March 21, 2013
In an email exchange with a Catholic attorney friend who sent me a link to a provocative article on www.reason.com, a website that seems devoted to the propagating the ideas of Ayn Rand and pooh-poohing any and all attempts to regulate anything, arguing that "Obamacare" was among other things driving up costs and driving down quality while prompting an exodus of physicians:
I was accused of being in perpetual "campaign" mode, to which I penned the following response:
The author of the article ("The Obamacare Revolt: Physicians Fight Back Against the Bureaucratization of Health Care: Will it make a difference?" by Jim Epstein, March 13, 2013) deplored "massive government interference in health care." This is rich since without Medicare and - to a much lesser extent - Medicaid, most physician practices would fold. As you age, your healthcare expenditures rise, and everyone over 65 in the United States has socialized medicine that pays most of their bills. Throw in Tricare and all the federal healthcare programs covering the 20% of Americans who work directly or indirectly for the government, and I fail to see how any healthcare entity could survive without this government "interference."
The assertion that "Obamacare, which takes full effect in 2014, will drive up costs and erode quality—and Americans will increasingly seek out alternatives" makes three assumptions that are not supported by the weight of serious analysis. Several key components of the Affordable Care Act (ACA) improve quality - the medical record not least among them - and having uninterrupted healthcare coverage over your lifetime - something far more possible than ever with the ACA - has been shown in study after study to decrease morbidity and mortality especially for chronic conditions (which consume the lion's share of healthcare spending). I am not sure what "alternative" exists to going to a physician or a hospital when you are sick unless the author is implying some Americans might sneak across the border à la Sarah Palin to get free healthcare in Canada, which would sort of defeat the points the author made elsewhere. "Obamacare" as he calls it does not affect the delivery or quality of care as much as it regulates the means by which providers are reimbursed for providing that care and the protections consumers have if they get sick.
I agree in transparency and competition, but this has been provided for decades by Medicare, which publishes all of its rates and provides an effective cap or anchor on doctors who wish to charge more exorbitant rates - the opposite of what the article charges - and managed care, mostly for-profit insurance companies that use Medicare rates as a starting point for fixing reimbursements to doctors and hospitals.
Most doctors complain not about undue interference by the government in the healthcare market but by the extraordinarily intrusive, cumbersome, and micromanaging managed care experiment, one launched at the behest of employers, not patients or providers, to drive down costs a few decades ago. It failed in that objective, but has created a massive overhead that now requires most physicians offices to hire full time people whose only job is negotiating through the labyrinth of for-profit plans (and Medicare and Medicaid) that are out there.
The ACA is not so much regulation of the healthcare marketplace as of the for profit insurers who have been gouging consumers and underpaying providers and hospitals after first dividing them up into take-it-or-leave-it cartels. I believe it was improperly sold as healthcare reform when it is more accurately insurance regulation to protect consumers while also ending free-riding in which the young and healthy could take a risk with all of our money by not paying into the risk pool, hoping they could always get government-mandated healthcare from an emergency room and perhaps disappear when it came time to pay the bill. No longer.
I am not aware of any physician revolt, although a number of older physicians left private practice to retire when managed care came along in the 1990s.
I was a contracted provider with dozens of managed care and insurance plans as well as Medicare and Medicaid. I found the latter two far less intrusive and easier to deal with. I understand this has not been everyone's experience, but the central issue that frustrates physicians is the idiocy of having to call a 1-800 to talk to someone reading from a script who has never met your patient and trying to convince them that the treatment you believe in your medical opinion is the best really is (and that they should pay for it).
A truly free market system could never work for medicine since a tiny minority of patients (and you and I will never know whether we will be in that group tomorrow) generate the vast majority of the costs. Only the super rich could afford the latest treatment for multiple sclerosis or cancer and it is unrealistic and frankly cruel to expect that those who are not wealthy should forgo treatment or die if they do not pass the wallet biopsy. But again, a truly free market, libertarian solution would be that those who are poor when they get sick or injured die, leaving the lucky and the wealthy to survive (and presumably contribute disproportionately to the gene pool). This is not the sort of Darwinian society I think any civilized person wants to live in. I certainly don't which is whatever we can do, however imperfectly, to decrease the 60,000 excess deaths every year in America from lack of health insurance is worth trying.
