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.

Embodying a right to health care

In a residency applicant’s personal statement, I came across this sentence about a doctor working among impoverished rural people: “His presence embodies their equal right to health care.”

Equal right to health care. When speaking about rights, I always hear that one person’s positive right implies an obligation on somebody else’s part to provide something. For instance, one person’s right to health care implies that somebody else has an obligation to provide that care.

The applicant’s quote turns this idea on its head. Our system and government do not recognize a right to health care. But by his presence, the doctor is a witness that, although these people might not be able to pay for health care, these people are valuable, they deserve health care, and he will provide it. The doctor’s presence embodies what our system and government do not acknowledge.

The presence of health care-ers in the most difficult and impoverished and hopeless corners of our society is the testimony that, since the doctor has the obligation to care for all who are patients, everyone has a right to health care. Since, in this country, the right to health care is not guaranteed by our system or our laws, it must be guaranteed by us (I write as a physician), by individuals and groups of care-ers, doctors and nurses and PAs and NPs and therapists who enact others’ right to health care by caring. Our self-acknowledged obligation to care for the sick wordlessly, but eloquently, proclaims that all those whom we serve have an equal right to health care.

Maybe someday the system will catch up.

Undocumented immigrants and health care

 

In a Perspective piece in last week’s New England Journal of Medicine, Dr. James Breen writes of a segment of the population invisible to health care system reform: undocumented immigrants. Breen asks, If the currently proposed incarnation of health care delivery reform becomes reality, tens of millions of Americans suddenly have insurance, and charity medical care is drastically reduced as the need for it dries up, what will happen to those undocumented immigrants who currently receive that charity care but neither have insurance nor would be eligible to receive it under the Affordable Care Act?

This is a real concern in the current political and social climate. Just as in the past it was considered legitimate to treat certain groups of people as less worthy of respect than others — in our country, most notably African-Americans — so today it seems to be accepted, even respectable, to consider undocumented immigrants as something a little above vermin. This lower-class status is assumed in public discourse, is a plank in political party platforms, and is even becoming enshrined in the law of the land.

Whatever one thinks of how we should ultimately deal with the issue of undocumented immigrants, the fact is, they are here. Roughly 11 million of them. They are endowed with the same human dignity as anyone else. And they will need health care.

In the parable of The Good Samaritan (Luke 10:25-37), Jesus contrasted an expert in the law with a traveling Samaritan. The lawyer asked, “Who is my neighbor?” — that is, “Who is deserving of my care?” The Samaritan didn’t ask who was his neighbor; he was the neighbor, to a foreigner. And in Leviticus 19 we read, “When a foreigner resides among you in your land, do not mistreat them. The foreigner residing among you must be treated as your native-born. Love them as yourself, for you were foreigners in Egypt. I am the Lord your God.” (NIV) God does not make a distinction between “legal” and “illegal” foreigners.  If our health care system does, then here is another place for the Church to step in and demonstrate God’s heart for “the foreigner among you.” By our advocacy for caring for these fellow humans, as well our actual provision of that care where possible, we can embody the love of God in a way that will contrast starkly with the increasingly strident voices around us.

 

Can the Church have a distinctive take on health care insurance reform?

The Supreme Court has finished hearing the case for and against various provisions of the Obama health care plan. All that remains now is to wait for the decision, which will be handed down sometime in June.

There is much to be opposed to in any scheme of health care insurance reform. If we are waiting for a perfect plan before we will declare our support, then we will never support any reform plan. However, I believe the problem of how to justly provide health care to all is an opportunity for the Church to counter the perception of alignment with partisan political agendas and show instead its alignment with an agenda that transcends political or personal preferences.

The doctrine of God’s love, of the self-giving agape which God demonstrates toward us and enables us to show to others, should surely influence our attitude towards health care reform. One expression in Scripture of what our attitude should be is found in Philippians, where Paul writes, “Each of you should look not only to your own interests, but also to the interests of others. Your attitude should be the same as that of Christ Jesus . . .” (Philippians 2:4-5) Much of our resistance to reform comes from considering only our own interests, to the neglect of the interests of others: placing our own desire for limitless choice over the interests of those who have virtually no choices; putting our desire to keep more of our income out of the hands of the tax collector over the interests of those with much more meager incomes who would benefit from the care increased taxes might provide; placing our general principled distrust of government higher in importance than the real good limited government intervention might be able to accomplish in this particular situation. As Christians, we can be concerned not first of all with our own rights and interests, but with those of others, and can willingly insist not on a right to maximum health care but only to a level that is socially equitable and affordable.

As Christians, we have a unique opportunity at this time in history to be a singular witness to Christ by approaching health care and its reform from a theological standpoint rather than the standpoint of a political party agenda or our own rights and interests. By overcoming the tendencies that naturally make us resistant to health care reform, we will show that we are conformed to something other than our culture or our own private interests. By making clear that the followers of Christ are advocates for those unable to afford care, even when it may be disadvantageous to ourselves, we will take our place among the ranks of our Christian forebears who, as they started the first hospitals and hospices in Europe, were at the forefront of health care reform in their day.

The real reason the Patient Protection and Affordable Care Act should be repealed (and it’s not the one the politicians give)

 

First, the bad news: Between 1980 and 2009, annual real per capita health expenditures grew by 4.1%. In the same period, per capita GDP (adjusted for inflation) grew by 1.8%.  In other words, health care costs grew faster than the money to pay for them. The inevitable endpoint, if such trends continue, is eloquently demonstrated in the graph from this 2005 study from the Robert Graham Center (a center for the study of health care policy), which projected that an annual US family health insurance premium would equal the average family’s annual income by the year 2025.

