Wednesday, July 22, 2009

Integrative Thoughts on Health Care Reform

Debate on health care reform is raging along predictable party lines. You are probably waiting for me to express the slightest leaning to the left or right to quit reading.

Such polarization of ideas is only hurting dialogue and paralyzing our country into inaction. While it is true that a free society needs to have opposing views to reach a consensus or compromise, I am afraid that the divisions among us are fostering resentments, misinformation and outright hatred that go beyond a healthy exchange of ideas.

So that you relax, I have to tell you I am an incorrigible fence-straddler, forever attempting to mix polarizing ideas to reach a middle ground that is often a lonely place that most shun as “lukewarm” from their entrenched extreme views.

I advocate a heath care system much like France’s or Germany’s: a mixture of what Democrats and Republicans want, that is, a public health system and a private system that cover everyone while satisfying economic and ideological realities.

Those afraid of socialized medicine, those who quote the horrors of “rationing” allegedly seen in Canada and England would be reassured that their capitalistic ideas would be preserved. People who want more than what the government would offer, which would be rationed health care, may supplement their coverage out of their own pockets through private insurance companies. We already do that with public schools, the post office, transportation, etc.

But, maintaining that a straight capitalistic solution, without government intervention is enough ignores the results of the Massachusetts’s experience: their costs have gone up 33% trying to cover people the old-fashioned way.

My interest in economics has led me to Adam Smith’s “Wealth of Nations.” His brilliant writings were a mix of Capitalism and Social Welfare, a fact you may study yourself. So, any proponents of Darwinian Capitalism may need to temper their passion for the “invisible hand’s” infallibility. Smith maintained that said hand needs to be tempered by government regulation. Check it out.

Besides, fixing our health care system is also an economic imperative; health care is now 16% of our economy and a significant drag on competition in those industries where foreign workers get nationalized health care. Ignoring these economic realities because of fear of European Socialism is not a realistic or constructive way to deal with these economic realities.

You may want to read “Going Dutch,” an excellent article in the New York Times magazine May 3rd 2009 (no doubt I just lost those readers who feel the Times is a communist paper.) The author spent some time in Amsterdam, where he realized that the Dutch health care system is an integral part of their society, even a perfect reflection of their way of thinking. After the initial shock that any isolationist American is likely to suffer, he warmed to the system and to European Capitalism. His ideas are worth studying. Please, take to time to do so. Essentially, the Dutch never lost what we initially had in our own country: benevolent health care administered by churches who gave freely, gladly, efficiently and rejoicing in the opportunity to serve our fellowman. The Dutch never turned health care into a business like we did. Can we honestly say we got a better system after we did away with benevolent care?

Some feel that there is nothing wrong with the quality of health care in America; they even maintain that health care in the USA is the best there is in the world. I wonder how they can dismiss the statistics that show the USA dead last in the developed world in practically all categories of health care, including longevity and infant mortality.

Just about all the industrialized countries that rank at the top of health care delivery have National systems of health care; and just about all of them spend half the money we do while providing better services. Our main problem seems to be the waste inherent in our system. About 33% of our health care dollar goes toward unnecessary services and/or those that have no proven value, except in the minds of those who perceive health care as a commodity to sell just to increase profits. A significant portion of health care services has never been proven to be of any benefit at all (J. Business Week May 29th, 2006.) Yet, we continue to do procedures like back surgeries and many other invasive interventions that have been roundly questioned.

It seems naïve to believe that the rotten culture of Wall Street never affected our Corporate Health Care industry. In my opinion, “profits at any cost” has long been the motto of those in charge of said industry. While “the business of America is business” will always be deeply woven in our culture, this does not mean that we cannot do business with a little more compassion.

Unfortunately, anyone trying to point out these facts is said to be some kind of socialist out of touch with the reality that socialism was defeated in the cold war. This argument is often followed by another mantra: Canadians and Brits hate their rationing socialized systems. While there are widely publicized horror stories in those countries, it turns out that 73% of Canadians and Brits are happy with their system, compared to 56% of Americans. Still, the French and German systems are better; they are the systems I feel we need to emulate.