What President Obama proposed and Congress passed and the Supreme Court validated as constitutional is not perfect - nothing is or will be. It draws its inspiration from Governor Romney's successful plan in Massachusetts (Massachusetts now enjoys close to universal healthcare coverage without the exploding of costs or collapse of private insurance that his opponents predicted). It is very similar to Switzerland, where insurance is private but compulsory with state support (usually at the cantonal (state) level for those who cannot afford the premiums). The Swiss cover everyone and spend far less on healthcare as a percentage of GDP than we do (universal healthcare lowers aggregate healthcare spending for a variety of reasons). Health insurance is not linked to employment (which I find a major fault of our system, one not currently addressed), so if you become sick and disabled, you don't have to scramble for a new plan or apply for state support.
Healthcare can never be freely traded in my opinion anymore than we can all self insure for our homes or our cars (realistically). Yes, if we forewent homeowner's insurance and had no fire or loss over 30 years, we might end up ahead, assuming we had the discipline to invest the premiums we would have spent and invest them wisely, but what about the young law school graduate saddled with debt who has a fire in year 2 out of law school? Insurance works because it exchanges an enormous but unlikely loss for a small but certain loss (the loss of premiums paid into a risk pool). At any time only a minority of people will draw from the risk pool, but we all benefit from knowing it could be us tomorrow. Whether private or public is immaterial (although I have a preference for public health insurance plans since they are far more efficient and do not require redistribution of premiums to CEOs and shareholders - all goes to healthcare). The point is that Dick Cheney's hunting partner could not have bartered his way through his multiple surgeries and rehabilitation no matter how many chickens he owned. And shopping around for the cheapest surgeon might save a few hundred or even thousand dollars but can a "consumer" who has just been shot really have the information to make the call about the best intersection of price and quality? He won't find free surgery. He will be writing a large check in an insurance-free world no matter how much he shops.
My final point is this: are there attorneys who use this model? Last time I checked, the average attorney charges a couple multiples of what the average physician does per hour. The day you guys are willing to barter for providing your professional services is the day I might find those advocating a barter system for physicians credible. ;)
The assertion that "Obamacare, which takes full effect in 2014, will drive up costs and erode quality—and Americans will increasingly seek out alternatives" makes three assumptions that are not supported by the weight of serious analysis. Several key components of the Affordable Care Act (ACA) improve quality - the medical record not least among them - and having uninterrupted healthcare coverage over your lifetime - something far more possible than ever with the ACA - has been shown in study after study to decrease morbidity and mortality especially for chronic conditions (which consume the lion's share of healthcare spending). I am not sure what "alternative" exists to going to a physician or a hospital when you are sick unless the author is implying some Americans might sneak across the border à la Sarah Palin to get free healthcare in Canada, which would sort of defeat the points the author made elsewhere. "Obamacare" as he calls it does not affect the delivery or quality of care as much as it regulates the means by which providers are reimbursed for providing that care and the protections consumers have if they get sick.
I agree in transparency and competition, but this has been provided for decades by Medicare, which publishes all of its rates and provides an effective cap or anchor on doctors who wish to charge more exorbitant rates - the opposite of what the article charges - and managed care, mostly for-profit insurance companies that use Medicare rates as a starting point for fixing reimbursements to doctors and hospitals.
Most doctors complain not about undue interference by the government in the healthcare market but by the extraordinarily intrusive, cumbersome, and micromanaging managed care experiment, one launched at the behest of employers, not patients or providers, to drive down costs a few decades ago. It failed in that objective, but has created a massive overhead that now requires most physicians offices to hire full time people whose only job is negotiating through the labyrinth of for-profit plans (and Medicare and Medicaid) that are out there.
