Priced Out The Economic and Ethical Costs of American Health Care Uwe E. Reinhardt; Reviewed by Christopher M. Hughes, MD

President Lyndon B. Johnson’s Remarks With President Truman at the Signing in Independence of the Medicare Bill July 30, 1965

President Lyndon B. Johnson’s Remarks With President Truman at the Signing in Independence of the Medicare Bill July 30, 1965:

“This is an important hour for the Nation, for those of our citizens who have completed their tour of duty and have moved to the sidelines. These are the days that we are trying to celebrate for them. These people are our prideful responsibility and they are entitled, among other benefits, to the best medical protection available.

“Not one of these, our citizens, should ever be abandoned to the indignity of charity. Charity is indignity when you have to have it. But we don’t want these people to have anything to do with charity and we don’t want them to have any idea of hopeless despair.”
……………..
“Many men can make many proposals. Many men can draft many laws. But few have the piercing and humane eye which can see beyond the words to the people that they touch. Few can see past the speeches and the political battles to the doctor over there that is tending the infirm, and to the hospital that is receiving those in anguish, or feel in their heart painful wrath at the injustice which denies the miracle of healing to the old and to the poor. And fewer still have the courage to stake reputation, and position, and the effort of a lifetime upon such a cause when there are so few that share it.

“But it is just such men who illuminate the life and the history of a nation. And so, President Harry Truman, it is in tribute not to you, but to the America that you represent, that we have come here to pay our love and our respects to you today. For a country can be known by the quality of the men it honors. By praising you, and by carrying forward your dreams, we really reaffirm the greatness of America.

“It was a generation ago that Harry Truman said, and I quote him: “Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection.”

“Well, today, Mr. President, and my fellow Americans, we are taking such action–20 years later.”
……………
“And through this new law, Mr. President, every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”
……………
“I said to Senator Smathers, the whip of the Democrats in the Senate, who worked with us in the Finance Committee on this legislation–I said, the highest traditions of the medical profession are really directed to the ends that we are trying to serve. And it was only yesterday, at the request of some of my friends, I met with the leaders of the American Medical Association to seek their assistance in advancing the cause of one of the greatest professions of all–the medical profession–in helping us to maintain and to improve the health of all Americans.

“And this is not just our tradition–or the tradition of the Democratic Party–or even the tradition of the Nation. It is as old as the day it was first commanded: “Thou shalt open thine hand wide unto thy brother, to thy poor, to thy needy, in thy land.”

“And just think, Mr. President, because of this document–and the long years of struggle which so many have put into creating it–in this town, and a thousand other towns like it, there are men and women in pain who will now find ease. There are those, alone in suffering who will now hear the sound of some approaching footsteps coming to help. There are those fearing the terrible darkness of despairing poverty–despite their long years of labor and expectation–who will now look up to see the light of hope and realization.

“There just can be no satisfaction, nor any act of leadership, that gives greater satisfaction than this.”

Why We Fight

Forgive the World War II reference, but as I write this, I am reminded of the estimate of 45,000 deaths attributable to lack of access to health care, not even counting the countless maimings, wounding, and psychological hurt inflicted on the uninsured and under-insured in America, it seems appropriate. It is not an existential threat to our democracy, but this is, make no mistake, a battle for the soul of our country. As Michael Moore put it in “Sicko,” is America about “we”or “me?”

As physicians, we are obliged to be about “we.” In the Charter on Medical Professionalism, we are enjoined to seek social justice in the delivery of medical care, to be good stewards of our health care resources. Specifically, physicians “should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

We are also our patients fiercest advocates, and that includes those who can afford to see us and those who cannot. We all have our favorite collection of horror stories of the American healthcare system leaving individuals to fend for themselves with no hope of accessing the system until it is too late. Part of my anecdote collection is here, and I always trot it out when I am told a third hand anecdote about how bad health care is in “other countries.” For most Americans, health care is pretty good, but for the uninsured or under-insured, America is a third world country: access to care is completely dependent upon ability to pay.

Remember that, only in America of all advanced nations, have we answered “No!” (or perhaps “Hell, no!” from some) to the question of whether, as Uwe Reinhardt has put it, “As a matter of national policy, and to the extent that a nation’s health system can make it possible, should the child of a poor American family have the same chance of avoiding preventable illness or of being cured from a given illness as does the child of a rich American family?” Medical ethicist Arthur Caplan argues that lack of access to health care is a fundamental road block to equality of opportunity in America, that placing the additional hurdle of untreated illness on a large segment of society is inherently unjust.

