Tuesday, August 18, 2009

Bad Medicine

Don't be fooled by the title...my thoughts on health care in the U.S. can't be easily pigeon-holed into a convenient slot...and in truth, most people's thoughts on the subject are the same...hard to classify, but that's not the impression we draw from the current news storm that drenches us daily with platitudes and misinformation.

I'll admit plainly that I oppose most of what is being proposed on Capitol Hill, not because I oppose the concept of health care reform, but because the choices being laid out before Congress today are largely toothless, hideously expensive and will likely only help a sparse few persons at a cost that most cannot afford.

To be brutally honest, if I thought that we were being presented with a choice that would make a large scale difference in the quality of care that America's working poor receive, I would support the effort and applaud it loudly, but like most people who fall into the category of independant voters, I feel a wave of suspicion creep over me when I hear the actual reform plans being discussed.

And let me be specific...I do not fear 'death panels', which are a genuinely pathetic twisting of words to misrepresent an actually useful initiative proposed by a Republican, transforming it into a scare tactic used by the lowest intellects in the GOP and believed by the lowest intellects everywhere else. Neither do I fear seeing private insurance forbidden to those who can afford it. This is another fiction that makes the GOP look foolish and inadequate as guardians of common sense and fiscal sanity. Given that the insurance lobbies are piling dollars into influencing both sides of the debate, it seems extremely unlikely that any bill that emerges will do anything more harmful than offering them a state sponsored opportunity to enroll millions of new customers who can look forward to the abuse the rest of already endure when trying to get a claim paid.

This is where my real distrust lies. Based on the partisan wrangling that passes for debate now, it's easy to draw the impression that anything useful, thoughtful or helpful will almost certainly be snuffed out of existence long before it could reach the Oval Office. What we'll likely be left with is a patchwork quilt woven from pure pork, transforming billions of tax dollars into a minimal service boondoggle that leaves millions underinsured. This isn't that different from what we have today...but it will cost oh so much more.

This in no way defends our current system, which amounts to a philosophy of "pay now or go die". For all the screams for the fringe that health care reform will result in poorer quality care for a majority of Americans, the irony is in their silence regarding the inequities of the system we have now. Medical debts are a staggering burden, since even fairly common treatments cost more here than in other developed nations. It is disgusting to watch relatives and friends pour hours of labor into getting a claim paid, stressed to the limit of their ability to cope WHILE dealing with illness as well. Our 'system' of health care is broken...badly...and just because the solutions being offered are ineffective half-measures, it doesn't mean that we don't have a problem.

Our spiraling costs for health care may have their roots in the dawn of nuisance-based malpractice suits, and while litigation and insurance to protect against it are costly, they are not the end all and be all of expenses. Stripping the right to sue for legitimate redress of grievances from all but the wealthiest of clients is not the answer, because wasteful litigation is a matter better handled by careful scrutiny of proposed cases, not the elimination of the right to sue. On this matter, left leaning lobbies (not surprisingly featuring many lawyers) favor suing the pants off of anyone who even looks like they might deserve it, and those lobbied by industry favor being made immune to any scrutiny or accountability for malfeasance; both wrong, both ultimately horrible extremes, both unworthy of being taken seriously. This is exactly why I wind up finding myself in the middle...and like it there.

More influential in the advance of high costs for health care was the switch from non-profit service mode to for-profit service mode. The fundamental philosophy behind administration of a hospital has shifted radically in just a few decades. We are living (and dying) with the effects of that change. No matter what people may claim, for-profit health care corporations unfailingly find themselves in the position of answering to shareholders...not patients. Sagging profits and share prices eventually add up to leadership necks on the chopping block and fresh new faces at the helm. To avert this, every half decent executive will labor to shear away costs and bolster share value. "Commitment to Quality Care" is a great phrase...but phrases mean nothing. Profit means a lot more than any string of syllables ever will. The patient has become the customer, and the customer is really just a source of income. With medicine there are always other customers, and every one of them is expendable. This is not a recipe for great care.

For decades, employer sponsored insurance has been the gold standard, but as costs rise and numbers of retirees grow, each requiring longer, more expensive care than ever before, even basic coverage has become incredibly burdensome for business, small and large alike. Just a few generations ago it wasn't an unreasonable expectation to demand solid, comprehensive insurance in exchange for a comparatively small contribution, organized and managed through one's employer. Unfortunately, margins are leaner these days, contributions have grown larger and larger and the coverage that smaller business can afford to offer is very nearly not worth the cost for the average lower wage employee.