I am afraid that “rationing” is the dirty word that public health proponents need to be more open about; that is exactly what a public health plan would be and we need to be upfront about it. But, before condemning rationing, let me ask you a question: would you spend $10,000 in the twilight of your life if it meant an extra 6 months of life? How would you feel if the prize tag was now $100,000? Or $1 million? How about 10 million? Surely you will concede there is an amount that will not be worth spending for those extra few months of life.

Public Health Care systems do indeed ration some services, especially at the end of life when about 1/3 of money is spend (at least Medicare does.) If we had a dual system (public and private) the wealthy could still buy those 6 months of life on their own, while those who choose the Public alternative would have to content themselves with a more streamlined, leaner system; but one that would provide essential, basic services to all citizens.

Mature societies realize that rationing is necessary in a world of finite resources. Mature societies don’t need to hide this fact. On the contrary, they are open about it because they view death as an integral part of living, without the adolescent angst that is so common in materialistic, younger societies. A frank discussion with a wise and caring doctor in the waning months of our lives has shown to significantly lower the utilization of unnecessary, expensive and often heroic interventions that leave everyone dissatisfied, but those who make money on the procedures and interventions foisted on the dying fearfully.

Mature societies are well aware of the opium of the people: “Bread and Circus.” Give any society plenty of cheap, subsidized food or “Bread,” (think of junk/fast food) and plenty of cheap, mindless entertainment, “Circus,” (think of reality TV, tabloids, etc) and it is easy to see why any discussion on end-of-life care and rationing becomes a tool to plant fear in the hearts of “health care consumers.”

Many of the very people who stand to benefit the most from a public health care system buy into the rhetoric that seeks to perpetuate the status quo. They often support and repeat the corporate agenda that seeks to protect their corporate interests, not the interests of the people. Bread and Circus is a well proven Roman principle. In my opinion we would do better to focus on another Roman principle: “Salus Populi Suprema Lex,” or “The Health of the People is the Supreme Law of the Land,” not the protection of our financial or insurance corporations, as important as they will always will be. But, make no mistake: their honor, greatness and power come from serving people, not the other way around.

These corporations are afraid that they may not be able to compete with a public health care system. I don’t agree with this argument. First of all, Medicare has not driven them out of business. They will always count with the support of all those who are afraid of rationing and afraid of anything related to government. Those who cannot accept the fact that corporate insurance companies have a 15-20% overhead cost, compared to 5% by Medicare will always do business with the corporate status quo. They will always have the support of those who continue to profit from the mess we have now.

The future of health care lies in maintaining people healthy with simple, cheap interventions like teaching them nutrition, healthy and simple lifestyles that are sustainable; in other words, prevention. This cannot be done by those who focus on maintaining disease and selling costly interventions that seldom bring the expected relief they are marketed for. Chronic health care delivery can only be provided by those who understand that health is something we teach patients to maintain through healthy lifestyles, instead of fear-driven selling pitches to get health from a bottle of pills or a surgical suite.

I dream that someday the incentives and reimbursement mechanisms will favor those doctors and providers who toil endlessly and with poor recognition or reward while trying to change toxic lifestyles one on one in their busy practices They do so while fighting the so-called-paragons of service, the insurance companies, for every little bill; reams of paper work are mindlessly filled trying to justify meager minutes and pennies spent trying to provide health care services in the trenches, while those who perform expensive procedures costing thousands of dollars have no trouble “doing business” with insurance companies.

I dream of a time when medical students will have a strong economical incentive to choose primary care, instead of high spending specialties. Today 20% of them choose primary care; we need 80% of them to make that choice. They will not, until it makes economic sense to do so. We cannot expect all of them to choose primary care out of a “calling to serve.” It would be nice. But consider your own motivation in choosing your career before ignoring economic realities in their expensive education that leaves them saddled with astronomical student loans.

Only a health care system that dares question the corporate culture that has gotten us where we are today can have a shot at healing our malaise. But, we cannot do this unless we retain the “business” side of health care as a real choice for those who want top of the line, un-rationed health care to be paid out of their own pockets, especially when they have worked hard to earn higher incomes.