It has been pointed out that Americans are singular in the world in our Christian religiosity, but this religiosity is characterized by public policy consistent with ruthless Social Darwinism in many respects, while Europeans are pointedly irreligious, yet have structured their societies to function along a very progressive commitment to social safety nets, social justice and equality of opportunity, as well as a very Teddy-Rooseveltian distrust of great accumulated wealth.

I, as do many, take pride in my religion’s unwavering commitment to Social Justice, Glenn Beck’s disapproval notwithstanding. It is what keeps me a Catholic, and I am sure it is what keeps many in other traditional churches. It is, in fact, fundamental to every religion, Christian, Jewish, Muslim, Hindu, Buddhist and more, and most non-religious philosophical paradigms as well. I am well aware, however, that the most influential book outside of the Bible in America, “Atlas Shrugged,” and its author, vehemently reject all such sentiment as counter-productive nonsense. And this book is widely commended by conservatives who consider themselves deeply religious Christians.

So, this basic ethical commitment to fairness, tending to the sick, the poor, the treating of others as we would wish treated, is pervasive among every population in the world, except for those who follow the Ayn Rand school. I cannot fathom this, as I think the cognitive dissonance of holding both Christianity and Rand dear would be incapacitating, but there it is, and it is rampant in our political and clerical classes.

The argument is frequently made to me that their Christianity only allows for individual charity, not state sponsored programs. That is nice in theory, but as even Mike Huckabee acknowledged:

“If there are a certain number of kids from single-parent homes who aren’t going to school and don’t have health care, you can say that’s not government’s job,” Huckabee told me. “Well, sweet and fine! But you know what? If the kid’s sitting outside the door of the hospital choking with asthma, do I sit there and say, ‘Oh, I’m sorry, I don’t think, philosophically, government should get involved’? I’d much rather the kid get help than I sit around and say I’m so pure in my ideology.”

And, frankly, the milk of human kindness has not flowed freely enough anywhere in the world to provide health care to a population, and I don’t expect it to do so now. I don’t think giving it another century to work itself out is a reasonable strategy.

We fight because of the fundamental unfairness of the system to so many. One in six Americans is uninsured, another one in six under-insured; the deaths, injuries, bankruptcies, anguish and degradation of basic human dignity are why we fight. The America I grew up in was working on being better than this. The Great Society programs of LBJ took us a long way forward, and we have been painfully stuck in place until the passage of the Patient Protection and Affordable Health Care Act in 2010.

PPACA represents our rejection of treating so many of our brothers and sisters and our patients as lesser human beings, less deserving, less worthy of our help. Let’s keep fighting for “We the People,” and fight those only concerned about “me.” Ayn Rand and Glen Beck notwithstanding.

Tea Partiers as Christians – Big Fail

Non-negotiable Core Beliefs from TeaParty.org’s Dale Robertson
(Founder/President) and my comments in italics.

Illegal Aliens are illegal.
Pro-Domestic Employment is indispensable.
Stronger Military is essential.
Gun ownership is sacred.
Government must be downsized.
National Budget must be balanced.
Deficit Spending will end.
Bail-out and Stimulus Plans are illegal.
Reduce Personal Income Taxes a must.
Reduce Business Income Taxes is mandatory.
Intrusive Government Stopped.
English only is required.
Traditional Family Values are encouraged.
Common Sense Constitutional Conservative
Self-Governance is our mode of operation.

….and Yes, we are a Christian Nation!

So, let’s start with the hilarious first, “Yes, we are a Christian Nation!” Well, not hilarious, just sad. Look through all of those and tell me which items would get Jesus all fired up? Nothing about universal access to health care (“when I was sick”), nothing about the unprecedented dependence on Food Stamps, not only to buy food (“when I was hungry”), but for subsistence needs (“when I was naked”), nor anything about our embarrassingly high incarceration rates for Americans (“when I was a prisoner”).