The ACA is not so much regulation of the healthcare marketplace as of the for profit insurers who have been gouging consumers and underpaying providers and hospitals after first dividing them up into take-it-or-leave-it cartels. I believe it was improperly sold as healthcare reform when it is more accurately insurance regulation to protect consumers while also ending free-riding in which the young and healthy could take a risk with all of our money by not paying into the risk pool, hoping they could always get government-mandated healthcare from an emergency room and perhaps disappear when it came time to pay the bill. No longer.
I am not aware of any physician revolt, although a number of older physicians left private practice to retire when managed care came along in the 1990s.
I was a contracted provider with dozens of managed care and insurance plans as well as Medicare and Medicaid. I found the latter two far less intrusive and easier to deal with. I understand this has not been everyone's experience, but the central issue that frustrates physicians is the idiocy of having to call a 1-800 to talk to someone reading from a script who has never met your patient and trying to convince them that the treatment you believe in your medical opinion is the best really is (and that they should pay for it).
A truly free market system could never work for medicine since a tiny minority of patients (and you and I will never know whether we will be in that group tomorrow) generate the vast majority of the costs. Only the super rich could afford the latest treatment for multiple sclerosis or cancer and it is unrealistic and frankly cruel to expect that those who are not wealthy should forgo treatment or die if they do not pass the wallet biopsy. But again, a truly free market, libertarian solution would be that those who are poor when they get sick or injured die, leaving the lucky and the wealthy to survive (and presumably contribute disproportionately to the gene pool). This is not the sort of Darwinian society I think any civilized person wants to live in. I certainly don't which is whatever we can do, however imperfectly, to decrease the 60,000 excess deaths every year in America from lack of health insurance is worth trying.
What President Obama proposed and Congress passed and the Supreme Court validated as constitutional is not perfect - nothing is or will be. It draws its inspiration from Governor Romney's successful plan in Massachusetts (Massachusetts now enjoys close to universal healthcare coverage without the exploding of costs or collapse of private insurance that his opponents predicted). It is very similar to Switzerland, where insurance is private but compulsory with state support (usually at the cantonal (state) level for those who cannot afford the premiums). The Swiss cover everyone and spend far less on healthcare as a percentage of GDP than we do (universal healthcare lowers aggregate healthcare spending for a variety of reasons). Health insurance is not linked to employment (which I find a major fault of our system, one not currently addressed), so if you become sick and disabled, you don't have to scramble for a new plan or apply for state support.
Healthcare can never be freely traded in my opinion anymore than we can all self insure for our homes or our cars (realistically). Yes, if we forewent homeowner's insurance and had no fire or loss over 30 years, we might end up ahead, assuming we had the discipline to invest the premiums we would have spent and invest them wisely, but what about the young law school graduate saddled with debt who has a fire in year 2 out of law school? Insurance works because it exchanges an enormous but unlikely loss for a small but certain loss (the loss of premiums paid into a risk pool). At any time only a minority of people will draw from the risk pool, but we all benefit from knowing it could be us tomorrow. Whether private or public is immaterial (although I have a preference for public health insurance plans since they are far more efficient and do not require redistribution of premiums to CEOs and shareholders - all goes to healthcare). The point is that Dick Cheney's hunting partner could not have bartered his way through his multiple surgeries and rehabilitation no matter how many chickens he owned. And shopping around for the cheapest surgeon might save a few hundred or even thousand dollars but can a "consumer" who has just been shot really have the information to make the call about the best intersection of price and quality? He won't find free surgery. He will be writing a large check in an insurance-free world no matter how much he shops.
My final point is this: are there attorneys who use this model? Last time I checked, the average attorney charges a couple multiples of what the average physician does per hour. The day you guys are willing to barter for providing your professional services is the day I might find those advocating a barter system for physicians credible. ;)
I was accused of being in perpetual "campaign" mode, to which I penned the following response:
I do not know what you mean by "campaign"
mode. Last time I checked, we won all the relevant campaigns I was
involved in. Healthcare is obviously my career and in many ways this
particular area is my passion for professional and moral reasons. I
have seen far too many people forgo treatment or face bankruptcy -
losing everything they ever worked for - simply because they got sick.
