Christopher M Hughes, MD. Talk to Harrisburg Community Health Action Network on Zoom.
I discussed concepts pulled from three books, adapted from 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. Feedback encouraged!
To read the summary article on my blog: http://bit.ly/377cjSs
Saturday, March 28, 2020
Three Books Zoom Talk, Christopher M. Hughes, MD, Recorded March 26, 2020
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.
-----------------
More to come? Thoughts?
Sphere: Related Content
Friday, January 17, 2020
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.
Sphere: Related Content
Notes and thoughts: Thinking fast and slow about universal healthcare.
Thinking fast and slow about universal healthcare.
I have been thinking about healthcare reform in general and
universal healthcare in particular, for decades now. I am well aware of the
admonition of Uwe Reinhardt that, in healthcare reform, everybody’s 2nd
choice is the status quo, and thus reform is hard-fought. But, because of an
excellent book by Michael Lewis, The Undoing Project, about the world
changing work of Daniel Kahneman and Amos Tversky, and Daniel Kahneman’s own
book, Thinking Fast and Slow, I
have been able see more clearly why healthcare reform is so damned difficult.
The major concepts explored in Tversky and Kahneman’s
seminal work on Prospect Theory and in Kahneman’s book explain the failure of
healthcare reform in America better than nearly anything I have explored
before. The only caveat I will add to this is that as the late Uwe Reinhardt
pointed out, Americans have also steadfastly refused to have the moral argument
about whether or not we should even strive for universal healthcare, let alone
how we should get there! “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.”
Thinking is divided into fast and slow subsets. System 1
thinking is fast and intuitive. It is also confident. Overly confident,
according to Kahneman. System 2 thinking is slow and deliberate. It is more
difficult, it takes more time, it is less confident.
System 1 thinking leads many to believe that any changes to
the US healthcare system that would make it more like any other nations
healthcare systems would be bad. This thinking occurs with minimal or no actual
reference data, other than what it picks up from its favorite news sources. If
the person has seen a story or two about waiting times in Canada, or a patient
not getting timely care in the UK, system 1 confidently trashes any talk of
change. The medical analogy, as taught to me during my medical school days is,
“One half-assed observation by me is equivalent to 3 randomized controlled
trials.”
Kahneman uses the following example: a bat and ball together
cost $1.10.
The bat costs a dollar more than the ball.
How much does the ball cost?
People intuit what is an incorrect answer, 10 cents, and
confidently do so, because they did not check. The answer is easy, but System 1
intuition confidently plows ahead with the incorrect answer.
Politicians, pharmaceutical and health insurance industries
as well as the many support industries around them, promote this thinking, in a
constant multimedia barrage, reinforcing false intuitions.
System 2 thinking is less confident and more deliberative.
It takes longer. It requires more effort. It requires a commitment. Thus, it
too often takes a backseat to our intuitive thinking.
All of our thinking is subject to the other forces outlined
in prospect theory, namely, reference points, loss aversion, framing,
availability, and the sunk cost fallacy.
In classical economic Utility Theory, the dollar is a
dollar. $5 million should make us happy. But if I start with $1 million and my
friend starts with $9 million, and we both end up with $5 million, I am much
happier than he is. Reference points and starting positions matter.
Consider the healthcare analogy. I have a “Cadillac health
plan.” You have no health insurance. Health care reform is proposed that will
give us all excellent health care coverage, covering virtually every medically
necessary expense we can have with minimal out-of-pocket expenses. If this
passes, from my perspective, I have lost the best of all possible worlds even
though the new coverage is essentially the same world. You are happy. I am not.
Most of us are familiar with the concept of loss aversion.
Since being introduced by Kahneman and Tversky, the concept has seeped into the
collective consciousness. Simply stated, we feel the pain of loss much more
deeply than the happiness of gain. If I offer 2 tickets, one with a guaranteed
win of $500 and one with a 50/50 chance of winning $1000 or nothing, most will
choose the guaranteed win. If I offer 2 tickets, one with a guaranteed loss of
$500 and one with a 50/50 chance of losing $1000 or no loss, most people will
take the chance to avoid the guaranteed loss of $500.