But these “Christians” did include those damn illegal aliens!! The Bible is terribly draconian on aliens:
Exodus 22: Do no wrong to a man from a strange country, and do not be hard on him; for you yourselves were living in a strange country, in the land of Egypt
And Leviticus is even worse: The alien living with you must be treated as one of your native-born. Love him as yourself, for you were aliens in Egypt. I am the LORD your God.
Anyway, may as well go through the rest of his list, briefly.
Pro-domestic employment. OK, we can agree on this one. However, I expect their view is very anti-union, which the Pope, at least (he’s Christian, right?) opposes.

Thus, the encyclical rises strongly to the defense of labor unions, which are still vehemently opposed by large numbers of politically conservative Catholics. The pope notes that unions “have always been encouraged and supported by the Church.

Stronger Military. How about smarter military? How abut defunding “Star Wars,” and preparing for the wars we are fighting and will fight in the future: “wars” against terrorist organizations. Oh, wait, that’s law enforcement and intelligence. Then how about focusing the Pentagon on human resources instead of lining the pockets of Haliburton, Blackwater, Northrup and the rest of the Military industrial complex. Eisenhower was so prescient and wise:

Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed, those who are cold and are not clothed. This world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children. The cost of one modern heavy bomber is this: a modern brick school in more than 30 cities. It is two electric power plants, each serving a town of 60,000 population. It is two fine, fully equipped hospitals. It is some fifty miles of concrete pavement. We pay for a single fighter plane with a half million bushels of wheat. We pay for a single destroyer with new homes that could have housed more than 8,000 people. This is, I repeat, the best way of life to be found on the road the world has been taking. This is not a way of life at all, in any true sense. Under the cloud of threatening war, it is humanity hanging from a cross of iron. … Is there no other way the world may live?

Gun Ownership is sacred. Fine, this is way low on my list of issues to get exorcised about but gun rights are not unlimited. Again, I don’t see this as being near the top of Jesus’ list for important aspects of national governance. Also, why is it that the most heinous crimes always seem to be done with legally purchased guns?
Government must be downsized, National Budget must be balanced, Deficit Spending will end. Reduce Personal Income Taxes a must. Reduce Business Income Taxes is mandatory.
Typical right wing BS. Run up the most massive deficits in the history of the country, first under Reagan and again under Bush, then bitch about it as Democrats try to clean up the mess (Clinton for Reagan, and Obama for Bush). I’ll let you all in on a little secret: Tax cuts never have, never will pay for themselves. “Supply side” economics, wherein lightening the tax burden on the wealthy so that they will supply more products and thus stimulate demand is as S-T-U-P-I-D as it sounds. Besides, investment income is taxed at such low rates already, the wealthiest in America have far lower tax rates than the rest of us! Patriots like Teddy Roosevelt would be out there railing against this injustice.
Bail-out and Stimulus Plans are illegal. Very stupid, poorly thought out, way too generous to Wall Street with not nearly enough regulatory “burden” injected in return for the favors. Did anybody else notice that the same stupid Ayn Rand- Milton Friedman stupidity that led to the S&L Bailout under Reagan-Bush I led Phil Gramm to believe they could do even more damage to the tenuous regulatory environment in place in the 90’s and everything would turn out just swell – for the “Fortunate 400”, and the pretty fortunate 40,000.
Intrusive Government Stopped. This is just so funny because of where I expect they see the government is being too intrusive and where I think it is too intrusive. I am one of those silly Bill of Rights types, and so I reject pretty much every intrusion into the lives of Americans that the chickens in the Bush administration thought were so vital to national security. And yet, I have been paying attention enough to realize that intrusions into the affairs of Corporate America in general, and Wall Street gambling, in particular, are vital to the stability and prosperity of the country.
English only is required. I guess this goes up above with how we treat each other and the strangers among us. I think Jesus, who spoke Aramaic, while living under Roman rule, might have a touch of sympathy for the non-English speaking.
Traditional Family Values are encouraged. This is a little tricky, in that Jesus and Christian tradition is so clearly liberal in matters of economics, social justice, immigration, etc., and yet Jesus was pretty darn tough on sexual issues. So, I’ll make an offer to the Tea Partiers: You make Jesus’ rule against divorce into law, help us with the big social justice issues like universal health care, reforming prisons, strengthening workers rights, and more, and then we’ll go after gay marriage. Deal?
Common Sense Constitutional Conservative Self-Governance is our mode of operation. I really don’t know what the heck this means, but I did find it amusing that there is another organization called “We the People” (From the Constitution – get it?) that is an ANTI-government, Tea Party type organization.
But I do think this last bit is critical: I think progressives view government as “us” (as in “We the People”) and conservatives view government – when they are not in power – as them. Even when my party was not in power, I still believed government was us, but that we had failed our country by allowing the Siths to win so many elections.
So, in summary, these people who constantly complain that we are not acting as a Christian Nation, seem to completely miss the point of Christianity, the social justice mission, the generosity of heart, the embracing of the weak, the poor, the hungry the sick, the loving of those NOT like us :

