Healthcare In America

#1. Do you think that the United States should develop a health care system that delivers the best possible care to the most possible people for the best possible price? Or not? The American health care system currently spends over 16% of our gross domestic product on the health care industry, the most in the industrialized world. I wrote “health care industry” because far less than 16% is actually spent on health care. A lot goes to profits of insurers, hospitals, and drug companies. Our average life expectancy is 21st out of 34 industrialized countries. We do not lead the world in any measure of health outcomes when considering the entire population. It is simply wrong to assert, as Mitch McConnell, Republican leader of the Senate, did recently, that we have the best health care system in the world.

#2. In spite of substandard outcomes, the American health care system seems oriented toward preserving a “free market,”capitalistic system that maximizes profits for insurance companies, hospitals, health care professionals, and drug companies. In such a system actual delivery of health care is accounted as a “health care loss.” (Our health insurance companies really do this.) Here the idea is to let market forces regulate the health care industry. What emerges from such a system is what we have now: a system where those who can afford it receive excellent care and many of the poor are left out almost entirely. Market forces produce the healthiest company, not necessarily the healthiest customers. Government programs such as Medicare and Medicaid care for some patients, but not optimally. In reality we actually have three or four health care systems in the USA: people can pay out of pocket for services when they are rendered; people can buy health insurance by themselves or through their employers who often subsidize the individuals’ purchases; or indigent people can be cared for by government-run programs. A fourth system is a combination of both government and private programs such as when people become 65, retire, become eligible for Medicare, and retain a private health insurance supplement either through their former company or purchased by themselves.

The two systems described above are often represented as either/or. As noted, our current system has a strong element of #2. The Affordable Care Act begins to approach #1 while retaining the private insurance model. The President signed the ACA. The Supreme Court found it constitutional. Republicans are apoplectic. The public as a whole is just about evenly divided between support and opposition to the ACA. One should also note that the Kaiser poll this week found that only 59% of the public even knew that the Supreme Court had ruled on the law. Lots of polls have shown that the public doesn’t really understand the ACA very well and, given that it has been debated for two years now, apparently has not made much of an effort to become better informed.

Our current system functions poorly as a health care system for the population as a whole. The ACA begins to remedy this. For those of us who have good insurance, we receive health care that is as good or better than anywhere else in the world. I have an MD; I have been a Professor of Pathology in a medical school; I have Medicare supplemented by Government Employees Blue Cross, Blue Shield, and my family and I have had immediate access to the University of California, San Diego, hospitals and clinics system. I know the physicians personally and have been able to choose doctors for myself and my family for my whole professional career and during my retirement. I am really lucky. But over 30 million Americans have no health care insurance at all. They, like the general public, don’t know a damn thing about medicine. They can tell a physician whom they like but they really can’t evaluate when they get good versus substandard care. When the uninsured get sick they show up to emergency rooms, usually sicker than they would have been if they had good insurance and could see a doctor sooner. Those of us who have insurance pay higher rates to cover the Hippocratic and legal obligations of Emergency Departments around the country to care for these patients. The ACA begins to deal with this problem by requiring everyone who can afford it to purchase health insurance, giving supplements to those who can’t afford to purchase a policy and assessing penalties to those who do not buy one. It has additional provisions such as forbidding health care insurance companies from excluding patients with pre-existing conditions, charging women higher rates, and cancelling policies when patients become ill. There are many other provisions that make sure that health insurance companies must deliver some health care to their customers rather than just concentrate on collecting premiums and making profits.