If I offer to flip a coin with you, and heads you win $1000
and tails you pay me $1000, you will not take that bet. Our loss aversion is so
high, that it requires winning about $2000 to overcome the loss aversion.
If I have Cadillac health plan, or even a standard
employer-based plant, I am so concerned that changing to a universal plan will
result in some kind of loss to me, I am inclined to fight vigorously to avoid
that chance. Here again, proponents of the status quo will foment fear,
uncertainty, and doubt. Fear, uncertainty, and doubt amplify the fear of loss
and the resistance to change.
We have all become familiar the consequences of framing the
argument. If, as a physician, I tell you that your chances of dying from
treatment I am recommending is 10%, there is a decent chance will decline to
treat. On the other, I tell you that this exact same treatment as a 90% chance
of success and survival, there is a significantly greater chance that you will
agree to it.
In universal healthcare debate, negatively framing the
possible consequences of change are exploited ruthlessly. If I tell you that
changing our health system will result in you losing the employer-based health
insurance plan that you have come to depend on, you will almost certainly
reject it.
If I tell you that transitioning to a universal healthcare
system will result in a more comprehensive coverage plan, less of your wages
going to your healthcare coverage and more going directly to you as increase
wages, a vast reduction in co-pays and out-of-pocket expenses, and that you
never have to worry about losing your coverage, whether or not you are too sick
to stay in a job or your job for our opportunities, likely I can convince you
that this is a good thing.
Alternatively, if I tell you that we will be transitioning
to a system, modeled on the Canadian system or British system, and the only
things you know about those systems are what you have been told in the media,
relentlessly, for decades, the uncertainty and potential loss to you and your
family become so overwhelming that you cannot possibly imagine accepting this
option.
This dovetails with the concept of availability. If we are
asked to guess how many words in the dictionary start with “R” versus have “R”
in the 3rd position, we will guess a far higher number of the former
than the latter. This is because we can think of lots of words that begin with
“R” very rapidly – they are “available” to us – and so we overestimate the
number of words beginning with it. Similarly, if the stories that come to mind
rapidly about alternative healthcare systems are of long waiting times and
forgoing treatments, our minds naturally fixate on these examples. As someone
who spent the last 15 years or so studying international healthcare systems, my
mind rapidly goes in the opposite direction, with myriad examples of better
access to care, lower costs, and so on that anchor my thinking to the benefits
of other systems, rather than the potential downsides.
Finally, the sunk cost fallacy is a bit harder to envision
in the universal healthcare debates, as it is well camouflaged. As a nation, we
have contributed trillions of dollars to the building up of massive companies,
both for-profit and nonprofit like, presuming that this investment is giving us
the best possible health care system. It is not. This is not to say that our institutions
are failing, quite the contrary.
We have the best trained healthcare professionals in the world. We have the
best medical research in the world. We have many of the best hospitals in the
world. But our para-medical companies are not serving us well. They have
created bloated, imperious, rapacious engines of profit, paying lip service to
the primacy of patients or members or participants or providers, but
legitimately only excelling at growth.
When we think of the scale of the infrastructure surrounding
the administration of health insurance plans, pharmaceutical manufacturers,
medical device makers, and the related supporting industries, the footprint in
the economy is massive. The workforce is massive. In health plans alone there
are armies of nurses and doctors and support staff and administrators
supporting them, whose sole task is called “utilization management,” what the
rest of the world knows as the “approval/denial people.” In the trenches of the
opposing armies, are their counterpart nurses and doctors and support staff and
administrators working for hospitals or clinics or doctors’ offices, engaged in
daily battle over whether the member/patient is “eligible” for the treatment or
payment being sought.
Wendell Potter has pointed out that, “Health insurers have
been successful at two things: Making money and getting the American public to
believe they’re essential.” They will not go quietly into that good night.
There is too much money on the line. Never mind that most of it adds no value
to the health care system (i.e., it is waste), it is a robustly reliable
revenue stream.
“One man’s waste is another man’s revenue.”
