Party politics, people’s lives

As health care financing rises yet again to the top of our national legislative agenda, some fundamental questions ought to be strongly considered. First, and most fundamental: Is some level of healthcare a right, that the government is therefore obligated to protect? Is it better viewed as a common good, like roads and fire protection services, that everybody pays for through taxes and everybody benefits from? Should it be treated as a luxury item, like large-screen TVs and designer clothing, that only those who can afford it get to enjoy?

Other important questions: What are the strengths and weaknesses of the current system of financing health care? Who does it benefit? Who does it harm? What will be the effects on patients, intended and unintended, of changing the current system? Who will benefit, and who will be harmed by those changes? What will be the effects on physicians and health insurance companies? How will any changes affect the patient-physician relationship, for good or for ill?

Is the free market the best way to finance health care? Or is it best publicly financed? Or some mixture of both? Why?

A most important question is, How does the system treat the most disadvantaged, the poorest, the most helpless or down on their luck, and the ones who need it the most? How should it treat them?

What should the ideal health care system for patients look like? Can we start moving towards that ideal? How?

Other fundamental questions will no doubt present themselves to the reader. However, instead of questions like the ones above, it seems that the following questions are being debated instead: Which party and which president designed the system we have now? If it’s not my party, how can we get rid of the current system (and who cares if we have nothing to put in its place, let’s repeal it anyway)? How can we protect our party (whichever one it happens to be) from the political fallout that will occur as changes are made? What does the ideal health care system for my party look like?

I have many patients who have benefited from the most recent changes to the system. I have others who are starting to feel the downside of those changes. For patients, it is not primarily about parties or presidents, but about their health, their lives, and whether they are treated with dignity by the health care system. Health care financing will always be expensive, and therefore contentious. But our contentions should be based primarily on concern for patients. Recent legislative discord on the subject seems to stem not from concerns about what is best for patients, but what is best for political party power.

Another election, another round of health care reform

Now that we Chicagolanders don’t have the World Series to distract us anymore, we have to go back to thinking about the upcoming election. Health care financing is of course one important issue in the presidential race. One side wants to repeal and replace the Affordable Care Act (aka Obamacare), the other wants to keep it and work to fix it. Whoever wins, it’s evident that changes are coming.

Archie Cochrane wrote a book in 1972 called Effectiveness and Efficiency: Random reflections on health services. The book was commissioned to evaluate the National Health Service (NHS) in the UK. An article about this book was published in the journal Medical Humanities last month, and a sentence from the article caught my eye:

Cochrane describes three different kinds of output from the NHS: ‘freedom from worry about the cost of medical treatment and care,’ ‘increased equality [of health care] between social classes and between different parts of the country’ and ‘improved care for those who cannot look after themselves.’

I don’t anticipate that we’ll be setting up a system anything like the NHS anytime soon. But as changes are made to the way health care is financed in this country, these three “outputs” or principles of Archie Cochrane’s would be a good start for sound and moral targets to aim for. There are still many, many people in this country who avoid getting necessary health care or taking their medications because of worry about the cost; there are large inequalities in health care between those of different socio-economic groups; and many of those who can’t look after themselves are discharged from hospitals to live on the street every day. However we decide to finance health care in this country, definitively addressing the plight of these groups is a moral obligation, and seems far more ethically compelling than protecting the interests of large companies or political parties.

The people who don’t deserve health care

By all accounts, since the beginning of the implementation of the Affordable Care Act (ACA, a.k.a. Obamacare), many previously uninsured people now have medical insurance. The ACA has expanded access to health care. However, many millions still do not have medical insurance: some by choice, but many because they still can’t afford it, even under the provisions of the ACA. And there are many others who now have insurance, but still can’t afford health care.

It is these latter groups, the ones that can’t afford insurance or health care, that particularly interest me here. Because these are the ones who by design of the law cannot afford health care. The law was written, deliberated, and passed with the full knowledge that as it was implemented, some people still would not have access to anything except emergency health care. The law excludes these people from access to health care.

Who deserves not to have access to health care? The unemployed? Those employed at minimum-wage jobs? Undocumented immigrants? “Welfare Moms”? Black inner-city families? Drug addicts? Lazy thugs?

