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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Three Books: A Summary of a Doctors for America Session held at the National Leadership Conference

Three Books: A Summary of a Doctors for America Session held at the National Leadership Conference on November 9, 2019

I recently did a workshop session at the Doctors for America National Leadership Conference in Baltimore. The session was titled Prospect Theory, Medical Industrial Complex and Social Justice in Health Care: 3 Important Books. I have recently had the opportunity to be able to devote some time to thinking about healthcare reform in general, and the distressing lack of progress toward universal healthcare in America spanning my entire career and beyond.

I came across the late Uwe Reinhardt's last book, Priced Out, which was a summary of his life's work: the ludicrousness of America's Healthcare Wonderland, as he calls it, and the ineffectiveness of any moral arguments to persuade the American political class to move towards universal healthcare. I had the opportunity to exchange a few emails with Prof. Reinhardt about 5 years ago. At that time, he seemed quite pessimistic about the opportunity of America moving forward. In his book, however, his life partner, Prof. Cheng, in her epilogue, makes it clear that he remained optimistic about America's chances for universal healthcare. He thought, she said, that we would probably stumble towards it and not actually make a cultural or societal decision, but that we would eventually get there in fits and starts.

Prof. Reinhardt's chief concern is that we never have the moral discussion required to propel us towards a universal healthcare ethic. Without the ethic, he argues, there can be no successful transition to a universal system. He has said that during healthcare debates, we have an incantation, "’we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”

He is right. We do not agree. We agree on the left that universal healthcare is an imperative, and those on the right agree that healthcare is a market commodity and should be treated like any other good or service. Of course, progress is made by convincing enough people in the middle that one's policy proposals or political arguments are worthy of implementation. One need not win over everyone. Medicare, Social Security, civil rights, and so much of America's progress in the past century was not unanimous. Given the opportunity, many conservatives would still reverse the New Deal, the Great Society, and of course, the Affordable Care Act.

Progressives have failed to win the moral and political arguments in favor of universal healthcare. As Wendell Potter has pointed out, the methodology of the entrenched and well-funded interests opposing progress are simple: fear, uncertainty, and doubt. Simple and devastatingly effective.

The Undoing Project: A Friendship That Changed Our Minds by Michael Lewis holds many of the answers as to why it is so effective. The book tells the story of the two psychologists who developed Prospect Theory. Prospect Theory was the basis of what we now call behavioral economics. It is the exploration of why we make the decisions we make. It is about why we make the irrational decisions that we make.

Briefly, our brains are fooled in a variety of manners. We have fast, intuitive thinking. This thinking is swayed by a variety of biases. Gains and losses are perceived from specific reference points. The fear of loss, risk aversion, is far more powerful than the lure of gain. Things that come to our mind easily, either through recency or frequency (availability) greatly impact our decision-making. The fast, intuitive mind is influenced heavily by these biases. And unfortunately, the fast, intuitive mind is very confident.

Our more logical, slow thinking brain is analytic. It is also unsure of itself because of its self-critical analysis. That is why a plausible and emotionally resonant feeling, as Mark Twain might say, is halfway around the world before a detailed policy proposal gets its pants on. Or, as Stephen Colbert might say, truthiness works.

There are many lessons to be gained from Prospect Theory, but the key insight from Daniel Kahneman is that “We don’t choose between things, we choose between descriptions of things.”

After reading The Undoing Project I was somewhat optimistic and excited about the possibility of using some of these techniques to combat the campaign of fear and uncertainty and doubt that is awaiting us as we march into an election year with healthcare reform as a major point of contention.

Unfortunately, I then read An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, by Elisabeth Rosenthal. Dr. Rosenthal provides a discouragingly comprehensive evaluation of the medical industrial complex and how it has come to dominate every aspect of the provision of healthcare. The chapters catalog the breadth: health insurance plans, hospitals, physicians, the pharmaceutical industry, the medical device industry, testing, laboratory, and all other manner of ancillary services, contractors, billers, coders, collections agency, researchers, not-for-profit organizations, and of course the rise of the massive healthcare conglomerates, euphemistically known as “integrated delivery systems.”

As Don Berwick recently wrote, there is $1 trillion of waste in the healthcare system. And one man’s waste is another man’s revenue. Dr. Rosenthal details all that waste and in doing so, lays down the markers on the battlefield. One side is well-funded and is fighting for its very existence. Or at least fighting for the very upscale version of its current existence, and desperate to avoid a comparatively spartan OECD-like existence.