The United States is alone in the developed world in this respect. In
fact, only in the United States would advocating for a move - however
imperfect - toward universal healthcare be controversial. These are
arguments other countries had and settled decades ago, most shortly
after World War II, and the right wing of other countries does not
attack the idea of insuring children, using economic theory as a smoke
screen. Instead, they argue about how but never whether or why.
The
article you sent me came from a provocative, far right web site apparently founded
on the principles of a radical atheist who called Catholicism a cult and
believed that compassion toward the least among us was weakness. Ayn
Rand's focus - and the focus of those who follow her - has been on
corporate profitability, not patient treatment or welfare. If you tout
such an article, apparently endorsing it, it seems that this is where
the "campaign mode" begins.
I agree with the last pope
(and presumably) the current pope, that healthcare is not a luxury or a
market commodity to be doled out to the highest bidder, but a universal
right. “Health justice should be among the priorities of governments
and international institutions,” Pope Benedict said.
We are all to work toward a "true distributive justice that guarantees
to all, on the basis of objective needs, adequate care” and that
“Justice requires guaranteed universal access to health care” which is a
“commonly accepted as a fundamental human right.” (As a matter of law,
when we signed the International Declaration of Human Rights, our
government agreed to the principle that access to healthcare is a
universal human right.)
I also agree with Pope John Paul's insistence
that the "intervention of governmental authority" on behalf of the
defenseless as "an elementary principle of sound political organization"
and that "one can only rejoice" that "states set up social welfare
systems to assist families … and pension funds for retirees",
reflections of a sense of national "responsibility" and "solidarity".
As you are aware, I am in sharp disagreement with many of the metaphysical claims made by the Vatican as well as their positions on reproductive health and gynecology, but I strongly agree with some of their positions, including their objection to the American invasion of Iraq (10 years ago yesterday), the death penalty, and its insistence that healthcare is a "fundamental human right."
As you are aware, I am in sharp disagreement with many of the metaphysical claims made by the Vatican as well as their positions on reproductive health and gynecology, but I strongly agree with some of their positions, including their objection to the American invasion of Iraq (10 years ago yesterday), the death penalty, and its insistence that healthcare is a "fundamental human right."
Other Christians such as evangelical progressive Jim Wallis
I deeply respect agree with my position here. There is no real
separation between my professional commitments to my patients, the moral
commitments I have as a citizen to insure that the policies put in
place protect the most vulnerable among us, and the politics which are
the way we get those policies in place in a democratic society.
I
know you are very intelligent and well-schooled. But you are not a
clinician and with all due respect are not in a position to speak for
us. Yes, some physicians are leaving medicine (as they always will) out
of frustration for various factors, but blaming this on a law that has
not been fully implemented is stretching. (It has been my experience
that people make decisions based on a complex cluster of factors of
which they themselves are not always consciously aware and which they
are not always willing to disclose.) The biggest complaints I have
heard are about issues I consider ancillary to the core reform aspects
of the law (reforms that the right has made no serious effort to
counter) such as electronic record requirements (and this, not because
it is a bad idea in theory, but because the proliferation of for profit
"solution providers" has been gouging doctors while delivering an
inferior product, yet another example of where a fractured, for profit
marketplace cannot solve a national issue such as healthcare delivery).
Your criticism of the ACA based on concerns
about whether it will continue to cover more Americans and end some of
the more egregious insurance practices are well-placed, but what
alternative is there at this point? The status quo is untenable and
deeply immoral.
I find it difficult to take of my
morality/political/clinician hat and pretend this issue is not as
pressing and as heartbreaking as it is. To me, after the Iraq war and
income maldistribution (poverty), healthcare access is probably the defining moral
issue of our time and one that I hope we can agree to come together to
fix in reality rather than shooting down the good in favor of the
perfect.
MV