Well, that is all very grim. What is the solution?
My proposal is to use both system 1 and system 2 thinking to
show the clear advantages of transitioning to a universal healthcare system in
America. I am not talking about “gaming” the American psyche, I am talking
about de-programming it from decades of misinformation propagated by the
special interests that continue to literally and figuratively make a killing
off of healthcare in America.
Continued in part 2. (When I get to it!)
Recommended reading:
Lewis, M. (2016). The
undoing project: A friendship that changed the world. Penguin UK.
Rosenthal, E. (2018). An
American Sickness: How Health Care Became Big Business and How You Can Take It
Back. Missouri Medicine, 115(2), 128.
Reinhardt, U. E.
(2019). Priced Out: The Economic and Ethical Costs of American Health
Care. Princeton University Press.
Sphere: Related Content
Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD
Priced Out
The Economic and Ethical Costs of American Health Care
Uwe E. Reinhardt
Forewords by Paul Krugman & Sen. William H. Frist
Reviewed by Christopher M. Hughes, MD
If you are a novice to the subject of health care policy,
the first few chapters of Priced Out will leave you dumbfounded
at the absolute mess we have made of healthcare in the United States. Professor
Reinhardt calls it a “wonderland,” and not in the pleasant sense. The
wonderland is the morass of payment schemes that allow a multitude of
administrators (insurers, pharmacy benefits managers, etc.) to skim just a few
cents off each health care dollar spent before the remainder makes its way to
those actually providing services to patients. Example after example highlight
the mess we have created at the altar of “the market” or “competition” or the
illusion of “choice.”
If you are in the morass, as a physician or nurse or student
of health policy, you will sigh in recognition of the things you may have
already known, but you will see more clearly with Prof. Reinhardt’s great
ability to make the complex comprehensible. For example, the highly “popular”
Health Savings Accounts, are known to be a sop to high income households,
especially healthy households, but Uwe points out that they have also sprouted
a cottage industry of administering these accounts, taking just a little
“haircut,” as he likes to say, of the billions of dollars that flow through
their accounts each year.
For me, as someone in the morass as a physician, a physician
currently working in the health insurance industry and someone who teaches
health policy, I was aware of most of the accretions and detritus that make our
health delivery system a mess, but Uwe always manages to add this kind of level
of detail to, well, just infuriate me! Other examples are the “categories” of
human beings we have in the US, from the poor to the near poor to the wealthy,
to those covered by Medicare or Medicaid or both or neither or those covered by
employer-based insurance to those in the Affordable Care Act Marketplace – or
not. He jokes that in most nations, there is only one category of human beings.
We have made micro-categories a high art.
Chapters on the outrageously complex mechanisms we use to
price services and how we pay the bills are head slapping. Even as one in the
middle of the morass, I am still shocked to see the insane specifics of how we
have passively allowed this all to go on under the banner of “competition” and
“market freedom” and other euphemisms for greed. Convoluted methodologies to
“control costs” by external administrative mechanisms rather than evidence-based
practice infuriate physicians and have spawned the multitude of staff in
doctor’s offices and hospitals to obtain “prior authorization” to prescribe
medications or perform surgeries or even to determine if one is sick enough to
be in the hospital.
The second half of the book focusses on the social ethic of
our health care system. Uwe states it plainly: “To what extent should the
better off members of society be made to be their poorer and sick brothers’ and
sisters’ keepers in healthcare?”
This is clearly more troubling to Uwe than the economics or
health care and how deranged our system has become. After the failure of the
Clinton Health Plan in the 90’s, he wrote a powerful article in the Journal of
the American Medical Association (JAMA) called, Wanted: A Clearly
Articulated Social Ethic for American Health Care. In it, he asked the precursor
to the above question: “should the child of a poor American family have the
same chance of avoiding preventable illness or of being cured from a given
illness as does the child of a rich American family?” He was clearly stung by
the idea that his adopted countrymen rejected this solidarity, in contrast to
every other nation’s resounding “yes” to the question.
