[culture] The politics of American healthcare

Having a bit of a discussion on Facebook with my friend Bryan Schmidt. We don’t agree on much politically, but we manage to get along just fine, and remain happily civil when we get into political interchanges. My response to his remarks from overnight was such that I’ve decided to promote it to a blog post.

Jay, I have a friend in England who hs been denied surgery by their public healthcare several times for surgery the govt claims is non-essential but his doctor says is. In fact more than one doctor because he got multiple opinions hoping to influence the govt decision.

Unlimited government healthcare can be great stuff.

As the case may be, though I’d hardly describe the UK system as “unlimited” anything. I’ll point out also that no system is perfect, but the UK has the virtue of nearly universal coverage without significant compromise in social outcomes measured by infant mortality, average life expectancy, etc., where in many cases their system provides superior outcomes to the American system.

Also, though you did not raise this point as such, I’d like to highlight the fact that many Americans don’t understand the difference between “single payer” and “single provider” systems. This is largely because the GOP, the AMA and the insurance industry have spent the years since WWII throwing up a deliberate cloud of confusion about “socialized medicine” in order to short-circuit any reasonable discussion of these concepts.

The UK has a single provider system. Canada has a single payer system. In the US, the VA medical system is an example of single provider. Medicare is an example of single payer. Oddly, most people in both those systems like them quite a bit, and would be appalled to discover they are victims of socialized medicine.

The issue is not privatization, it’s capitalism. HMOs and drug companies and our culture of greed have created a health care environment where the rich get the best and everyone else settles.

I don’t think we disagree much here. Healthcare is a market segment where the profit motive is fundamentally at odds with the nominal mission, which creates a permanent tension.

The government can’t run health care any better than any other of its failed, mismanaged programs, espc. In this culture of greed.

Now you’re falling into empty conservative rhetoric. Ronald Reagan’s greatest, most successful lie was “Government is the problem.” Government is no more automatically prone to failure than the private sector is automatically prone to success. The private sector fails all the time. Look at the statistics on the number of private sector mergers and acquisitions that meet their stated financial and business goals. It’s abysmally low. Likewise, look at the statistics on how many major IT projects are cancelled or truncated. If the market were the magic conservatives like to think it is, companies would never go out of business.

Similarly, plenty of government programs work very well. Emergency services, for example. Virtually every community in the United States has a publicly-operated fire department, which generally enjoy sufficient funding and little political opposition. And fire departments tend to poll very well. How well would private sector fire departments function?

When you make a baseline assumption that everything government does will be a mismanaged failure, you’ll find plenty of evidence for that due to observational bias.

For whatever it’s worth, I don’t presumptively assume that government healthcare is the answer. As it happens, Medicare is by far the most efficient healthcare funder in this country, measuring by overhead. That is to say, Medicare spends a larger percentage of every dollar on healthcare than any private sector insurance provider. It also polls very well in customer satisfaction. Hardly a failed, mismanaged program.

What government’s proper role here is in regulation. That’s how our system is established, right there in the Constitution, Article I, Section 8, Clause 3 — Congress is given the responsibility “To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes”.

The conservative panacea of industry self-regulation is a laughable myth. This has been demonstrated over and over again through our history, from the Gilded Age to Enron to the Wall Street derivatives nonsense of recent years. For-profit companies are by design and law intended to maximize both revenue and profit. Our current system evaluates this on a quarterly basis, with the “long view” being a year or two. There are explicit structural incentives for private health insurance providers to limit payouts, and reduce or eliminate coverage for expensive insureds. Like, say, me.

So whether government enters the coverage business directly (say, by expanding Medicare) or simply regulates the behavior of insurance providers, it must have a role.

Also, for more on my response to Ronald Reagan’s anti-government rhetoric, see this post of mine.

If we want to change health care, we need to redefine it as about “Care” and “Health,” not a family’s egos. When the Schiavos can waste hundreds of thousands of dollars and resources keeping alive their dead daughter, money and resources better spent on someone with the hope of a quality of life, while other people die of diseases and injuries we long ago learned how to easily treat, the system is broken not from conservatism but from its heart. It’s not about what it’s supposed to be about, but the soft, bleeding heart Americans can’t give up, can’t let people go, can’t allow our loved ones to die. Fine if those poor people do, but not our families.

The Schiavo case is a very odd example to cite in making a conservative argument, given the specifics of it. Her life was prolonged (at great expense, as you point out) against the wishes of her husband through the effort of significant conservative legal and political muscle, given that her parents had rallied the Right-to-Life movement. That was pretty much the opposite of bleeding heart liberalism, forcing government intervention into a private family matter and seeking to remove the decision from the hands of her husband, where it legally and morally rested. Conservative action prolonged Terri Schiavo’s life, extended the expense for years, and made a political and media circus out of the tragedy of her death.

