Single Payer Health Care – The Moral Healthcare Blog

We’re not ready for Single Payer Healthcare (because we disagree on basic morality)*

“A common incantation during debates on health reform… is ‘that we all want the same thing; we merely disagree on how best to get there.’ That is rubbish.”

– Uwe Reinhardt

In a 2011 Republican Presidential debate, candidate Ron Paul was asked a pointed question about what to do with someone who needed expensive healthcare but did not have insurance: “Are you saying that society should just let him die?” Some in the crowd jeered “Yeah!” Paul indicated that as a physician, he did not find it acceptable to do so and offered charitable care from “churches” based on his experience of practicing medicine in the in the early 1960s, before Medicare and Medicaid, eliciting applause from the crowd.

Last year, I attended the Keystone Progress Conference in Pittsburgh, PA for a few hours. I attended a panel discussion of progressive candidates who lost their elections in deep red districts. One of the things I heard was straight out of this Ron Paul universe – all four of these candidates said they were surprised that so many of the conservative voters were afraid, of having others “get over on them.” That these others would get free healthcare and they were going to have to pay for it, for “those people” to be freeloaders that they would have to subsidize, etc.

In 2013, Dan Munro, writing for Forbes magazine, on the anniversary of Martin Luther King, Jr.’s “I have a Dream” speech, pointed to several myths so common to conservative thought about America, in particular our backwards interpretation of the “bootstraps” fable:

“the myth that literally anyone – through hard work and determination – can rise out of any poverty and become rich and prosperous. We salute, praise and deify everyone who does. But there’s a dark side to this myth. Anyone who doesn’t isn’t working hard enough – or doesn’t have enough determination. In effect, they’re a loser – and nobody wants to pay for the healthcare of those losers.”

Veronica Combs paraphrased it as ”There is a real meanness in the conversation about who should have healthcare, an implication that people who need help somehow don’t deserve it, or that they are taking advantage of ‘the rest of us.’”

All of this, of course, is not really news. Making a moral case for universal health care in any form is denounced as socialism or “not the job of government,” or as Ron Paul said, that we must “assume responsibility for ourselves.” The American Medical Association has famously opposed movement towards universal healthcare, from the Truman Administration to the passage of Medicare and Medicaid and through opposition to major parts of the Affordable Care Act.

Martin Luther King, Jr., noted that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” Many have railed about the inhumanity of Americans towards each other regarding healthcare, and the late Professor Uwe Reinhardt has asked for decades, “To what extent should the better off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in healthcare?” Americans, capable of unbridled generosity in helping individuals pay for a transplant or some other services when the individual in question is deserving, are ruthlessly coldhearted when compassion is requested for those they deem undeserving, as the Tea Party crowd showed us in 2011.

Reinhardt was clearly stung by the idea that his adopted countrymen (he was German born US citizen) rejected this solidarity, in contrast to every other nation’s resounding “yes” to the question. He also pointed out that the way Americans avoid the moral question that faces us is to play the game framed by the introductory quote: we pretend that the problem is that we disagree on policy, writ small and large, and find ourselves down rabbit holes about the reimbursement for an anesthesiologist for a fifteen minute unit of time with or without a nurse anesthetist!

Every other nation has started with the moral and ethical question over their values as a society and worked towards a solution to provide healthcare to all their people, “deserving” or not. As another professor noted:

“The last time I taught in the Semester at Sea program, I found it necessary to interpret for our students the rich “social capital” that runs through the Northern European societies we were visiting. What they knew and had read in their guide books was that not many people are in church on Sunday morning, especially compared to the florid religiosity of the United States. So their working assumption was that Americans take religion seriously and Europeans don’t. The new thought that amazed them was that the unchurched Europeans live in social democracies deeply saturated with historic Christian values, while the much-churched Americans celebrate a society characterized by a ruthless social Darwinism that the God of the Bible, Old and New Testament alike, denounces.”