Now, the good news: A study in this week’s Annals of Family Medicine updated the projection, taking into account the passage of the Patient Protection and Affordable Care Act (PPACA) and the recent slowing of health insurance and wage increases. The new calculations push the date when the family’s premium will equal the family paycheck all the way back to 2033!

The PPACA got a lot of people hopping mad, and in an election year, it has become a huge political hot potato. Many feel it went too far, and therefore should be repealed. However, if the studies mentioned above are even close to accurate, the thing should be repealed, not because it went too far, but because it didn’t go far enough. It provided cosmetic surgery when what the patient needed was a heart transplant.

Many Christian voices have joined the chorus attempting to shout down the PPACA. However, this seems to me to be fiddling while Rome burns, because with or without the PPACA, our health care system is becoming unsustainable, and people — real people, like you and me, and disproportionately the poorer among us — are suffering physically, financially, emotionally, and yes, spiritually, because of the ruin they face from health care costs. And without radical change, more and more will join their ranks.

A large portion of Jesus’ recorded ministry involved healing the sick. The main difference between the sheep and the goats in the Matthew 25 parable is how each treated “the least of these.” It is those “least” that will suffer the most as health care costs become increasingly untenable. Therefore, as Christians, we should be at the forefront of efforts to ethically control healthcare costs and provide some level of basic, dignified healthcare to all. These efforts may or may not entail greater government involvement in health care. The recent controversies over contraceptive coverage show what can happen when the responsibility for health care reform is left solely to the government. But either way, it would reflect well on Jesus Christ if his followers took the lead in ensuring that compassionate health care is within the reach of all people. This will require radical change, as well as self-sacrifice; but who is in a better position to lead the way than the followers of the One who changes lives radically because of his self-sacrifice? The PPACA cannot deliver this; if the PPACA is repealed, it should not because it went too far, but because it didn’t go far enough.

Breaking News: Insurance Coverage Affects Access to Health Care!!

 

Okay, so maybe it’s not breaking news:  the type of insurance you have may affect whether or not you can get in to see a doctor.  In particular, if you have Medicaid-Chidren’s Health Insurance Program (CHIP) insurance (sometimes called “Public Aid”), you might have trouble finding a doctor who will see you.

In a study published in the June 16th New England Journal of Medicine, women posing as mothers of children with common health conditions called 273 pediatric specialist clinics throughout Cook County, Illinois.  They made two calls, one month apart, to each clinic, trying to get appointments for their purported children.  The calls were identical, except that one time the callers said they had Medicaid-CHIP insurance;  the other time, they said they had Blue Cross Blue Shield, a “good” private insurance.  The results are unsurprising but sobering:  66% of the callers reporting Medicaid-CHIP coverage were denied an appointment, compared with 11% of those reporting private insurance coverage.  For those Medicaid-CHIP patients who did get appointments, the average wait for the appointment was 42 days, compared to 20 days for the privately insured.

On the surface, one might attribute these inequalities to a bunch of bad, greedy doctors.  The reality, however, is more complex.  In Illinois, Medicaid-CHIP pays about 20 cents on the dollar (when it finally gets around to paying, which is sometimes six months after the fact).  Because of this, physicians may actually be spending more money than they take in for each Medicaid patient they see.  One can only  do that for so long and still keep the doors open and the lights on.  No, the inequalities do not merely stem from the behaviors of individual, money-hungry doctors;  the inequalities are built into a disastrously flawed system.

I am looking forward greatly to the upcoming CBHD conference examining the “Scandal” of Christian influence on bioethics.  Christians are perceived as being very concerned about issues like abortion, physician-assisted suicide, and embryonic stem cell research, which threaten human dignity by estimating a person’s worth based on their age, appearance, or utility to society.  But it seems that we are perceived as being less concerned about the structural, systemic factors built into our health care “system” which daily lead to insults to human dignity by estimating a person’s worth based on their pre-existing conditions, income, or occupation (i.e., their ability to get insurance).  I wonder, if we Christians really stood out in society because of our concern for the latter as well as for our concern for the former, whether we might not have a greater hearing and make a greater difference in all areas of bioethics.  (Remember Mother Theresa?)

Hope to see you at the Conference!

How Important Are Those with Moral Status to Us?

I have a friend who is from Africa.  She sees a lot of things in this country from a different perspective that makes me think, and sometimes makes me uncomfortable.  We were recently in a discussion in a group at church about how we define who has moral status and how that impacts our moral decisions about human embryos and fetuses.  After the discussion she said she had noted that many Christians in America were quite passionate about the value of the life of those who were unborn, but didn’t seem to care as much about those who were born.  She said we stand up for the value of the lives of the unborn whom we will never know and who do not put any demands on us, but seem to neglect the value of the lives of those around us who are in need because valuing their lives would put demands on us.

I think my friend is right.  If we really believe that all human beings have full moral status we need to help people see the moral problems with abortion, destructive research on embryos, and the making and discarding of excess embryos in IVF, but we need to do much more.  We need to affirm the moral worth of those who have been born.  We need to care for widows, orphans, the poor, and those who are oppressed.  We can see God’s heart for them in the prophets and in Jesus.  There are many Christians who reach out to those in need and love them in tangible ways that express their understanding of their value as human beings.  More of us need to do that.  I need to do that more.