As Upton Sinclair once said, "It is difficult to get a man to understand something if his livelihood depends upon his not understanding it." As Wendell Potter more recently said, “Health insurers have been successful at two things, making money and getting the American people to believe they’re essential.”

I finished my remarks, and opened up the floor for discussion. We spent a fair amount of time reviewing the concepts above. I specifically asked for help in developing framing and arguments that might help us in our advocacy work. Several themes emerged, and I have highlighted them here.

1.    Talk about the moral case for health care. We discussed the deserving-undeserving framing, the puritanical streak in American politics, and the fear of others "getting over on us." I told the story of having gone to a progressive conference after the 2018 election. I had the opportunity to hear from four progressive candidates who lost their races in conservative districts. All four of these candidates said they were surprised that so many of the conservative voters were afraid, almost exactly as I had phrased it to you, of having others ‘get over on them.” That these others would get free healthcare when they were going to have to pay for it, for “those people” to be freeloaders that they would have to subsidize, etc.

2.    Talk about work arounds and hassles. I pointed out that the second half of Dr. Rosenthal’s book was a guide for those who are trying to deal with the Wonderland of American healthcare. While quite useful in the here and now, it amounts to a series of workarounds of the system as it exists. Useful, to be sure, but it is not a prescription for ending the need for workarounds. As Teresa Brown recently put it in a New York Times piece, American healthcare system is one giant workaround.

3.    Talk about student debt, medical school tuition and physician income. We had a discussion about the rabbit holes, as I call them, of excruciatingly detailed policy points surrounding any healthcare reform. As Uwe notes, whenever this happens, we then engage in protracted and useless arguments over the value of quarter hour of an anesthesiologist time, or other some such parochial detail of concern. It was pointed out that these concerns arise out of the value of medical school education and residency training, the heady medical school costs and student debt, as well as physician income. The group argued to take these issues head-on. Have a discussion about subsidizing medical school and have a discussion about the relative value of the various specialties. Have a discussion about work hours and on-call time, medical liability, and the many other practical issues moving towards universal healthcare system.

4.    Talk about price control and administrative simplification. There is no love lost between physicians and the rest of the healthcare industry. There is also no love lost between consumers of healthcare services and the healthcare industry. The group felt that it was well worthwhile to point to alternative methods of controlling costs in the healthcare system. We discussed Prof. Reinhardt’s maxim that “It’s the prices, stupid!” We discussed the unconscionable waste of time and money spent dealing with health plans, from in-hospital utilization management to outpatient prior authorization for everything from procedures to medicines to wheelchairs. These issues potentially put us on the same side with the public and politicians.

While driving home from the conference, I began listening to Daniel Ariely’s Predictably Irrational. Prof. Ariely spends a significant amount of time discussing the difference between market norms and social norms. The way we behave around wages, prices, rents, and other payments are our market norms. The way we behave around doing each other favors, helping one another and other activities that do not involve financial exchanges, are our social norms. He provides many examples showing that things one might do unhesitatingly under the structure of social norms, are out of bounds under market norms. For example, lawyers asked to do work for a nonprofit company at a very low rate reject the proposal. Lawyers asked to do pro bono work readily agree. Injecting finance into a situation that normally operates on social norms profoundly alters the perception.

It occurs to me that this is at the center of Prof. Reinhardt’s assertion in his book. We will endlessly and vociferously debate on the number of and reimbursement for, angels dancing on the head of a pin, and always avoid the underlying discussion of whether we, as Americans should be the keepers of our less fortunate brothers and sisters for their healthcare needs.

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Who Will be Uninsured After Health Insurance Reform? - Robert Wood Johnson Foundation

 

The ACA would reduce the number of nonelderly people without health insurance by 28 million—from 18.9 to 8.7 percent.

Of the 23 million still uninsured, 40 percent would be eligible for, but not enrolled in, Medicaid or the Children’s Health Insurance Program (CHIP). A further 22 percent would be undocumented immigrants.

The majority of those uninsured—19 of the 23 million—would be nonelderly adults:

• Thirty-seven percent—mostly young singles without dependents—would be eligible for Medicaid, but not enrolled.
• Twenty-five percent would be undocumented immigrants.
• Sixteen percent would be exempt from the individual mandate because they would not have an affordable insurance option.
• Eight percent would be eligible for affordable subsidized coverage in the health benefit exchanges.
• The remaining 15 percent—most higher-income families with dependents—would likely be subject to the mandate, having an affordable private insurance option despite not qualifying for a subsidy.