What is preventing us from having the basic moral argument about our values regarding health care? The answer is three-fold. The first is a strong puritanical streak in American culture that prompts many of us to divide our fellow citizens into camps of deserving and undeserving people. The second is a now unfathomably large industry that has much to lose should efficiency and order find their way into the American Healthcare system. The third is our human cognitive biases that lead us to sloppily assume political and moral positions that will take years of work to overcome, using cognitive psychology to reframe the debate and convince people that doing the right thing is the right thing to do — for everyone.

Lessons from Vermont’s Health Care Reform — NEJM

Policymakers and stakeholders in other states can learn some lessons from Vermont regarding ACA reform. First, engaging stakeholders while providing transparency at each stage of reform builds support for transition efforts. Second, the adage “work smarter, not harder” applies to the enormous task of implementing health care reforms: a central board can coordinate all implementation efforts, reduce redundancy and bureaucracy, and improve transparency. Third, the development of a health insurance exchange presents opportunities for state-specific health care innovation. And finally, instead of resisting the inevitable federal reforms in the name of federalism, states may capitalize on federal financing opportunities to build new state health programs and realize cost savings.

Lessons from Vermont’s Health Care Reform — NEJM

T.R. Reid: Can We Really Fix U.S. Health Care?

From the Commonwealth Club of California Podcast is here.

Friday, September 18, 2009, 12:34:52 PM

T.R. Reid, Correspondent, The Washington Post; Commentator, National Public Radio; Author, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

For 100 years, U.S. presidents have unsuccessfully strived to provide universal health coverage. When LBJ created Medicare in 1965, he thought the program would gradually be extended – to people over 60, then 55, then 45, etc., so that everybody would have government health insurance by 2000. Decades later, the Clinton plan failed. George W. Bush created Medicare Part D. Barack Obama says we have the best chance ever this year to fix our health-care system. Is he right? Reid weighs in and reveals what we can learn from health-care models across the globe.

This program was recorded in front of a live audience at The Commonwealth Club in San Francisco on September 14, 2009.

A very good listen. Excellent tid bits about health promotion in Britain, insights into the minds of Canadians and more!

Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform | Video Cafe

Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform Video Cafe:

“Isn’t it amazing what a little clarity to your argument can bring you isn’t it? Like arguing for real reform instead of the mushy middle. Anthony Weiner did a fantastic job on Morning Joe today and he actually left Scar speechless for a moment when trying to get him to answer just what the insurance industry does to benefit anyone. Of course Scarborough turned that around into ‘You’re arguing for a government takeover of health care’ shortly afterwards, but he never could give any decent defense of why this country needs the insurance industry.”

From Crooks and Liars, what a great video! An articulate advocate for Single Payer.

I’ll ask the question again: What value do private insurers add to health care?

The painful side effects of Obama’s healthcare reform – Los Angeles Times

The painful side effects of Obama’s healthcare reform – Los Angeles Times:

“Now, I’m well aware that having 47 million people who can’t afford medical care is a genuine social problem — although many of those millions are illegal immigrants, people between jobs and young folks who choose to go insurance-bare. I’m also aware that I can’t necessarily have everything I want, whether it’s a dozen pairs of Prada boots or a pacemaker at age 99. I know that Medicare is on the greased rails to a train wreck, and not just because of spiraling costs but because doctors are fleeing the system because they’re sick of below-cost reimbursements and crushing paperwork. There are ways to solve some of these problems: healthcare tax breaks, malpractice reform that would lower the cost of practicing medicine, efforts to make it easier to get cheap, high-deductible catastrophic coverage, steps to encourage fee-for-service arrangements of the kind that most people have with their dentists.

“In short, as someone who’s not getting any younger, I’d like to be the one who makes the ‘difficult decision’ as to whether I can afford — and thus really want — that hip replacement in my extreme old age. Sorry, President Obama, but I don’t want ‘society’– that is, government mucky-mucks — determining that I’ve got to go sit on an ice floe just because I’m old and kind of ugly, no matter how many fancy degrees in medicine or bioethics they might have.”