Whoever it is, we as a nation — our government — obviously believe that some people don’t deserve access to health care. Otherwise we wouldn’t enshrine in law a health-care delivery system that doesn’t deliver health care to everybody.

And will a health care reform plan constituted by the two words “Repeal Obamacare” do any better?

Thoughts on varied subjects: commercial surrogacy, professionalism, and Obamacare

A potpourri of stories from this week that prompted bioethical musings, in no particular order . . .

The BBC News website ran a fascinating, heartbreaking story this week about women in India who are paid to gestate other women’s babies: commercial surrogacy, a billion-dollar-a-year industry in India. The main figures in the story — a woman named Vasanti living in a dormitory for commercial surrogates, who is carrying a baby for a Japanese couple; and the doctor who runs the IVF clinic and dormitory — spend much of the story talking about how positive the practice of surrogacy is. Thus it is jarring — and revealing —  to get to the last sentence in the story, where Vasanti says, “. . .we want a good future. That’s why we [did] this, and not in my entire life do I want my daughter to be a surrogate mother.” (Italics mine)

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Last week’s JAMA ran a narrative by Gordon Schiff, MD, which begins,

It’s 5 PM on a Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors.

(If you have a JAMA subscription you can read the whole thing here, otherwise it has been reposted for free  here.) Dr. Schiff’s reflections on this incident are eloquent and worth reading and pondering. From the perspective of a Christian physician who also works with the underserved, I am saddened at how far our profession strays from its moral foundations when  a detached, medicine-as-business model replaces the self-giving care that Christ modeled.

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You may have missed it, but new provisions of the enormous law affectionately known as “Obamacare” went into effect this week with the beginning of open enrollment and the opening of online insurance marketplaces. The new law is extremely complex and promises to raise health insurance costs for many, including myself, at least in the short term. Lots of people are complaining about it, some more savagely than others. Many of my colleagues and patients have bemoaned it, and with good reason. But there is one group who have not complained to me about it at all: my patients who do not have, and until now have not been able to afford, health insurance.

Implementation Day!

As this posts, on the day of the rollout of the Affordable Care Act, a.k.a. Obamacare, we have the makings of high political theater. As with the implementation of most things (federal laws included), Wagnerian music fills the background of what proves to be a change that will likely fail to live up to apocalyptic expectations. Ditto the government “shutdown.” Nor are we ushering in a new era of universal health and wellness, with songs of praise to the federal bureaucracy breaking out.

I have little of substance to add to what Jon Holmund said in his excellent blog post last week. All I will do is add some reflections from my own vantage point.

Much is written about the trend toward part-time hires and diminishment of hours for existing employees in businesses, which include an eclectic mix from Home Depot to Trader Joe’s to Forever 21. United Parcel Service (UPS) will curtail family benefits. This was all, by some accounts, unexpected among the planners of the legislation. By other accounts, it was part of a conspiratorial plan to make the law unworkable and (Wagnerian music cue here…) force an even more Draconian plan on a stodgy America toward a Canadian/European model. Again, good theater, but I have worked with people that are crafting legislation that they consider essential; they expect all good things will come from it, not that it will be a speed bump on the road to something really good. The president didn’t want to attach his name to a law that would be quickly supplanted because of its inadequacies.

My veterinary practice is small potatoes. I am nowhere close to the fifty-employee threshold that is ostensibly impacted by the new law (see Trader Joe’s, et al. above). So why am I hiring a new receptionist, one who will replace a full-time employee that had health care benefits, one that will work a 28-hour week? It saddens me to do it, because I thoroughly appreciate the fact that my business (like other kinds of medical practices) has traditionally cared for staff that don’t make outstanding wages and that feels some sense of ministry to patients and staff alike. I am just too worried to hire another full-time staff member.

My unscientific talks with other “safe” small businesses (under fifty employees) finds that we all fear what happens if things go terribly wrong—if young, healthy people ignore the mandate to buy health insurance (and thereby subsidize the sick and old). What if these people just pay the penalty (or “tax” as the Supreme Court has determined it) or otherwise feel that a government that sometimes seems incapable of much that would be deemed “competent” will never “find them” to force enrollment in one of the healthcare exchanges? A quick fib on a 1040EZ may be enough to keep Uncle Sam at bay.