He explains that our tendency in American political life is
to pretend that our disagreements on health care are due to the details and how
to get to universal health care. So rather than have the broader ethical
discourse that could answer the two extremely important questions he has posed,
we camouflage and misdirect and devolve our discussions to the best way to
bring market forces to bear or how to properly fund Medicaid in the states. We
never answer the basic question of whether we should strive for
universal healthcare.
He has said elsewhere, “A common incantation during debates
on health reform, for example, is ‘that we all want the same thing; we merely
disagree on how best to get there.’ That is rubbish.”
He spends a significant section of the book exploring his
framing for this fundamental disagreement among conservatives and liberal. But
he does not have an answer for us on how to get where he clearly wants us to go
– as explicitly stated by his widow, TM Cheng in her epilogue – “he
passionately believed in universal healthcare.”
In an exchange I had with him a few years ago, he wrote,
“the problem in America is that the elite does not share a consensus on what
the social ethic governing American health care should be. I am not sure it
ever will reach such a consensus.”
In the epilogue by Dr. Cheng, she documents his hopes and
thoughts and, surprising to me, his optimism in America. We would hobble along,
he thought, and continue to figure things out as we went, and perhaps
technology can improve our lot.
The book left me less optimistic about our chances to reach
consensus, but more committed to trying to make it so. Profs. Reinhardt and
Cheng spent decades trying to advance American healthcare and continually try
to engage on the ultimate questions of our social ethic, paraphrased by Michael
Moore in Sicko as, “Are we about me, or we?”
The glimmer of hope I still have rests on two foundations.
Uwe’s clear-eyed articulation of the questions we have before us and their
obvious answers and my faith in the doctors and nurses who provide
healthcare in the trenches, as we like to say, and who have long ago had
enough.
In 2002, “Medical Professionalism in the New Millennium: A
Physician Charter,” was published as a Project of the ABIM Foundation, the
ACP–ASIM Foundation, and the European Federation of Internal Medicine. In the
Charter are calls around the Principle of social justice, Commitment to
improving access to care, and Commitment to a just distribution of finite
resources. It specifically charged the medical profession to “promote justice
in the health care system, including the fair distribution of health care
resources. Physicians should work actively to eliminate discrimination in
health care, whether based on race, gender, socioeconomic status, ethnicity,
religion, or any other social category.”
The Charter argues that “Medical professionalism demands
that the objective of all health care systems be the availability of a uniform
and adequate standard of care. Physicians must individually and collectively
strive to reduce barriers to equitable health care. Within each system, the
physician should work to eliminate barriers to access based on education, laws,
finances, geography, and social discrimination. A commitment to equity entails
the promotion of public health and preventive medicine, as well as public
advocacy on the part of each physician, without concern for the self-interest
of the physician or the profession.”
This Charter has been endorsed by virtually every group
within organized medicine, from the American Medical Association to the
American Board of Radiology to the American Nurses Association. While it is not
explicitly a call for universal healthcare in America, it is hard to view the
principles and not see this as the logical conclusion. And in fact, at the time
of its publication, there were quite a few dissenting commentators who saw it
as just that, and so rejected it.
I am taking Prof. Reinhardt’s last book as the plainspoken
economic and practical case to shake ourselves free from this embarrassment of
a “system” we have watched become a more hideous monster than we ever
contemplated. I am also taking it as the simple moral argument for why
we need to change. We must stop allowing ourselves to be pulled into
discussions about what flavor of health care reform we like best, and have that
knock-down, drag-out fight about who we are as a nation. Are we the nation that
cheers when one of us gets struck by a car and is left to die because they
chose to forego health insurance? Or are we the nation that sees ourselves in
the suffering of others and wants to help?
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Tuesday, January 29, 2019
Friday, May 4, 2018
In Texas Hospitals, You Don't Get to Decide to End Care | Houston Press
In Texas Hospitals, You Don't Get to Decide to End Care | Houston Press: 2016
[Full disclosure - I don't know if this has been changed at this time.]
"In Texas it doesn’t matter what instructions you’ve previously given or what your relatives say: If you’re in critical condition, you’re dependent on machines to survive and hospital officials decide it’s time to pull the plug, you will die. And it’s completely legal."