Who Will be Uninsured After Health Insurance Reform? - Robert Wood Johnson Foundation

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Hawaii's Lessons - NY times

In Hawaii’s Health System, Lessons for Lawmakers

Since 1974, Hawaii has required all employers to provide relatively generous health care benefits to any employee who works 20 hours a week or more. If health care legislation passes in Congress, the rest of the country may barely catch up.

Lawmakers working on a national health care fix have much to learn from the past 35 years in Hawaii, President Obama’s native state.

Among the most important lessons is that even small steps to change the system can have lasting effects on health. Another is that, once benefits are entrenched, taking them away becomes almost impossible. There have not been any serious efforts in Hawaii to repeal the law, although cheating by employers may be on the rise.

But perhaps the most intriguing lesson from Hawaii has to do with costs. This is a state where regular milk sells for $8 a gallon, gasoline costs $3.60 a gallon and the median price of a home in 2008 was $624,000 — the second-highest in the nation.

Despite this, Hawaii’s health insurance premiums are nearly tied with North Dakota for the lowest in the country, and Medicare costs per beneficiary are the nation’s lowest. Hawaii residents live longer than people in the rest of the country, recent surveys have shown, and the state’s health care system may be one reason. In one example, Hawaii has the nation’s highest incidence of breast cancer but the lowest death rate from the disease.

Bottom line? Employer mandate ensures near universal health care. Duh.

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Kaiser Family Foundation Health Policy Tutorials and Compendia

Tutorials:

KaiserEDU's tutorials are multimedia presentations on health policy issues, research methodology or the workings of government.

Here are a few to get started (I haven't yet, but put them here for reference and eventual use!)

Health policy experts provide overviews of current topics in health policy. Watch and download slides from these and other tutorials:
The Public and Health Care Reform
A Primer on Tax Subsides for Health Care
Expanding Health Coverage to the Uninsured

They also have Compendiums:

These modules include background summaries along with links to academic literature, policy research and data sets on current health policy issues, such as:
U.S. Health Care Costs
Health Information Technology
Addressing the Nursing Shortage
The Uninsured
International Health Systems

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AMNews: Oct. 13, 2008. Baucus previews uninsured debate for next Congress ... American Medical News

AMNews: Oct. 13, 2008. Baucus previews uninsured debate for next Congress ... American Medical News:

"Washington -- Sen. Max Baucus (D, Mont.) will try to advance a major health system reform bill with bipartisan support next year. But the chair of the powerful Senate Finance Committee might consider using a budgetary tactic to force adoption of the measure with a simple majority vote if broad support does not materialize.

Baucus, speaking Sept. 23 at a U.S. News & World Report forum on the uninsured, said he plans to outline his measure later this year. The Senate Finance Committee -- a key stop for most health care legislation -- has held a series of hearings on health system reform in recent weeks to lay the groundwork for a major bill."

The article goes on to suggest caution will be in the air to avoid upsetting the status quo too much.

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Cost of Covering the Uninsured: Health Affairs

Covering The Uninsured In 2008: Current Costs, Sources Of Payment, And Incremental Costs

"Providing full-year coverage to all Americans currently uninsured for any part of the year would increase their medical spending by $122.6 billion in 2008, over and above their current spending (while uninsured) of about $86 billion. The increase in total spending corresponds to 5.1 percent of total health care spending and 0.8 percent of gross domestic product (GDP). For comparison purposes, a recent analysis estimated that the tax subsidy received by privately insured workers with employer-sponsored insurance was more than $200 billion in 2006.27 The 5 percent increase is also smaller than the average annual increase in total health spending of 7.6 percent per year since 2000.28

"The estimate implicitly assumes that the uninsured's new coverage would reflect the distributions of public and private coverage and benefits held by lower-income and lower-middle-income insured people and that their medical care use would also be similar. The cost estimate would change if the new coverage were either much more generous (very low cost sharing, as in Medicaid) or less generous (high deductibles) than current coverage. Similarly, it assumes that provider payment rates and administrative costs under various public and private plans would stay largely the same. Various health system reforms, such as competing private health insurance plans within purchasing pools, greater use of public programs' fee schedules, or expanded use of health information technology, could reduce the estimated incremental resource cost of expanding coverage. A recent report from the Commonwealth Fund estimates that a menu of fifteen savings options could reduce health spending by $1.55 trillion over ten years.29"

Perhaps I am being hyperbolic, but this reminded me of Steinbeck:

"There is a crime here that goes beyond denunciation. There is a sorrow here that weeping cannot symbolize. There is a failure here that topples all our success. The fertile earth, the straight tree rows, the sturdy trunks, and the ripe fruit. And children dying of pellagra must die because a profit cannot be taken from an orange. And coroners must fill in the certificates – dies of malnutrition – because the food must rot, must be forced to rot.
" The people come with nets to fish for potatoes in the river, and the guards hold them back; they come in rattling cars to get the dumped oranges, but the kerosene is sprayed. And they stand still and watch the potatoes float by, listen to the screaming pigs being killed in a ditch and covered with quicklime, watch the mountains of oranges slop down to a putrefying ooze; and in the eyes of the people there is the failure; and in the eyes of the hungry there is a growing wrath. In the souls of the people the grapes of wrath are filling and growing heavy, growing heavy for the vintage."