In spite of what Mitch McConnell recently said, our outcomes for the population as a whole are way down the list of health care systems worldwide. Why do we accept this? Is Capitalism so holy that it must be accepted on faith or is it an economic system with strengths and weaknesses like all other systems invented by human beings? First we must acknowledge that Capitalism was not delivered to man by God on Mount Sinai. Parenthetically, neither were the Ten Commandments. Capitalism also is not enshrined in the Constitution. It is an economic system invented by human beings that has evolved in our society and others over time. Does it always offer the best solutions for all of society’s needs?
Is Socialism, another economic system developed by human beings, evil? When, God forbid, socialized systems work better than Capitalism for some of society’s problems (as they do in health care for the whole population) must we reject these approaches because they threaten Capitalism? Is the good health of our whole society less important than the protection of the capitalist model in all areas of society, even to the point of lying as Mitch McConnell does? Remaining true to the model, several Republican governors have announced that they will not implement the expansion of Medicaid to cover more of the uninsured in their states as mandated by the ACA even though the Federal Government will pay ALL of the costs for the first three years, then decrease gradually to 90% by 2020. This strikes me as starting the Civil War all over again. According to history as taught in the former Confederacy, the Civil War (the War of Northern Aggression) was fought over States’ Rights. However the States’ Right that was in question was the right to enslave Negroes. At the end of the War 600,000 lives were spent. After Reconstruction, committed now to segregation if not slavery, the South went on to establish the Jim Crow society which took another 90 years to take down. Are the Republican governors who have announced that they won’t expand Medicaid in their states willing to sacrifice the health of many of their citizens, who are not surprisingly black, to uphold their philosophical views? They might be because Mitch McConnell said on a Sunday morning interview on Fox TV on July 1 that the care of 30 million uninsured people was not the issue, it was the process by which the ACA was enacted. He steadfastly avoided presenting any plan to take care of these uninsured people. Looking back in history, this objection sounds a lot like the objections made to Social Security under Roosevelt, integration of schools under Eisenhower, and the Civil Rights and Voting Rights bills under Johnson. When President Johnson signed the Voting Rights bill he famously remarked, “I’ve lost the South for a generation.” It’s lasted longer than that. Of course, one also needs to be cognizant of McConnell’s statement at the beginning of the Obama presidency that the primary goal of Republicans would be to deny President Obama a second term. Mitch has remained faithful to his pledge.

Other Republican leaders and spokesmen have lent support to the idea that they don’t really care too much about the problem of 30 million Americans without health insurance. In an interview on MSNBC on June 29 the Attorney General of Texas was asked why he opposed the ACA and what he was planning to do about health care in Texas where about 25% of the citizens do not have health insurance. This is the highest rate in the United States. He said that his opposition to the ACA was not about health care but was about the technical aspects of the law. It was a big government program. Rick Perry, the Governor has said it’s about being free. Neither the AG or Governor ever answered the question about caring for Texans lacking health insurance. One might recall that no Republican except Mitt Romney has ever actually proposed taking care of the uninsured and Romney now disavows his accomplishment when Governor of Massachusetts. Annoyingly to him, the law he signed seems to be working pretty well. But the law he championed offends the conservative base he needs to win the election so, true to his style, he now opposes it. The previously quoted Mitch McConnell said that what we’re not going to do is institute a European- style health care system here in the United States. I wonder which of the several systems in Europe that outperform ours he finds objectionable. John Boehner, Speaker of the House, has been similarly uninformative about Republican plans to take care of uninsured people. In summary, it is fair to say that the Republican leadership has no legislative plan to take care of those who have no insurance now. They’ve never proposed a plan to do so. Even under the heat of TV lights and persistent reporters they still propose no plan other than to repeal “Obamacare.” Since the individual mandate to purchase insurance was originally a conservative proposal, one has to seriously consider that current Republican opposition to the ACA is mostly because it represents a legislative victory for the President.

