Saturday, February 22, 2020

We’re not ready for Single payer healthcare (because we disagree on basic morality) Warning – this is a draft of a much longer paper, I hope!


“A common incantation during debates on health reform… is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.” – Uwe Reinhardt
In a 2011 Republican Presidential debate, candidate Ron Paul was asked a pointed question about what to do with someone who needed expensive healthcare but did not have insurance: “Are you saying that society  should just let him die?” Some in the crowd jeered “Yeah!” Paul indicated that as a physician, he did not find it acceptable to do so and offered charitable care from “churches” based on his experience of practicing medicine in the in the early 1960s, before Medicare and Medicaid, eliciting applause from the crowd.
Last year, I attended the Keystone Progress Conference in Pittsburgh, PA for a few hours. I attended a panel discussion of progressive candidates who lost their elections in deep red districts. One of the things I heard was straight out of this Ron Paul universe – all four of these candidates said they were surprised that so many of the conservative voters were afraid, of having others “get over on them.” That these others would get free healthcare and they were going to have to pay for it, for “those people” to be freeloaders that they would have to subsidize, etc.
In 2013, Dan Munro, writing for Forbes magazine, on the anniversary of Martin Luther King, Jr.'s “I have a Dream” speech, pointed to several myths so common to conservative thought about America, in particular our backwards interpretation of the “bootstraps” fable:
“the myth that literally anyone – through hard work and determination – can rise out of any poverty and become rich and prosperous. We salute, praise and deify everyone who does. But there’s a dark side to this myth. Anyone who doesn’t isn’t working hard enough – or doesn’t have enough determination. In effect, they’re a loser – and nobody wants to pay for the healthcare of those losers.”
Veronica Combs paraphrased it as ”There is a real meanness in the conversation about who should have healthcare, an implication that people who need help somehow don’t deserve it, or that they are taking advantage of ‘the rest of us.’”
All of this, of course, is not really news. Making a moral case for universal health care in any form is denounced as socialism or “not the job of government,” or as Ron Paul said, that we must “assume responsibility for ourselves.” The American Medical Association has famously opposed movement towards universal healthcare, from the Truman Administration to the passage of Medicare and Medicaid and through opposition to major parts of the Affordable Care Act.
Martin Luther King, Jr., noted that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” Many have railed about the inhumanity of Americans towards each other regarding healthcare, and the late Professor Uwe Reinhardt has asked for decades, “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in healthcare?” Americans, capable of unbridled generosity in helping individuals pay for a transplant or some other services when the individual in question is deserving, are ruthlessly coldhearted when compassion is requested for those they deem undeserving, as the Tea Party crowd showed us in 2011.
Reinhardt was clearly stung by the idea that his adopted countrymen (he was German born US citizen) rejected this solidarity, in contrast to every other nation’s resounding “yes” to the question. He also pointed out that the way Americans avoid the moral question that faces us is to play the game framed by the introductory quote: we pretend that the problem is that we disagree on policy, writ small and large, and find ourselves down rabbit holes about the reimbursement for an anesthesiologist for a fifteen minute unit of time with or without a nurse anesthetist!
Every other nation has started with the moral and ethical question over their values as a society and worked towards a solution to provide healthcare to all their people, “deserving” or not. As another professor noted:
"The last time I taught in the Semester at Sea program, I found it necessary to interpret for our students the rich “social capital” that runs through the Northern European societies we were visiting. What they knew and had read in their guide books was that not many people are in church on Sunday morning, especially compared to the florid religiosity of the United States. So their working assumption was that Americans take religion seriously and Europeans don’t. The new thought that amazed them was that the unchurched Europeans live in social democracies deeply saturated with historic Christian values, while the much-churched Americans celebrate a society characterized by a ruthless social Darwinism that the God of the Bible, Old and New Testament alike, denounces."
What is preventing us from having the basic moral argument about our values regarding health care? The answer is three-fold. The first is a strong puritanical streak in American culture that prompts many of us to divide our fellow citizens into camps of deserving and undeserving people. The second is a now unfathomably large industry that has much to lose should efficiency and order find their way into the American Healthcare system. The third is our human cognitive biases that lead us to sloppily assume political and moral positions that cold be overcome with rigorous analysis and vigorous debate.
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More to come? Thoughts?



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