'via Blog this'
Wednesday, March 14, 2018
Pharmaceutical corporations need to stop free-riding on publicly-funded research | TheHill
Pharmaceutical corporations need to stop free-riding on publicly-funded research | TheHill: "The White House’s report suggests that it costs an estimated $2.6 billion to develop a new drug today, though they’re basing this on a single, non-transparent pharmaceutical industry-supported study with problematic methodology.
In reality, companies receive substantial publicly-funded support from the government. A recent study found that all 210 drugs approved in the U.S. between 2010 and 2016 benefitted from publicly-funded research, either directly or indirectly.
Taxpayers contribute through public university research, grants, subsidies, and other incentives. This means people are often paying twice for their medicines: through their tax dollars and at the pharmacy.
At Doctors Without Borders/Médecins Sans Frontières (MSF), we see each and every day the human suffering caused in the places we work and many countries outside the U.S. by treatments being rationed or people being denied essential medical care due to high drug and vaccines prices."
'via Blog this'
Monday, February 26, 2018
Why conservatives are so obsessed with guns.
Why conservatives are so obsessed with guns.:
"A more workable psychological explanation begins by noting that psychologists have found consistent differences between conservatives and liberals in personality traits, attitudes, and moral stances. To summarize some of the research findings, conservatives tend to be more likely than liberals to accept or even embrace authority that is perceived to be legitimate. Conservatives tend to be more moralistic and more conventional than liberals. They tend to have a stronger need for order and control and stability and a greater dislike of change.
"Conservatives also tend to value equality less than liberals. They have less empathy and are more likely to see human nature as bad. Compared with liberals, their moral sense is less centered on fairness and kindness and more on loyalty, deference to authority, and moral and sexual purity. Conservatives also show a greater tendency than liberals toward dichotomous thinking and have a stronger need for certainty and cognitive consistency. (“I don’t do nuance,” George W. Bush famously told Joe Biden. )
"The differences are not universal, of course, and there is nothing intrinsically bad or intrinsically good in the characteristics typical of either camp. But conservatives tend to lean one way, liberals the other.
" And some of these differences appear to be directly expressed in divergent beliefs relevant to the gun control debate. For example...
"...But it is hard for conservatives to accept these arguments. The interaction between characteristic conservative personality patterns and universally shared patterns of cognitionleads to conservatives being disproportionately skeptical of evidence provided by “experts” and scholarly studies. So conservatives turn to other means to soothe their anxiety. Some project their own anger onto others, fantasizing that people of color, immigrants, and feminists are the cause of their own inner torments. Anger, if nothing else, makes them feel bigger and more powerful."
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Friday, December 1, 2017
Wednesday, May 17, 2017
Some Americans spend billions to get teeth whiter. Some wait in line to get them pulled. | The Washington Post
As the distance between rich and poor grows in the United States, few consequences are so overlooked as the humiliating divide in dental care. High-end cosmetic dentistry is soaring, and better-off Americans spend well over $1 billion each year just to make their teeth a few shades whiter.
Millions of others rely on charity clinics and hospital emergency rooms to treat painful and neglected teeth. Unable to afford expensive root canals and crowns, many simply have them pulled. Nearly 1 in 5 Americans older than 65 do not have a single real tooth left.
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Sunday, January 29, 2017
Long Waits for Doctors’ Appointments Have Become the Norm - The New York Times
Long Waits for Doctors’ Appointments Have Become the Norm - The New York Times: "The Commonwealth Fund, a New York-based foundation that focuses on health care, compared wait times in the United States to those in 10 other countries last year. “We were smug and we had the impression that the United States had no wait times — but it turns out that’s not true,” said Robin Osborn, a researcher for the foundation. “It’s the primary care where we’re really behind, with many people waiting six days or more” to get an appointment when they were “sick or needed care.”
The study found that 26 percent of 2,002 American adults surveyed said they waited six days or more for appointments, better only than Canada (33 percent) and Norway (28 percent), and much worse than in other countries with national health systems like the Netherlands (14 percent) or Britain (16 percent). When it came to appointments with specialists, patients in Britain and Switzerland reported shorter waits than those in the United States, but the United States did rank better than the other eight countries.