If this happens, the premiums we pay, the ones small businesses will face, could be awful. This potentially means eliminating insurance for our staff, people who are struggling to get by as it is, and that is a grievous thing. Will it happen? No-one knows. But fear of the unknown, fear of promises from political figures that have themselves fallen into disrepute, urges caution. I am hopeful that all fears are proven too great, that small businesses, including my practice, will find that it is of little real consequence and that we can go back to hiring full-time employees and letting them join health insurance plans. It’s my Pollyannaish side.

Ironically, I think there may be little appetite to delay the onset of Obamacare, even among its critics in the world of business. Perhaps citizens of the United States feel like we’re on a 9-foot cliff waiting to jump into a cold lake below. We could stand there longer and fear the result a little more, or we could just jump in and then deal with what we will then know. Sink or swim, just don’t keep us hanging. Another year of waiting is hardly something to cheer.

Over the weekend I did a 37-mile bike tour (with my energetic 10-year old son) that offered several things for me to process. One of the things I like about cycling is the way it slows things down. Certainly it lets me face my own mortality—there are parts of me that hurt that I hadn’t expected. But it also makes a rider look at each house we pass, each farm and orchard and lake cottage, and think about those who live inside. Sometimes the people look back, and then the narrative in your mind has faces to connect with it. I thought of my staff, present and future, and I thought of what would happen to my body that is aging (perhaps faster after my ride!) and is now facing the loss of the insurance that my wife’s employer has felt the need to give up in January (one I understand all too well). What do I expect will come of us, and them?

This ride took us past small towns with tiny homes and rural areas with aging mobile homes, past elaborate horse farms and Lake Michigan “cottages” that were worth millions. What happens to the inhabitants of each when cancer strikes? Do I really want a system where the former are denied care and the latter can circumvent the system to get it? Where does my family fit? My sense of distributive justice is stymied by the sense that fallen humanity can’t have it all, and that the gulf between the haves and have-nots has, if anything, been heightened in recent years.

But cycling also helps me face my own idolatry. I can easily ride 100 miles when studying a route on my computer screen. Hills, pedals, knees and rough pavement humble me to reality. And I can fear the consequences of health care policy that could kill me, kill my family, kill my business, pull the safety net out from under me, take away the care I “deserve” as much as the rich weekenders on the Lake Michigan beaches.

And then I have lost trust in a God that I have promised to trust with everything, who has given me a life of which I am only a weak steward. I fear jumping into a cold lake from which I will ultimately be rescued, no matter what, and yet my anxiety ignores my rescuer. Yes, I am to be dedicated to justice and wholeness among human beings while I am on Earth. But I am not to be so lost in the process that I cannot recognize who is in charge, if I am swept up in the drama and fail to appreciate in whose hands my healthcare ultimately lies.

Ethical Bullies, Part 2

You know you’re having a bad summer when you could be asked how your administration is weathering the scandal and you must genuinely reply, “Which one?” Washington scandals have long been filled with equal measures of the profound and the petty. Comedians have fresh material each night because the character list of each scandal is filled with people bearing foibles, everymen who acquire some power and suddenly climb heavenward, and loudly crash earthward, with modern-day wings of Icarus. But some of this lighter fare conceals the darker side of human behavior.

The recent issues with the Internal Revenue Service and their targeting of specific groups seeking not-for-profit incorporation are humorous in their absurdity (the IRS asking for reading lists and content of prayers is as laughable in its bureaucratic hubris as it is disturbing) but offer some real cautions for Americans.

Americans’ disdain for the IRS is legendary and crosses socioeconomic lines. That itself offers some comfort. There is a “we’re all in this together” sense that is as American as the notion of government by the people, for the people. That is what makes this recent scandal so upsetting. Columnist Peggy Noonan in her recent blog gets to the bottom of what makes this different from that more sanguine, egalitarian animus. One of her friends comments that in the gold standard of political scandals, Watergate, it “’was elites using the machinery of government to spy on elites. . . . It’s something quite different when elites use the machinery of government against ordinary people. It’s a whole different ball game.’”

