. It’s a timely read in light of the bar brawl over health care that’s brewing in the U.S. legislature this week. Of particular interest are his snapshots of the health care systems of the UK, France, Germany, Japan, Taiwan, Canada, and Switzerland, systems about which I held many cherished misconceptions. All of these countries provide universal health care coverage for their citizens, but they do so in very different ways. Some countries are single-payer systems; in other countries, costs are paid by multiple (not-for-profit!) insurance companies, and employers and workers share the cost of insurance premiums. In some countries patients must pay a co-pay, in others they never see a bill. In some countries people have long waits for specialist care, in other countries they get in the same day. Despite the differences, there are some very important similarities. First and foremost, everybody in the country is covered and has access to health care. Everybody can see any doctor; none are “out-of-network.” By almost every population health measure from childhood mortality to life expectancy, these countries far surpass the United States. And they do so at a cost that is a fraction what the United States spends for health care.

The attitudes expressed by representatives of the various countries are revealing. In France, one doctor says, “It would be stupid to say that everybody is equal . . . But when we get sick–then, everybody is equal.” The founder of Germany’s system, Otto von Bismarck, called it “applied Christianity,” and said, “A rich society must care for the poor.” Japan has an individual mandate; everyone must sign up with a health insurance plan. As one Japanese doctor said, “It’s considered an element of personal responsibility, that you insure yourself against health care costs. And who can be against personal responsibility?” The report that helped launch Canada’s Medicare system reads, “Economic growth is not the sole aim of our society. The value of a human life must be decided without regard to . . . economic considerations. We must take into account the human and spiritual aspects involved.”

Reid reiterates several times that he believes that societies have a moral obligation to make health care universal. But in this country, there is another mindset, another ethic, that stands in opposition to that view: the view that at best government has no business getting involved in health care, and at worst that government is evil and must be prevented from extending its nefarious reach into health care. Adherents to this ethic often use the term “Socialized Medicine” in a pejorative sense to refer to any health care system that has more government involvement than their own. According to this ethic, the spectre of Socialized Medicine covers a multitude of sins, as in:

  • In our system millions of people don’t have access to health care. But at least we don’t have Socialized Medicine.
  • Untold numbers of people are afraid to leave jobs they dislike because of health insurance concerns. But at least we don’t have Socialized Medicine.
  • Despite paying way more than any other country for health care, our country has worse health outcomes. But at least we don’t have Socialized Medicine.
  • Many people can’t go see their doctors that they have seen for decades because they are suddenly not “in network.” But at least we don’t have Socialized Medicine.
  • Our for-profit health insurance companies have the highest administrative costs in the world, which is a large part of the reason we pay so much more for such lower quality. But at least we don’t have Socialized Medicine.
  • Thousands of people — uninsured and insured — face financial ruin every year because of medical costs. But at least we don’t have Socialized Medicine.
  • Thousands of people die each year in our country because of diseases that could have been treated had they had access to health care. But at least we don’t have Socialized Medicine.

If we really think Socialized Medicine is so evil, then we had best scrap that purest form of Socialized Medicine which is in our midst: the VA system. While we’re at it, we really ought to dismantle Medicare as well. But if we’re not willing to take those simple steps — if Socialized Medicine is after all not quite so evil in these instances — then we should be willing to debate different forms of financing health care on their own merits, and not merely dismiss any discussion with a nebulous term that we fondly imagine carries such moral weight that it lays to rest all other urgent ethical questions about our own system.