Speaking as someone who’s been at death’s door more than once in the past two and a half years (I came within about two minutes of death at the time of my original ER admission that led to the primary cancer diagnosis), I’d strongly prefer my loved ones not let go and allow me to die. I don’t think it’s a simple as people being willing to let go, and I don’t think that’s a “bleeding heart” issue.

It’s a sick, corrupting philosophy which government control doesn’t change. I’ve been around the health industry all my life. My dad’s a doctor, mom’s a nurse, dad trained paramedics and techs, uncle developed ultrasound tech and died of cancer for his effort — it’s a bigger problem than “limited government.” It’s an attitude.

Again, I don’t think the American dysfunction around end-of-life issues is an inherently political issue, though it is certainly subject to politicization. Palin’s mendacious “death panels” meme is a very good example of conservatives explicitly undermining efforts to make end-of-life care reasonable, for example. The dysfunction is much deeper in our national psyche than that.

9 thoughts on “[culture] The politics of American healthcare

  1. pelican says:

    Wow- huge crush on this post. Incisive, eloquent, and covering a lot of ground. Thanks.

  2. Pam Adams says:

    My (admittedly limited) understanding of Great Britain’s healthcare system is that the person would be free to hire a private doctor to treat him. He is in no worse position than the person who can’t access our healthcare system due to a lack of insurance. In fact, he’s better off than the uninsured American because he is eligible to be treated for all other health issues except for this one where he and the government disagree.

  3. Stevie says:

    Pam

    Your understanding is correct.

    Jay

    Props to you for such a well-written and analytical response on a red-hot button issue.

    We have something vaguely similar going on with the concept of assisted suicide, which, according to those who oppose it, will result in all disabled people being rounded up and slaughtered.

    Admittedly I have an interest; I am disabled but I have the unshakeable conviction that I do not have the moral right to insist on others suffering dreadfully because it might benefit me when it comes to being rounded up for the slaughter.

    That unshakeable conviction also reflects the fact that the vast majority of human beings are not-mass murderers, and that they will not suddenly become mass murderers just because we changed the law…

    1. Cora says:

      The problem with assisted suicide IMO is that in countries where it is legal, e.g. the Netherlands, there have been cases where there people were given assisted suicide for conditions that were not terminal (e.g. chronic depression) and even a handful of instances where there was no consent, e.g. children and highly religious people, who object to suicide on principle (But they would suffer, so doctors did it anyway). That’s not a mass slaughter of disabled and terminally ill people by any measure, but even one case of a person killed against his or her explicit will is one too many.

      I also fear that people with extremely serious conditions would be pressured into choosing assisted suicide, because their life is deemed unendurably awful (and expensive to maintain) by someone else’s judgement. I know a man who has been suffering from multiple sclerosis for many decades and is by now completely paralyzed and has lost sensation everywhere except in his face, e.g. a life that a lot of people would not consider worth living. Yet this man eagerly wants to live and he is the only one who can make that decision.

      If assisted suicide were to be legalized, it would have to be extremely strictly controlled, even stricter than in the Netherlands, where theoretically the controls are pretty strong (only terminal patients, two doctors must independently confirm the diagnosis, wish to die must be explicitly and repeatedly stated etc…) but in practice transgressions have happened. And the decision must be made by the patient and the patient alone.

  4. Cora says:

    I’m not British and my one experience with the NHS was not so great. However, regardless of what Americans of a certain political persuasion may believe, the NHS does not let people die, if there is hope of saving them, and it does not deny people crucial surgery. If your condition is unpleasant but not life-threatening (e.g. hip replacements and the like), you may end up on a waiting list, but you will get treatment.

    The German system is basically what would be called a “single payer” system in the US – I actually prefer “single provider”, because IMO a single provider system would minimize administration costs and other overheads. The German system is definitely not perfect, particularly with regards to “everyday medicine”, e.g. you have to pay extra for certain tests, for plastic rather than metal fillings (and the metal fillings are known to be toxic), for injections that reduce swelling after tooth extractions, etc… But if you have a serious or life-threatening condition or if there is suspicion of a serious condition, you get any treatment or test or surgery you need. I even know cases where e.g. breast reductions or liposuction, i.e. basically cosmetic procedures, were paid by insurance, when they were deemed medically necessary. I got my tooth braces fully paid by my parents’ insurance. Contraceptives are never covered, unfortunately, and abortions only in the rarest of circumstances. So in short, it could be better, but it doesn’t kill people, at least not due to neglect and costcutting. And neither in Germany nor in the UK would someone be forced to work through chemotherapy like you had to.

    So no, people don’t die due to “socialist medicine” whatever that may mean. Besides, genuinely socialist countries generally had/have excellent health care systems.