The IRS has grown to be an organism so large that it has developed its own culture, taken on its own agenda. That agenda may be supportive of the presidential administration in power or opposed to it. It WILL be supportive of a larger role for government which will ensure its eternal survival and flourishing. It’s really something quite primal: the purpose for which the entity ever existed is replaced by the continued growth of the organism by whatever means. Comedian Bill Maher, whose comic genius was long ago supplanted by an indulgent biliousness, asked, “Is it unreasonable to target an anti-tax group? This is after all a group that named itself after a tax revolt that wants to abolish the IRS. It’s like when a cop gets shot, the cops kind of take that personally.”

Maher was too clever by half. The IRS collects revenue; it doesn’t provide defense against evil. Maher thinks they should go after anyone, even institutionally weaker prey, which form an existential threat to the growth of the organism that is the Internal Revenue Service. But in accepting that we must also begin to reject the notion that we have a government that, despite a few bad apples, genuinely seeks to serve the public, the citizens who give it power and a mandate. The IRS is not the police, who protect the public from dangerous and fearsome people, but is increasingly fearsome itself. There is something to be grieved there. A close family member, not usually a crackpot, who faces an IRS audit for the first time ever felt constrained in speaking about it with me for fear that our telephone conversation may be under surveillance. I wanted to laughingly dismiss her talk; I couldn’t.

Within this current unpleasantness for the IRS come fresh reminders that it will be integral in the implementation of Obamacare, something that should offer cheer to no one. Those who claim to “know” Obamacare, on both sides, must know more than its architects and implementers, none of whom seem to know much at all until it starts to play out. Its dismal public polling numbers may reflect a number of factors, but there is a necessary push to reverse those numbers to keep the law alive in the court of public opinion.

This is the Obamacare “perfect storm”: an act predicated on “affordability” must prove itself financially, where it won’t matter just how many people are covered and how darn good that coverage is for all kinds of things if the premiums for the young and healthy go up 80 percent, implemented by massive government agencies like the IRS and the Department of Health and Human Services, in which the public has increasingly lost faith.

I wonder if, in retrospect, the desire for broader, bipartisan support (which never materialized) that made affordability such a tenet of the new law, was a grievous error. For now we have an agency that has proven its ability to bully ordinary people, even as they form larger groups. These groups are no match for an institution, a leviathan within a leviathan, which can consume them as it grows in size and stature. Yes, there is hyperbole there. But these huge organisms we call the IRS and HHS MUST make “affordable” WORK. If Obamacare goes down, the larger organisms will get smaller. That can’t happen. The path of least resistance to affordability is the weak. It is the elderly and the disabled in particular. They are, at least once sick, terribly expensive and quite easy to bully. Physician-assisted suicide and euthanasia and “selective reduction” and the “abortion assumption” for mentally or developmentally-challenged fetuses seem less gruesome when a huge government agency that has to “make things work” grows too large and self-perpetuating to see that flesh and bone human beings will reap the harvest of their decisions. The IRS and HHS, like other large bureaucracies, have developed their own ethics, and will have sophisticated answers to why the decisions they make are right. Agencies with agendas and “house ethics” have been given tremendous power, and we have much to fear that this power will be abused.

I genuinely hope I’m wrongheaded here. I know that many, many people in government, including people who work for the IRS, have servant hearts and genuinely hope to see a nation and a world positively transformed by their work. But I also see institutionalized bullying at work here, and think that it is not too great a jump to see an organization dedicated to self-flourishing, charged with making a very expensive thing “affordable” as a means to that flourishing, doing what must be done to ensure that the numbers add up. So whether you support the various Tea Party groups or not, or have some dedication to the quirky, sometimes misguided and often cranky groups that have kept our democracy in check for over 200 years or not, there needs to be a serious level of concern about the IRS scandal. Americans deplore anything that would submit healthcare to the forces of bullying (the HMO’s of the 1990s proved that). The IRS scandal reminds us that we ain’t seen nothing yet.

On the 2012 Vote

Well, we had a national election last week, if you hadn’t noticed the sudden loss of political hatchet ads encumbering all forms of media, and I will gladly offer the first (perhaps only) post-election bioethics blog. First, there are great risks in making post-mortem assessments on a still-warm corpse that has yet to have a rational pathologist examine it, and the 2012 Election has yet to enter full rigor mortis. It is far too easy to make overgeneralizations that are either too rosy or too gloomy at this point. Electoral politics in a democracy, as George Will put it, will inherently create some disappointment among the citizenry.