Wages have also taken their toll on the concept of health care. Specialists are costly, and medicine is no longer practiced as a general body of knowledge, but rather as a collection of niche markets, each commanding a higher wage per hour than in days gone by. This isn't to say that demanding work that requires extensive education and training doesn't deserve higher pay, but when the luxury and elective specialists earn noticeably more than men and women who save lives daily, we've moved toward a system that prioritizes all the wrong things. To reduce staffing costs, nurses, physician's assistants, LPN's, CNA's and MA's are becoming overtaxed substitutes expected to work outside their purview in exchange for lower wages. This is one of the root causes of strikes that plague corporate hospitals today, and the solution is more staff, but that inevitably drives prices up and profits down. Where is the answer? Honestly, I don't have one either, but acknowledging that health care is subject to unique needs that aren't easily answered in a purely for-profit system is a good start.

Now we come to drug costs, which are a racket that easily puts running numbers to shame. Speaking for those who have seen production cost vs. sale price comparisons, most businesses only WISH they could mark up their product like that and get away with it! Can you imagine a drop-forged hammer, made (theoretically) for a dollar, and selling for $30, $300, or even $3,000? And what are we getting for these exorbitant prices? A list of side effects that take up so much space that flyers have to be attached to every bottle! Prescription drug deaths, intentional and unintentional, are becoming a rising problem, both in terms of lost lives and in terms of malpractice and class action suits that wouldn't even be necessary if drugs weren't so poorly regulated and heavily prescribed. Again, lobbies from either side of the political spectrum, industrial or public safety-minded, overstep with answers too extreme for easy compromise, and we remain at an impasse, unable to navigate our way toward safe and affordable care.

That brings us to the middlemen who help cushion the cost of these high priced curatives...the insurers and co-ops and HMO's who make up the industry that adds yet another layer of staff and associated costs to an already mind-frying situation. One shining truth exists: you get what you pay for, and this basic truth is seen here like nowhere else. You can get coverage cheaply in this country, right now, even without a health care reform package passed by Congress. There's only one catch...that coverage will SUCK beyond anyone's ability to adequately describe. It's not entirely unlike calling a newspaper 'coverage' when you're outdoors, naked...in January.

Insurance doesn't exist to help. It exists to collect money by offering to spread the costs around to a wide pool of people who all contribute at one rate or another. If you don't mind paying the exorbitant rates that aren't too troublesome for high income brackets, you can enjoy knowing that you won't often run into situations where large checks have to be doled out to cover the remaining balance. If you aren't from one of those higher income brackets...well, you might very well be better off keeping those dollars for a rainy day rather than spending them on a plan that might cover the comparatively inexpensive doctor visit or prescription, but almost none of the tests, specialists or follow ups...which is where the bills begin piling up. This is at the root of the working uninsured. That money can't be wasted on a boondoggle that barely covers the start of serious health care, so people do without and allow their personal health to deteriorate until care is required and becomes much more complicated and expensive.

Like many other industries, insurers jumped on the Wall Street bandwagon and owe their allegiance not to customers, but to board members and share holders. This isn't a statement about right or wrong...it's just an honest fact about doing large scale business. Profits must always increase if possible. Costs must always be driven lower. When the margin is in danger, cut, cut, cut to the bone. This isn't an environment that fosters a sense of responsibility for providing comprehensive coverage. It just isn't. Not because it's "evil" or "good", but because good or evil are irrelevant measurements compared to "profitable" or "not profitable".

To sum up, these are the questions that we aren't asking loudly enough: can ANY purely for-profit system ever deliver the goods to a reasonable majority of Americans, and if it can, what can we do to ensure its profitability and long term survival? Are employers genuinely no longer able to keep up with the rising costs? Is the institutional concept of the insurance company even trustworthy as a component of a system for delivering health care? Can cost reductions be enacted that could make our existing system viable again, or would that only stall for time, pushing the question back to become another generation's struggle? Is a national health care program even viable while we retain so many elements of our existing system? Would greater transparency in the political process allow us a window into how and where the misinformation and confusing numbers come

These are great questions, but the answers won't be found while waving guns outside of town halls. They won't be found by buying into panic-inducing rhetoric from the people on the receiving end of lobby and think tank dollars or by listening to shock jocks peddling anxiety and fear for a quick buck. If answers are ever going to be found, they will be found by careful examination of each issue, by weighing observable facts and by discussing them rationally. There is room for passion in this debate, but there is no room for hysteria or deliberate fraud. If you want answers, they are born of thought and reason, not through howled recriminations and shaking fists. It isn't as fun as shrieking incoherently and muddying the waters with references to totalitarians of bygone eras, but it's a hell of a lot more effective.

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