    The Schiavo case is a different matter altogether, because as far as I know, the parents and their supporters paid for keeping her alive and not an insurance company. They weren’t wasting any resources apart from their own and that’s their good right. And IMO as long as you’re willing to pay for it and find a doctor/hospital to do it, you can have any medical procedure you want, even if it won’t do any good. I also disagree with you that the husband automatically had a moral right to decide the woman’s fate that trumped that of her parents. Terry Schiavo was her parents’ daughter a lot longer than she was married to her husband, so why should he decide? She was his wife, not his property.

    As for the government automatically being worse at handling things than the private sector, that’s a big load of crap. Take a look at the oil spill in the Gulf. The US spends an enormous amount of money on the navy, coast guard, military forces. All of whom stand around and wring their hands, waiting for BP to do something. There is insufficient equipment, there is no response plan, nothing. Whereas most European countries have government agencies with trained personnel which handle oil spills and other marine disasters and all of them would have handled the Gulf spill a lot better than the “stand around, look worried and do nothing” attitude in the US.

    1. Jay says:

      Just a quick note, I did not intend to imply that Terri Schiavo was her husband’s property. Under American law and custom, the spouse is next of kin, with sole and full responsibility in these situations absent a prior clear statement of intent by the incapacitated person (for example, via healthcare power of attorney), or court intervention. That’s simply the way it works over here. Obviously whether it should work that way is open to discussion, but that’s a separate question.

  5. Carmelo Rafala says:

    I’d like to call bullshit on your friend Bryan.
    I live in the UK, and NEVER has critical surgery been denied that I am aware of. NEVER.

    Never has the gov. interfered with decisions on any major or minor surgery. If a particular type of surgery is not covered by the universal health system, then the doctors direct you to a private doctor.

    But then, this seldom happens, as almost all surgery is available on the NHS.

    I had surgery last year. No government official sat in the room. It was me and my doctor. We decided to do the surgery, and we did it. End of story.

    I bloody HATE Americans who think they know what the hell they are talking about. Just because they have a so-called “friend” in the UK who may have had an issue, said American thinks they sudden know it all about the UK NHS.

    Let me tell you, paying a few pennies a year so that I can get what I need to save my life is better than dying in the US because the insurance provider–who takes masses of money from you– said “We don’t pay for that”. Well, what are you paying for? What price can you put on life?

    The UK is not perfect. Sure. No place is.

    And I have experience living the US, being born in CT. So you are free in the US are you? My insurance company at the time told me I had to choose from THEIR list of doctors, and I could not have my family doc. Then they proceeded to tell me what treatment I could have and not have.

    There are no gov men telling you what you can have in the UK, but in the US you have office men who are not medical professionals telling you what you can have. Sounds crazy? It is.

    Enjoy your so-called medical freedom.

    Sorry for the rant, Jay. I couldn’t let this go by without weighing in.

  6. Kathryn says:

    I have a few questions.

    “In the US, the VA medical system is an example of single provider. Medicare is an example of single payer. Oddly, most people in both those systems like them quite a bit, and would be appalled to discover they are victims of socialized medicine.”

    Oh, my. People in the VA system like it quite a bit? Then why are there so many appalling stories of horrible care? People using Medicare like it quite a bit? Then why are more and more doctors refusing to treat Medicare patients? Will Medicare patients be left to quacks and the bottom 10% of medical school doctors? I’m not saying that this is right or fair, but this seems to be what is happening.

    “If the market were the magic conservatives like to think it is, companies would never go out of business.”

    Ah, NO. The market works WHEN companies, bad companies, go out of business. Bad decision makers lose their jobs; bad marketing departments are disbanded; bad products are recalled and are sold no more. Which is not to say that there should not be government regulations of companies. Bad companies should be dissolved, by the government and the media, if the market is too slow or too unaware to do it quickly.

    “Similarly, plenty of government programs work very well. Emergency services, for example. Virtually every community in the United States has a publicly-operated fire department, which generally enjoy sufficient funding and little political opposition.”

    You need to read more about the billions of dollars in unfunded government pensions. The firefighters in Clark County, Nevada, refused to amend their pension scheme or give up their generous automatic raises, even after they were faced with a severe reduction in force. Locally, people suffering from 15% unemployment are outraged by this intransigence by the fire department. Counties and cities will be forced to cut their staffing levels and response time will lower. As in most inefficient government schemes (education), the private sector will jump in to create pay solutions to cover normal government jobs. If only inefficient government operations were allowed to fail and be replaced, then less people would be alarmed at government incompetence.

    I believe there is definitely a place for government. I love libraries and roads and elections. I just wish that more of the decisions were made on the local level with local control and funding.

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