Tuesday, March 07, 2006

Coming Healthcare Crisis

As a healthcare chaplain, I deal quite a bit with bioethics, ethics at the end of life, and ethics regarding healthcare of the poor. For those who don't know it yet, there is a huge crisis coming in the healthcare of our country. Let me quickly explain:

Healthcare costs are rising. Insurance rates are rising. This means that fewer companies are offering their employees health insurance, and the ones who are doing so, are charging more money from the employees. This means that fewer people can afford health insurance. Without insurance, people cannot pay for healthcare. Nobody pays for a surgery by writing a check.

What happens to uninsured people who need medical care? They go to the emergency department of their local hospital. Hospitals are required by law to treat people who come to the emergency department, regardless of their ability to pay. How can a hospital afford to do this? By jacking up the price for all the people who are able to pay -- those with insurance. So, insurance prices go up, meaning fewer people can pay for insurance. So those people go to the emergency room, driving prices even higher. By the way, the emergency room is the most expensive way to provide healthcare -- by far.

Let me add some ethical considerations into the equation. The United States is the only industrialized country that has uninsured people. Our infant mortality rates are higher and our life expectancy is lower than average for industrialized countries. Yet, we spend far more than any other country on healthcare. We are spending more than 15% of our gross domestic product on healthcare. The country that spends the next highest is Switzerland at 10%. So, we're paying more, and getting much less than any other country.

Universal healthcare has its problems. Certainly the plan offered by Clinton was very problematic, but there are other ways of looking at universal healthcare. There is no way to provide the best healthcare to everybody, everywhere. We must discriminate who gets healthcare. The two ways to discriminate in the world are by time and by money. In the USA, we've decided to discriminate by money. If you have money, you get healthcare. Every other nation in the world has decided to discriminate by time. If you want to see a doctor, it is free, but you might have to wait a few weeks or months. The ethical question is this -- Is healthcare a commodity like sofa or computer or car? Or is healthcare a right, like clean water and police protection? I believe healthcare should come to all people. It is a right-to-life issue. In the USA, we disagree.

As it turns out, the USA is sicker than other countries -- perhaps injustice has its consquences.

Where do we go from here? I like the recent legislation in Maine. The state requires all companies of a certain size to provide affordable healthcare for all employees and their families, otherwise huge tax penalties. The tax penalties will then go to help pay for the healthcare of those company's employees. Basically, if you have a job, you and your family have healthcare. It's not universal healthcare, but it's getting closer, and is viable in a political atmosphere of supreme devotion to individualistic capitalism. We'll see how the debate continues.

These are pretty random thoughts. It occurs to me that I might think through the structure of these thoughts better and write an essay about it.


Anonymous Anonymous said...

Let's also remember the demographic aspect of the insurance crisis. The Baby Boomers, the largest demographic segment in the country, are getting old and thus require more medical treatment. Theoretically, the younger, healthier generations (X & Y) would cover the cost by paying more into the system than they use in benefits. However, since the younger generations are smaller, the ratio of net payers to net benefiters is shrinking, which means premiums have to go up.

> As it turns out, the USA is sicker than other countries -- perhaps injustice has its consquences.

Now, before you go proclaiming that the healthcare crisis is divine judgement for not having socialized healthcare, let's consider other possible points:

1) I'm not sure how all the demographics work out, but I suspect that the baby boom may have been a predominately American phenomenon (or at least not as pronounced elsewhere), which means that the U.S. may have a greater percentage of its population in an age bracket that faces high risk of illness. Or maybe not. With birth rates dropping in Europe, they have a greying population as well.

2) Americans, on average, have chosen to live unhealthy lifestyles--as exemplified by our obesity rate. I would suggest that this is contributing greatly to any disparity in rates of illness.

> If you want to see a doctor, it is free, but you might have to wait a few weeks or months.

First, it's not really free. Under socialized healthcare it's paid for by taxes, so as healthcare costs continue to rise that means increasing taxes, which has a host of implications that are hard to predict.