Nothing like folksy wisdom for understanding and dealing with the complexities of health care reform and modern bioethics. The usual right wing disinformation and misdirection are especially tiresome. So, to the rebuttal:

First pillar of fear mongering on health care reform: rationing. Be afraid, be very afraid. Ignore the rationing (by income and economic class) that’s already going on. Ignore rationing by private health insurers. Ignore spiraling costs that will soon have all but the top tiers of income earners on shoe-string insurance plans. Forget all that, just worry about the potential for rationing.

The point of Ms. Allen’s piece is that health care will be rationed by using arbitrary clinical parameters to deny care based solely upon costs. Or, she also warns, that some procedures will be denied based upon scientific, non-arbitrary clinical parameters, specifically along the lines of England’s National Institute for Health and Clinical Excellence which publishes guidelines and does medical and economic analyses of medical treatments to determine whether they are worth it to individuals and to society as a whole. I’m sure Ms. Allen finds it infuriating that some all other societies consider how utilization of finite resources affects everyone, not just the well off.

Interesting thing, that concept of “allocating scarce resources.” It is actually one of the centerpieces of medical professionalism developed by the American Board of Internal Medicine, the American College of Physicians and the European Federation of Internal Medicine and adopted by the American Medical Association and many other physician organizations. The Charter states, “The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.”

This brings up fear mongering pillar two, always frame the debate as a choice between our current “system” or, the systems of either Canada or England, two countries that, while providing universal health care, because of their parsimony, have performed in international health care outcomes research almost as badly as does the United States! It seems genuinely ludicrous (but convenient for generating insecurity among the under-informed) to set as the benchmark for improving our health care system two countries who only do a bit better than we do. I have yet to see an opinion piece from a conservative decrying the inferior care and long wait times in France or Germany, the top performing countries in the world. That’s because they provide excellent care to all of their citizens, have no longer waiting times than our own, have much more satisfied physicians and patients and do it all at a sizeable discount to ours.

Another classic tactic is blaming the poor, the unhealthy, the “other.” On one hand, Ms. Allen laments the imposition of the 47 million uninsured onto our system, and forecasts that it will lead to unacceptable waiting times for those of us already “in.” A few paragraphs later she notes her understanding of the seriousness of the issue of the uninsured, but then posits that many of these 47 million don’t really need or deserve health care insurance as they are illegal immigrants or between jobs, etc. My brother was nearly bankrupted by being “between jobs” and having an illness in his family.

Back to our story. Ms. Allen makes a troubling conflation by muddling together limiting the amount we spend on health care in the last months of life with limiting health care to the elderly. There is a HUGE difference.

Ms. Allen cites the example of the hip fracture treatment President Obama’s grandmother received before her death and the pacemaker placed into the 99 year old mother of a town hall audience member as cautionary tales, indicating the “government run” healthcare would allow these patients to simply die because some intellectual, academic physicians in their ivory towers will give the thumbs down sign and demand their euthanasia. How sad that the public’s opinion of physicians and medical professionalism has deteriorated so badly that this is their expectation. Or, if not their expectation, but their cynical gambit that others will think this rings true.

Here’s the difference: Obama’s grandmother was terminally ill with cancer. The questions surrounding her surgery boiled down to whether it would improve her comfort in her last months and whether the surgery would ultimately shorten her life. As it turns out, it appears to have done both, making this a difficult case to slice down the middle as black and white. That’s why decisions like this cause ethical dilemmas: there are pros and cons to the decisions. There are sometimes non-operative decisions involving immobilization, aggressive pain management and other palliative measures that avoid the pain Mr. Obama was rightly concerned about. And sometimes these measures, especially in extremely frail elderly patients, are the right measures, because they avoid the very high mortality associated with surgery and other aggressive measures in this population.