So it turns out that America has its own waiting problem. But we tend to wait for different types of medical interventions. And that is mainly a result of payment incentives, experts say."
'via Blog this'
Friday, January 13, 2017
Uwe E. Reinhardt: U.S. Health Care Prices Are the Elephant in the Room - The New York Times
Uwe E. Reinhardt: U.S. Health Care Prices Are the Elephant in the Room - The New York Times:
In most other countries, prices for health care goods and services are not negotiated between individual health insurers and individual physicians, hospitals or drug companies, as they are in the private insurance sector in United States.
Instead prices there either are set by government or negotiated between associations of insurers and providers of care, on a regional, state or national basis. The single prices for other countries shown in the chart therefore can be taken representative of prices actually paid there.
By contrast, as can be seen in the charts, in the United States there is quite a range of prices for the identical good or service.
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Sunday, January 18, 2015
Hospice Is Becoming a Chain Business - Forbes
Large multi-agency, multi-state hospices are fast become the primary source of end-of-life care in the U.S.
According to a new study, chains cared for nearly half of all hospice patients in 2011, a dramatic increase from a decade before when small organizations (mostly non-profits) provided three-quarters of all care. And my own review of their financial reports suggests the biggest chains have grown even more since 2011.
The paper, authored by David Stevenson of Vanderbilt University and Jesse Dalton, David Grabowksi, and Haiden Huskamp of Harvard Medical School, was published in the January issue of Health Affairs (firewall). The authors did not look at the relative quality of care at any of these facilities. Nor did they calculate how long patients remained in hospice care at the chains. But they shed valuable light on how the business of end-of-life care is changing.
Hospice care is overwhelmingly funded by Medicare. And payment rates are generous enough that for-profits have long made inroads into this care model. The new study shows that, like many in the medical care industry, hospices are scrambling to consolidate so they can benefit from the economies of scale and marketing advantages of being big. Publicly-traded companies are responding to investor demands for increasing revenues.
Small non-profits still served more patients than for-profit chains in 2011, but Stevenson and colleagues found their share has been shrinking rapidly. In 2000, they cared for about 53 percent of enrollees. By 2011, they were caring for only about 37 percent. Over the same period, the for-profit chains’ share of enrollees grew from about one-quarter to nearly half. Non-profit chains accounted for roughly another 10 percent.
in 2000, a typical for-profit chain operated 5.6 agencies with 2,300 enrollees. By 2011, those firms owned an average of seven agencies with an average roster of 2,700 Medicare patients, according to the study. By contrast, a typical mom-and-pop for-profit cared for only one-tenth as many people–about 220.
In some cases, corporate hospices are not just growing, they are getting huge. The paper reports that in 2011, the five largest for-profit chains owned 283 agencies with 190,000 patients. But the biggest players have grown even more since.
Hospice Is Becoming a Chain Business - Forbes
Sphere: Related ContentHealth Insurance Startup [co-op] Collapses In Iowa : Shots - Health News : NPR
Health Insurance Startup Collapses In Iowa : Shots - Health News : NPR:
"It was a heck of a Christmas for David Fairchild and his wife, Clara Peterson. They found out they were about to lose their new health insurance.
"Clara was listening to the news on Iowa Public Radio and that's how we found out," Fairchild says. They went to their health plan's website that night. "No information. We still haven't gotten a letter about it from them."
David Fairchild and Clara Peterson own a small cleaning business in Iowa. The couple had health insurance via CoOportunity Health before the co-op faltered.
Clay Masters/Iowa Public Radio
The two are the sole employees of a cleaning service and work nights. Fairchild has chronic leukemia but treats it with expensive medicine. Last year they saved hundreds of dollars switching from the insurer Wellmark to a plan run by CoOportunity Health. For the first time in a long time, Fairchild says, they felt like they had room to breathe.
"Basically it covered our office visits; covered exams," he says. "It covered all but $40 of the medicine every four weeks. It was just marvelous. It probably was too good to be true."