Cheers,

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Health Blog : Changes Brewing on Capitol Hill for Health Insurance

Health Blog : Changes Brewing on Capitol Hill for Health Insurance:

"Next year could see the biggest push in more than a decade to transform how health insurance works in this country. Obama and McCain have both proposed significant changes, and the Democrats just hammered out a platform plank that says the party is “united around a commitment to provide every American access to affordable, comprehensive health care.”

Meanwhile, Congress is busy hatching its own plans.

During the Health Blog’s recent field trip to DC, we spoke with Sen. Ron Wyden, an Oregon Democrat who’s pushing a health reform bill that would make some big changes to the system.

The bill, known as the Healthy Americans Act, would require everyone to buy health insurance. But instead of sending a check to the insurance company, the premium for basic coverage would be tacked onto your federal income tax. You’d choose from health plans offered by private insurers in your state or region. If you wanted to buy a plan
that covered more than the basics, you’d pay extra.

There’s a lot more to it than that (including various taxes and subsidies), but those are the basics. You can read the whole bill for yourself here."

We've noted this before, but it really seems we may be acheiving critical mass/crisis for big change to occur...

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State (MA) health plan underfunded - The Boston Globe

State health plan underfunded - The Boston Globe:

"The state's new subsidized health insurance program will cost 'significantly' more than the $869 million Governor Deval Patrick proposed in his 2009 budget just two months ago, the state's top financial official said yesterday, after insurers were granted an increase of about 10 percent.

To close the gap, the Patrick administration has asked insurers, hospitals, healthcare advocates, and business leaders to propose ways to cut costs and raise revenue. During two closed-door meetings in the last two weeks, several dozen proposals have been put forward, including raising assessments on insurers, hospitals, and businesses. The goals are to solve the short-term funding problem for next year and ensure the long-term survival of the state's near-universal health insurance initiative.

Leslie Kirwan, secretary of administration and finance, declined yesterday to discuss specifics of the proposals or the size of the budget gap, but said that without changes, the state doesn't expect 'to be able to live within' the proposed budget."

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Washington State Results — Code Blue Now!

Washington State Results — Code Blue Now!:

"In December 2007, CodeBlueNow! worked with The Gilmore Research Group, a Northwest market research firm, to conduct a phone survey, known as the CodeBlueNow! Pulse®. The CodeBlueNow! Pulse® is intended to gauge the public's views about priorities in health care reform. CodeBlueNow! intends to use this data to give voice to citizen's values and ideas on health care reform."

I haven't had time to digest all of this. There are both a full report, an executive summary and links to Iowa results on this page.

Just glancing though, I don't find anything to surprising, though I think some of the results reflect a lack of knowledge of the current system and options by the particpants. For example, asking about "government run healthcare" is so loaded as to beg for an uninformed answer. Perhaps they phrased it better in the telephone scripit, I don't know. But even so, most people at least recognize how dysfunctional our system is, but possibly don't appreciate the possibilities and options that could be accomplished with some strong national leadership.

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Getting to Universal Health Insurance Coverage Conference - Kaisernetwork.org

Sweet! Follow the links to watch these lectures on your PC. Podcasts would be nice, but, hey, it's free!

Getting to Universal Health Insurance Coverage Conference - Kaisernetwork.org:

"National Academy of Social Insurance's 20th annual policy conference focuses on achieving affordable health coverage for all Americans. The conference brings together the major participants in the health coverage debate to frame the problem, compares specific policy proposals, and identifies ways of overcoming the obstacles to reform.

January 31st Sessions

Welcome and Opening Speaker
What Should Be the Role of Employers in Delivering Health Insurance?
Luncheon Speaker: The Real Health Reform Debate We Need to Have
How Should the Private Insurance Market be Structured in a Universal System of Coverage?
How Should We Balance Affordability and Comprehensive Coverage?


February 1st Sessions

Can an Individual Mandate Promote Individual Responsibility?
Point-Counterpoint: Is Medicare-for-All the Best Option?
How Can We Overcome the Barriers to Change?"

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