The medical team, had they made the decision not to operate, would not have been bureaucrats determined to painfully end the life of an elderly cancer patient, but a compassionate team of professionals, balancing the patient’s quality of life in her last months (pain, hospitalization, removal from family and home, etc.), with her wishes and goals – perhaps to see her grandson elected President! When we strive to provide excellent end-of-life care, we balance all of these issues and we counsel our patients and their families as best we can because it is the right thing to do, not because it saves money. We would do it if it cost more: that is apparently the decision arrived at in this case. The calculation was made, as it should always be, based on the goals of the patient and family, not on a corporate balance sheet and potential executive bonus.

The second case, of the 99 year old requiring a pacemaker, is actually not much of an ethical problem. I agree with President Obama that these decisions should not be made based on “spirit,” but they certainly can be made based upon clinical guidelines and the individual patient’s health status. Regardless of this woman’s spirit, if she was a frail 99 year old with advanced chronic heart or lung disease, or with advanced dementia and a feeding tube for nourishment, one would be hard pressed to justify placing an expensive pacemaker or defibrillator into her, but a healthy 99 year old is another matter. It is important to note that Medicare did not deny either of these patients care, as a private insurer may have.

The other inappropriate conflation is the issue of limiting the amount we spend with limiting the amount we spend on treatments without proven benefits or with benefits so limited as to make them frivolous in most senses. If we presume that any guideline that determines a treatment not useful to be rationing, we will be in a world of economic hurt. This is actually the point of Comparative Effectiveness Research (CER), to try to figure out what we do that is costly but adds no value to patient care on one extreme, and figuring out what is relatively inexpensive and saves lives on the other.

Her assessment of the inherent inferiority of screening mammograms every three years compared to annually demonstrates precisely the need for CER: The automatic assumption that more testing means better outcomes. This is actually one of the bigger problems with American medicine, the automatic assumption that doing something, and not just something, but the newest latest most expensive something, is always best. Should the 99 year old patient get the latest greatest pacemaker? Maybe, but having some CER to help us make intelligent judgments should be lauded, not reflexively ridiculed by the anti-intelligentsia.

Update: a link to this item on my dailykos diary and a lively discussion.

In Poll, Wide Support for Government-Run Health – NYTimes.com

In Poll, Wide Support for Government-Run Health – NYTimes.com:

“Across a number of questions, the poll detected substantial support for a greater government role in health care, a position generally identified with the Democratic Party. When asked which party was more likely to improve health care, only 18 percent of respondents said the Republicans, compared with 57 percent who picked the Democrats. Even one of four Republicans said the Democrats would do better.”

Complete Polling Results here.

Check this out: a total of 85% said health care needed either completely rebuilt or fundamental change. And 86% think health care costs are a very or somewhat serious economic issue.

OTOH, 77% are generally satisfied with the health care they personally receive, but 94% recognize that people not having insurance is a very or somewhat serious problem. there is hope!

Missoulian: Single-payer mentions draw cheers at Baucus-sponsored health care talk

The hearing ranged broadly over the possibilities for reform, but what clearly resonated for McArthur was something Baucus’ chief of staff, Jon Selib, said a couple of times.

Discussing why a single-payer system of health insurance wasn’t viable, Selib made reference to the more than 150 million Americans who are covered by some sort of employer-provided health care.

“A lot of people like that,” Selib said.

When the time came for questions, McArthur stood up and asked a simple question. Looking across a standing-room-only crowd of about 275, he asked how many were happy with their employer-based health insurance.Less than 10 people raised their hands.

“The number is bogus,” McArthur said. “It’s not working for 95 percent of us.” McArthur drew resounding applause.

In fact, any mention of single-payer health care insurance brought raucous cheers and clapping.

Any other solution to health care reform – including Baucus’ “balanced” plan that would create a mix of public and private plans – was received more coolly.

Tuesday’s session was one of a handful of events Baucus is sponsoring around the state this week. He chairs the Senate’s powerful Finance Committee, and is the point man on health care reform.