Second, while time-discrimination may be more equitable in a sense, I'm not sure I would consider it ethical. Forcing people to wait "weeks or months" for treatment isn't exactly merciful.

> The ethical question is this -- Is healthcare a commodity like sofa or computer or car? Or is healthcare a right, like clean water and police protection? I believe healthcare should come to all people. It is a right-to-life issue. In the USA, we disagree.

Let me paraphrase this argument:

1. If healthcare is a commodity (i.e. optional), then it can be paid for by private insurance.
2. If healthcare is a right, then the government must supply it exclusively.
3. Healthcare is a matter of life or death, so therefore it is a right.
4. Therefore, healthcare should be socialized.
5. BTW, since the USA does not have socialized healthcare, they are obviously evil.

I would suggest that #2 is a false premise, which creates a false dichotomy.

Finally, while I'm being "devil's advocate", let me point out a possible downside to the Maine legislation. The legislation forces business to incur a cost--either through paying employee healthcare premiums or paying tax penalties. That means that they'll likely have to find other costs to cut in order to stay in business. That, in turn, may mean cutting salaries, laying off employees, or even going out of business entirely. Now, reduced salaries may be tolerable as long as the employees receive affordable healthcare, but the other options mean that there will be an increase in the uninsured and the unemployed.

I sympathize with your desire for all people to receive affordable healthcare, but I think socialized healthcare can only substitute one crisis for another.

- Steve

7:24 PM, March 07, 2006  
Blogger W Sofield said...

Steve, you make some very excellent points. Thanks so much for responding with such helpful critique and clarification.

First, I do not think socialized healthcare is free from problems. Of course, not. But the problems are more equally spread to everyone. Society bares the burden, rather than the poor, and that makes more sense to me, biblically, theologically, and ethically. You're right that making somebody wait for months for healthcare is not merciful, but neither is allowing people to die of cancer without the possibiltiy of being seen by a physician (except Emergency care, which is woefully inadequate for most major diseases). If I had to pick between A)Healthcare for some, but fast if you got it, and B)Healthcare for all, but wait your turn, I'll pick B everytime.

Secondly, your points about Maine's healthcare legislation hurting businesses is well taken, but can be countered by saying that people will be healthier and better able to make money for their companies. My company, Baptist Health South Florida is the only non-profit healthcare organization in the black in South Florida. It is a leader in the nation's healthcare industry in a variety of areas, and with the new emphasis on evidence-based medicine from the federal government, it is about to be thrust into the spotlight on the national scene. One reason for it's success, I think, is its amazing dedication to the health of its employees. I have a personal traininer, a nutritionist, a gym, all sorts of health incentives and programs. If I smoked, they would pay completely to help me stop smoking. Weight Watchers is free. Family counseling (short term) is free. Our health insurance premiums are very low, and people here work very hard. BHSF also gives its employees lots of vacation time to rest. Investment in health is good business, long-term (though not short-term).

Thirdly, as to my statement, "injustice has its consqences" I was referring to natural consequences, not necessarily divine consquences. Institutional racism (another injustice) has the consqence of discounting a great wealth of creative and intellectual resources (i.e. black people). In the same way, our choice of a healthcare system may be (partly) responsible for our further bad choices in diet and exercise, which results in our poor health.

Fourth, when I say the USA is sicker, I mean all sorts of indicators that take into account the population. For example, we have higher infant morality rates than other industrialized countries. I'm not talking about the number of people in the hospital. I think it's pretty clear that we're fatter and less active than other countries, which is not an issue of generational size. It's an indication, I think, that our system is not working. In fact, this is my main point. If we are so unhealthy (and we are), let's not work so hard to defend our system, let's learn from others who are spending a fraction of what we spend on healthcare and have longer life expectancies.

I'd be very interested to keep this discussion going. I think this is a discussion that needs to be happening for me, and for millions of people across the country. We aren't talking about it, and I think that's a big source of the problem. Who's next? What do you think?

8:57 AM, March 08, 2006  
Blogger jonponder said...