Was this a “status quo” election? Does the level of polarization and acrimony that the last two years have displayed look good to a majority of voters? Are issues in bioethics, from the government’s role in embryonic stem cell research to the healthcare delivery system, now essentially settled? I think “yes” answers to any of these are hard to believe. This election seems more to me like a call to bring back the same football team members that lost last season with the admonition to have a “do-over.” I don’t mean this to be entirely pessimistic. Gridlock is bad because it keeps government from solving important problems, but good when it prevents bad laws or bad governance from doing damage. Circumstances change. People learn from the past and change.

So here are a few of my thoughts on the new (or not-so-new) world of American politics. First, whatever we think of Obamacare (and there are proponents and opponents aplenty within the Trinity family), we would be wise to learn how to navigate it. It is omnibus, to be sure, but its particular components are likely still open to interpretation. Instead of repeal efforts (almost certainly futile) or blind acceptance (almost certainly unwise), staking out turf within the law’s confines will be essential. What will become of the rights of conscience that physicians have enjoyed for centuries, and which are already under assault on various fronts? What of the rights of churches, who operate hospitals and medical colleges, to take theological and moral stands that may lie contrary to popular sentiment? Now is the time to engage the provisions of this law; whether we agree or disagree with it, we have an ethical injunction to affirm human dignity and protect the vulnerable, and the vehicle to do it over the next few years is through its implementation. Anyone who believes that our healthcare system has been fully “reformed” is delusional; with or without Obamacare there is much to do within the arena of healthcare delivery.

This brings me to my second point. I am certainly not a proponent of fighting the culture wars of the 1980s and 90s, or of the “Take America Back” mindset. This is increasingly manifesting itself as counterproductive and a lousy strategy for building political alliances among a populace that is becoming more pluralistic by the day. I do, however, think there are moral issues upon which we must be willing to die on the mountaintop, at least politically and perhaps literally. The issues that involve respect for human life, whether it be nascent embryos in freezers and research labs or the dying who stare into the emptiness of dementia in a nursing home wheelchair, are worth fighting for. Regardless of political party, we can stand on principles of honoring the lives of human beings, created in the Image of God, at all stages and irrespective of capacities. If we believe what we say, we will not be quiet when human life is reduced to a commodity. We are to “provide for the common good” and “promote the general welfare,” but always must never forget to “secure the blessings of liberty” for all Americans, including those who do not have a voice.

That said, the way we engage the public square must change. It has been changing. One way we do it is with good science. We should all be encouraged by the Nobel Prize shared by scientists from Japan and the UK that have found ways to use adult stem cells to make tissue that can transform into embryo-like stem cells, a process that is not ethically problematic. Success draws an audience for what we have to say, and the best science need not be separated from solid ethics.

We also must fine-tune our arguments into relatable terms. If exit polls are to be believed, the voters this year showed a disconnect between the purely rational or empirical, where the losing presidential candidate scored higher on almost every category on economics, and the emotional (or at least intuitive) where the presidential candidate that could best empathize with voters was selected. I do not want to glibly say the electorate is irrational, but we do face a nation where post-modern notions of narrative and experientialism seem to triumph over the evidence-based criteria of modernity. Bioethics, in support of human dignity, will need to understand how to do narrative better and to make positions clear in creative ways that can appeal to nominal Christians, Hindus, and agnostics alike. It will not be easy. It is essential.

Third, justice is a principal tenet of bioethics, and one in which we must recognize that we’ve ceded social justice issues for far too long to other voices. Minimizing abortions and working against the current of support for physician-assisted suicide and euthanasia will always be vital bioethical issues. But human trafficking, distribution of HIV drugs, worldwide orphan care and healthcare for America’s poor are bioethical issues, and they are issues of increasing importance to young people, including young evangelicals. For example, California, considered the “Greece of America” economically and written off as a lost cause by the right, passed a strong human trafficking initiative last week. The opportunities for collaboration and common ground are great even in this polarized environment. Maybe we can study these issues, make our best case, fight hard for the protection of human dignity, and still recognize that those who disagree with us are flesh and bone human beings like us.

For those who seek to follow Jesus, elections are less about winning or losing and more about what new ways God will let His glory be known through His people in whatever political circumstance they find themselves. Neither a time for gloating or despair, but one for doing our best work.