He did not attend Tuesday’s meeting, but Selib did, and he heard what the senator himself has heard since he announced that single-payer wasn’t really on the table.

As Selib worked to massage that point, one man barked out, “Oh bull—-.”

Tom Roberts, president of the Western Montana Clinic and moderator at the session, asked the crowd to be civil, but the man had made his point.

PNHP : Good links in letter for members

Dear PNHP Colleagues,

This Friday evening (May 22) the Bill Moyers Journal on PBS at 9 p.m. EDT will feature a discussion with Dr. David Himmelstein, co-founder of PNHP, and other single-payer advocates, asking the question “why isn’t a single-payer plan on the table in Washington?”

This important media event is emblematic of a recent surge in media interest in the single-payer alternative (see below) – a surge in large part fueled by the bold and courageous acts of civil disobedience undertaken by PNHP members and others before the Senate Finance Committee earlier this month.

Yesterday the conservative editorial board of the Times-Union in Albany, N.Y., made an impassioned appeal to Congress to put single payer on the table.

Dr. Margaret Flowers, one of the first persons arrested by the committee for speaking up for single payer, explains why she did so in this op-ed in the Baltimore Sun. She has given radio and newspaper interviews almost every day since her arrest.

Others who took part in the D.C. actions have been profiled in the media, too: see, for example, these portraits of Dr. Judy Dasovich and Dr. Carol Paris.

Dr. Paul DeMarco, writing in the Spartanburg (S.C.) Herald Journal, explains why, as a conservative, he supports single payer and the principle of mutual aid. (His op-ed ran directly alongside an opposing view by Sen. James DeMint, R-S.C.).

In their May 16 letter to The New York Times, Drs. Arnold Relman and Marcia Angell, past editors of the New England Journal of Medicine, explain how “We don’t need more money; we need a new system.” In another recent NYT letters column, Dr. Laura Boylan writes, “As long as the logic of our system is set by a huge for-profit multi-payer bureaucracy, we will continue to get low value on the health care dollar.”

This is just the tip of the iceberg. For example, Dr. Himmelstein was on NPR’s Diane Rehm Show Monday, along with Sen. Bernie Sanders (I-Vt.) and others.
……………..
I thought this was worthwhile to pass along…

UPDATE: Fixed the links! Sorry about that!

Letter – Schumer Health Care Plan – NYTimes.com

Letter – Schumer Health Care Plan – NYTimes.com:

“Re “Schumer Points to a Middle Ground on Government-Run Health Insurance” (news article, May 5):
There are a number of problems with Senator Charles E. Schumer’s so-called middle ground on universal health care. While your article acknowledges some of the structural ones — like whether a federal program could ever be subject to state laws — it doesn’t acknowledge the major issue: What is best for health care consumers?
What system is going to provide the best care? How can we provide meaningful health care to the greatest number of people with the resources available? What policies can we carry out now to ensure that there will be sufficient caregivers to meet our needs in the future?
These are the questions that we should be asking. As an advocate for consumers, I am distressed to see yet another health care discussion that focuses on the impact on insurance providers’ bottom line. The fundamental purpose of the health care system is to provide health care, not to protect and perpetuate an industry.
Richard Mollot
Executive Director, Long Term
Care Community Coalition
New York, May 5, 2009″

Well said. I was listening to a Center for American Progress Podcast of a talk given to them by Max Baucus, and I kept thinking, where is the vision? It was mostly about how we were stuck with working with our current system and tweaking it into some public-private amalgam that would be “uniquely American.” This is disappointing in many ways, but I primarily am disappointed that he reflects that stubborn conservative world view that we cannot learn from other countries, that their experiences mean little or nothing to us. If you take that view, then transformational change is impossible to envision, and you are stuck with timid change.

But also troublesome is the complementary idea that America cannot do this, because we must think so timidly, in such limited ways. JFK said, “we choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too.”

Where is THAT America, Senator Baucus, Senator Schumer?