It was for them. CoOportunity Health has failed. The Affordable Care Act set aside funding for health care co-ops, to enable the organizations to compete in places where there aren't many insurers. CoOportunity Health was the second- largest co-op in the country in terms of membership, and one of the largest in terms of the federal funding it received.
But then CoOportunity hit a kind of perfect storm, says Peter Damiano, director of the University of Iowa's public policy center. First, the co-op had to pay a lot more medical bills than those in charge expected."
Please read on...
'via Blog this'
Friday, December 12, 2014
JAMA Network | JAMA | Reshaping US Health Care: From Competition and Confiscation to Cooperation and Mobilization
Sphere: Related ContentIn this issue of JAMA, 3 Viewpoints, by Powers et al,1 Fuchs,2 and Fisher and Corrigan,3 address problems, possibilities, and mechanisms for reshaping the US health care enterprise to better meet community needs at an affordable cost.
In their Viewpoint, Powers et al1 grapple with a question as old as democracy: How can productive collective action, which is required for a state to succeed, emerge from the factional divisions for which protection is required for democratic principles to succeed?
The founding fathers of the United States debated this vigorously. In the most famous Federalist Paper,4 Madison favored a large republic in the hands of a meritocracy to counterbalance the passions of a majority “faction” that might overwhelm legitimate minority interests. Others wanted to protect states’ powers, arguing that smaller political units could be more responsive to local groups.
Madison defined a faction as “a number of citizens, whether amounting to a minority or majority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.”4
Health care is ground zero for this problem, and the stakes are immense. Health care is a behemoth “faction” that controls one-sixth of the US economy and distorts the nation’s economic and political future. I recently ran as a candidate for governor of Massachusetts, and, in the course of an 18-month campaign, I saw vividly the effect of this dominating industry on the opportunities for the total well-being of a population of nearly 7 million people.
Sunday, December 7, 2014
Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.
Thought I’d blogged this before, but this is from an excellent piece on Libertarianism’s most famous proponent and his own change in perspective later in life.
How could a thinker as brilliant as Nozick stay a party to this? The answer is: He didn't. "The libertarian position I once propounded," Nozick wrote in an essay published in the late '80s, "now seems to me seriously inadequate." In Anarchy democracy was nowhere to be found; Nozick now believed that democratic institutions "express and symbolize … our equal human dignity, our autonomy and powers of self-direction." In Anarchy, the best government was the least government, a value-neutral enforcer of contracts; now, Nozick concluded, "There are some things we choose to do together through government in solemn marking of our human solidarity, served by the fact that we do them together in this official fashion ..."
We're faced then with two intriguing mysteries. Why did the Nozick of 1975 confuse capital with human capital? And why did Nozick by 1989 feel the need to disavow the Nozick of 1975? The key, I think, is recognizing the two mysteries as twin expressions of a single, primal, human fallibility: the need to attribute success to one's own moral substance, failure to sheer misfortune. The effectiveness of the Wilt Chamberlain example, after all, is best measured by how readily you identify with Wilt Chamberlain. Anarchy is nothing if not a tour-de-force, an advertisement not just for libertarianism but for the sinuous intelligence required to put over so peculiar a thought experiment. In the early '70s, Nozick—and this is audible in the writing—clearly identified with Wilt: He believed his talents could only be flattered by a free market in high value-add labor. By the late '80s, in a world gone gaga for Gordon Gekko and Esprit, he was no longer quite so sure.
Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.
Sphere: Related ContentSunday, November 2, 2014
Trends With Benefits | This American Life
An amazingly helpful look into what our disability program has become. Done with the usual attention to humanity and detail as we have come to expect from This American Life.
490: Trends With Benefits
Mar 22, 2013
The number of Americans receiving federal disability payments has nearly doubled over the last 15 years. There are towns and counties around the nation where almost 1/4 of adults are on disability. Planet Money's Chana Joffe-Walt spent 6 months exploring the disability program, and emerges with a story of the U.S. economy quite different than the one we've been hearing
Trends With Benefits | This American Life
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