A friend of mine is running an alternative insurance company called Samaritan Ministries. It's based on the idea of christian community (and the rediculous-ness of the mainstream insurance companies). Everyone who agrees to membership pays an annual fee (which goes to running the company) and an additional monthly fee in place of an insurance fee. When a member has a medical need, they tell the company (it's called Samaritan Ministries) and they publish it in a newsletter, and they direct other members of their network to direct their monthly payment directly to the recipient. So, they essentially get a stack of checks in the mail whenever they have a medical need. They dont feel this is annoying, but encouraging, because usually the checks include encouraging notes, prayers, etc. Samaritan also has a team of people whose primary job it is to haggle with the hospitals to lower the actual bills of the members in need.
I heard about this and thought that it sounded rickety, and dangerous, but i was encouraged that it actually does work better for the hospitals in most case. Insurance companies have their own teams of sharks who argue down hospital bills, and even then, they dont promise to pay all the bills... what they actually pay is more like a 'settlement'.
My friend told me that in some cases, the hospitals are excited about the idea, because it means they will actually get paid instead of having to deal with the insurance companies.
This also excludes the possiblity for embezzlement and misuse of funds by the company, since no real money (aside from yearly subscription fees) actually change hands within the company.

I've also heard of other models of healthcare like community doctors- General practicioners who work on a community-negotiated salary and whose sole job is to meet the needs of the group of people (generally, 100-200 well connected, affluent people) in a church community. This is cheaper, since doctors dont have to deal with the politics of a hospital, and is more beneficial to people who get more direct attention. When a greater medical need arises, the community also bonds together to meet a member's costs. Usually this model results in lower prices for all, and is often offset by the doctor agreeing to take on the needs of a number of low-income families people who have less-than adequate healthcare as part of his duties.

There are a whole lot of new approaches which are starting to emerge in healthcare, and i hope one of them will work and catch on instead of having to resort to socialized medicine. But it seems that they all rely on community.

Perhaps now economics are teaching us of the importance of community.

1:24 PM, March 08, 2006  
Blogger W Sofield said...

great comments. Wow, thanks so much. I've heard of the Samaritan Ministries. I'm curious about it, and somewhat skeptical, too -- for the same reasons as you. I guess I'd like to see more numbers. I like the idea in theory, for sure.

I think communities working together for healthcare is a form of socialized medicine. I think we all ought to be thinking about ways to provide healthcare to the whole society, rather than thinking about how I can make sure that I get healthcare. Because if you are healthy, that will help me to be healthy, too. You've given some great examples, thanks.

1:41 PM, March 08, 2006  
Blogger jonponder said...

if you'd like, i can ask my friend (he's the VP of Samaritan) if i can pass his email along to you to ask questions, etc. He's pretty laid back, and i'm sure i could get him talking about it, but i dont know if he wants me farming his name out.

2:25 PM, March 08, 2006  
Blogger W Sofield said...

Actually, jonponder, I'm pretty set with health insurance for myself personally. But I'm more interested in the theory. I'm interested as a thinker, as a theologian, as a Christian, but not as a consumer, yet. I don't have any specific questions, per se. I'd be interested in a discussion of how it works, and where the weak spots are. When and why do customers get angry? When and why do people withdraw from the service wishing they had never started. When and why do people love the service? Who are the clients and why? These kinds of things. Not interested in a sales pitch right now, but maybe later. If your friend has info or resources like this, then, yes, I'd love to learn.

3:10 PM, March 08, 2006  
Blogger jonponder said...

Oh yeah, that's what i meant. My friend is a big geek about the 'theory' of it all. In fact, he's in the process of writing a book about "anti-insurance" that is in it's final draft stage. I'll let you know what it's called when it is released.

4:25 PM, March 08, 2006  
Blogger jonponder said...

well, here is the blog of a good friend of mine who also works at samaritan. He's also a fellow geek/theorist.


he's kind of a pastor's kid, homeschooled, goth, neo-puritan, and role-playing gamer all in one... definitely an interesting guy.

4:34 PM, March 08, 2006  

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