To be fair, one also needs to consider the problems of growing entitlements and that the ACA will put government bureaucrats in charge of something that has previously been in the “care” of private sector, insurance industry bureaucrats. Both of these eventualities have problems. Insurance company bureaucrats make decisions biased toward maximizing company profits. They work very hard to delay and deny payment of claims. They find reasons to exclude potential customers from coverage both before and after they buy policies. They have no interest in providing health care to those who can’t pay for it. Businesses are established to make a profit. To a health insurance company, delivery of health care is part of its overhead. The result has been 30 million uninsured Americans. Governments, except dictatorships, are obviously not established to make a profit. The preamble to the Constitution begins, “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common Defence, promote the general Welfare,…..” Profit is not mentioned anywhere in the Constitution. Nor is God. Promoting the general welfare is. We the People establish our Rights and Privileges. But government bureaucrats administering welfare programs get tied up in forms and tend over time to invent more and more forms, trying to make a rule for every eventuality. Their natural tendency is to make a regulation for everything and this produces delays. But they are not motivated to increase profits for their employer. I worked in the VA system for over thirty years. Though some of the bureaucrats were slow and plodding, sometimes maddeningly so, almost all of them really were concerned that all beneficiaries would receive every aspect of care to which they were entitled by law. I would also point out that the VA system, for all of its many flaws, has excellent outcomes when you compare its patient base to similar patients treated in the private sector.

Why don’t some people care about the health and welfare of their fellow man? Judeo Christian precepts teach that taking care of your neighbor is a positive good. And I would ask, where did Jesus ever say to care for your neighbor but, God forbid, don’t let the government do it? Most of those who oppose the ACA trumpet their Christianity except the Libertarians who are really not the driving force here. Libertarians support an “every man for himself” philosophy. So, is the Republican opposition to the ACA driven by Calvinism, tribalism, flat out racism, selfishness, or what?

The “Birther” movement concerning President Obama may be viewed as somewhat sanitized racism. “Birthers” charge that he is not one of us, not because he has a dark skin which is officially not a permitted objection, but, in spite of dispositive evidence to the contrary, that he was not born in the USA and therefore he is not a real American entitled to be President. Calvinism encompasses both tribalism and selfishness. It holds, among other things, that the Elect of God are revealed by their station on Earth. One is therefore justified in ignoring the poor and downtrodden among us because they are going to Hell anyway. One other criticism I have just heard is that rights are given by God and that the ACA is a right given by the government. The Declaration of Independence does say, “We hold these Truths to be self-evident, that all Men are created equal, that they are endowed by their Creator with certain inalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness…” The capital letters, as in the Constitution, are an 18th century convention of capitalizing nouns similar to German today. A couple of points are worth making here. What Jefferson wrote was not entirely true even in his time. The Constitution, written over a decade later, accounted slaves as only 3/5 of a person and they were not given the right to vote. Nor were women or American Indians. Eighty years later, the Pursuit of Happiness certainly did not accrue as an inalienable right to the plains Indians. Ask Crazy Horse and Sitting Bull. And, in Jefferson’s time, there was a discussion about whether or not the third right granted by the Creator should be Property or the Pursuit of Happiness. John Locke had proposed Property but only the wealthy tended to have property. The Electoral College was established precisely so that the final decision on who would be elected President would be left to these wealthier, wiser, white, Christian men, not the great unwashed. So the Creator did not speak unambiguously about the Rights He granted.

The idea that the ACA is objectionable because it is a government-granted, not God-granted right should be viewed in the light of an observation by Mark Twain. He said, “Travel is fatal to prejudice, bigotry, and narrow-mindedness.” A disturbingly high percentage of Members of Congress do not have passports. Travel to foreign countries will teach anyone immediately that all “rights” are, in fact, granted by governments and change from border to border. And, try to find Life, Liberty, and the Pursuit of Happiness enunciated as rights in the Bible. Rights also change over time. Women were not granted the right to vote in national elections until the XIXth Amendment was ratified in 1920. And, perhaps surprisingly, the XVth Amendment granted the right to vote regardless of race, but not gender, in 1870. Black men were allowed to vote before white women. Rights evolve as do concepts of what is good for society as a whole, the general Welfare. This includes ideas about health care. Remember that the Constitution was written before physicians recognized the value of washing their hands.

In light of all this, can a good spin be put on the Republican opposition to the ACA or is it simply misinformed, partisan politics?