If you love those who love you, what credit is that to you? Even ‘sinners’ love those who love them. And if you do good to those who are good to you, what credit is that to you? Even ‘sinners’ do that. (Luke 6)

Cheers,
———
Update just to add this from
“…How terrible it will be for those who make unfair laws, and those who write laws that make life hard for people. They are not fair to the poor, and they rob my people of their rights. They allow people to steal from widows and to take from orphans what really belongs to them. (Is 10:1-2 NCV)”

Exodus 22:21 “Do not mistreat an alien or oppress him, for you were aliens in Egypt.

Bible in Basic English

Do no wrong to a man from a strange country, and do not be hard on him; for you yourselves were living in a strange country, in the land of Egypt.

And Leviticus 19:34

‘The stranger who resides with you shall be to you as the native among you, and you shall love him as yourself, for you were aliens in the land of Egypt; I am the LORD your God.

Just throwing this in for all of those who get the vapors when the subject of providing health care for illegal aliens comes up.

First, we should do it because it is the right thing to do, but on a more pragmatic level, just as with all of the other uninsured in the country, it costs a lot less to take care of them in an ongoing, preventive manner rather than during crises in our EDs and ICUs.

I’m going to post a few more here for my own future reference…

Matthew 5:43-48, Love for Enemies

“You have heard that it was said, ‘Love your neighbor and hate your enemy.’ But I tell you: Love your enemies and pray for those who persecute you, that you may be sons of your Father in heaven. He causes his sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous. If you love those who love you, what reward will you get? Are not even the tax collectors doing that? And if you greet only your brothers, what are you doing more than others? Do not even pagans do that? Be perfect, therefore, as your heavenly Father is perfect.

And the version from Luke 6:27-36

“But I tell you who hear me: Love your enemies, do good to those who hate you, bless those who curse you, pray for those who mistreat you. If someone strikes you on one cheek, turn to him the other also. If someone takes your cloak, do not stop him from taking your tunic. Give to everyone who asks you, and if anyone takes what belongs to you, do not demand it back. Do to others as you would have them do to you.
“If you love those who love you, what credit is that to you? Even ‘sinners’ love those who love them. And if you do good to those who are good to you, what credit is that to you? Even ‘sinners’ do that. And if you lend to those from whom you expect repayment, what credit is that to you? Even ‘sinners’ lend to ‘sinners,’ expecting to be repaid in full. But love your enemies, do good to them, and lend to them without expecting to get anything back. Then your reward will be great, and you will be sons of the Most High, because he is kind to the ungrateful and wicked. Be merciful, just as your Father is merciful.

And here is a very nice summary for the Biblical case for social justice from the United Church of Christ website, with this nice bit:

God, however, requires both charity and justice, and justice can often be achieved only through the mechanism of government. The view that nations, as well as individuals, will be judged by the way they treat the weakest and most vulnerable among them is deeply embedded in the witness of prophets such as Isaiah, who said:
How terrible it will be for those who make unfair laws, and those who write laws that make life hard for people. They are not fair to the poor, and they rob my people of their rights. They allow people to steal from widows and to take from orphans what really belongs to them. (Isaiah 10:1-2)

Jesus criticized and disobeyed laws when they got in the way of helping people. He healed people on the sabbath, for example, even though all work was prohibited on the sabbath. Religion and government were intermixed, so Jesus was challenging the law of the land. The threat Jesus posed to both religious and political authorities led to his crucifixion.

Government is not the only or always the best instrument to deal with injustice. But it is one of the institutions created by God part of God’s providence for the welfare of people. Because we live in a democracy, a nation with a government of the people,” we have a special privilege and responsibility to use the power of our citizenship to promote public justice and reduce hunger.