Thinking Collectively about Health Care

Oh my. It seems obvious that making this a “good progressive” vs “bad libertarian” is simply a very very bad idea.

Can’t we see that this is providing fodder to those who wish to make excessive money on healthcare? Isn’t this about what is the best most effective treatment? Isn’t this about changing money driven medicine?

This “health insurance reform” isn’t “health care reform.” Sure it is a part of it, but it is not the complete picture, nor may it be the imporant part. There is paying for volume, monopolists, defensive medicine, fraud, abuse, excessive compensation, money being spent to avoid healthcare rather than fund it, etc. etc. etc.

Oh my, please don’t buy into the notion that just because someone identifies with libertarian values that they are uncaring people.

Republicans aren’t bad people, Democrats aren’t bad people, nor are libertarians or progressives. Sarah Palin isn’t a bad person, nor is John Edwards. David Letterman isn’t a bad person, and neighter is O’Reilly. I believe Rachel Maddow and Glenn Beck both mean well.

Let’s follow what President Obama says and stop the veiled implications that some people are good and some clearly wish evil on their fellow citizens.

Oh my, please.

Maggie has done a great job of describing the problem in her book, “Money Driven Medicine” and a lot of very good advocacy on changing the culture of financial results before medical results. I’m sure she sees what she wrote in this post as true and good and right, and some of it is.

But the idea that simply because people don’t agree with you makes them cold and uncaring? Maybe they simply think a different way?

And if they have mistaken beliefs, we need to educate them, not imply that they are less compassionate. We need to include them, not revile them.

The very best arguement I have seen is simply that healthcare is not a standard supply follows demand market. In healthcare demand follows supply! Build it and they will come! Therefore a “market driven solution” simply won’t work because this isn’t a standard market.

Now, if a libertarian sees healthcare as not a “market” then its pretty obvious that the standard solution does not apply and the only solution then may be single payor.

How about that, libertarians supporting single payor.

Why not?

Maggie Mahar urges us to think collectively. This is always a good idea, but I am not sure the relationship between “me” and “we” is that simple.
Here is what she says:
“This means that it is essential to think about healthcare collectively. Asking, “What will reform mean for me and my family?” is not the way to achieve universal care. We should ask “What will it mean for all of us?” How can we allocate resources to achieve affordable, sustainable, high quality care for everyone? No movement that urges history forward has ever been built on narrow self-interest.”
Is asking how reform will impact someone and their family a sign of narrow self-interest? I think not. Morals and values and religious tenets usually start with the “me”, not the “we”.
Here’s one approach, from Rabbi Hillel: “If I am not for myself, then who will be for me? And if I am only for myself, what am I? And if not now, when?”
The same approach in Luke, 6:31: “And as ye would that men should do to you, do ye also to them likewise.”
Or from #13 of Imam Al-Nawawi’s Forty Hadiths: “None of you [truly] believes until he wishes for his brother what he wishes for himself.”
Each begins, but does not end, with the “me.”
So asking what health care reform means to me and my family is a reasonable, even moral place to start. The experience of the last go-round on health reform shows that starting health reform from what we will do to help others when the listener is likely in deep trouble themselves is a recipe for defeat.
Equating self-interest with “narrow self interest” also does not urge history forward.

Nick & Ed

Thanks very much for your comments.

Nick–

Everyone who I have ever known who quoted Hillel put the emphasis on the second statement. (See for example, Dr. Jerry Avorn’s book “Powerful Medicines”– the beginning of the final chapter)

It is very, very easy to be for yourself–especially if you belong to a people with a long and terrible history of being persecuted.

But if we want a better world, looking beyond our families, groups, tribes, etc. is the only solution.

Hillel says: “If I am only for my self WHAT am I” (Note he says “what”–not “who”–this is telling.

The answer is ” Nothing.” The person who is only for himself has lost his humanity; he has lost his selfhood.

One can not have a “self” without a full appreciation of and recognition of the “other.”

(See also Martin Buber)

Ed–

I’m afraid you came pretty close to losing me when you said that Glenn Beck “means well.”

Neverthless, let me address the issue at hand– reducing health care waste.

I agree that this is the goal of reform not just to save money, but to lift the quality of care.

Where is the waste? Well-insured people (including those on Medicare) receive the bulk of the unnecessary tests, treatments, surgeries, etc.

They need to begin to realize that often, when it comes ot healthcare, less is more. If we’re going to afford universal coverage,they too, should think twice before wasting resources.

Yes, healthcare is, by and large, supply driven.

But the patient who wants an angioplasy as a “quick fix” for angina (when he would be better off with medication, change of diet and exercise) also plays a role.

The patient who refuses to accept he fact that back surgery will not help his back pain. .

The patient who refuses to accept the fact we have no evidence that PSA testing for
prostate cancer saves lives-also plays a role.

The poor are much less likely to be overtreated. As one doctor who worked with poor patients in the rural South put it: “They’re just not demanding (even when they should be). They don’t have the same sense of entitlement.”

In addition, Medicaid pays very poorly (70%, on average of what Medicare pays,) so hospitals, nursing homes etc. have little financial incentive to overtreat Medicaid patients (or totally uninsured patients.)

If we want to rein in health care inflation, we should redistribute health care dollars, spending more on chronic disease management for the poor (who are much more likely to suffer from chronic diseases) and less on unncessary tests for the “worried well.”

I totally agree that if pepole are mistaken in their beliefs, one should try to educate them, not revile them.

And I didn’t mean to do that.

But to live in a nation where there is so much poverty, so many people in need, through no fault of their own–including children–and still be able to say “I didn’t make them poor or sick. Why should I have to help them?” does suggest a real lack of compassion.

This isn’t just “thinking in a different way.” It’s a lack of empathy, a lack of imagination, that, I’m afraid, is a by-product of the “Me Decade” (the 70s) followed by the “Greed Decade” (the 80s.)

I didn’t invent these terms–cultural historians did.

As a people, we need to reinvent ourselves, and that means learning, once again, to think in terms of “we.”

I think that began to happen with children who came of age (turned 18) in the 1990s. In school (k-12) they began to learn to work in groups.

And as they became older (in the 1990s) they looked around and saw that greed wasn’t working out very well. (Some of the best-paid white collar wokers were laid off in the early 1990s– then came the stock market crash of 2000, followed by the real estate debacle of the past few years.)

Many college graudates who would have become investment bankers 5 years ago are now turning to very different professions that are not nearly as money-driven.

Finally, libertarians are not likely to support single-payer becuausee single-payer systems require that everyone pay higher taxes (based on income) to support not only the poor, but foreigners who happen to be traveling in their country, immigrants, etc.

I am so in favor of health care reform as long as it means reducing the cost of medical services. My wife recently tripped and sliced open her knee. It was Saturday so a trip to the emergency room seemed wise. It took three stitches to close the wound properly. Our medical bill was over 900 dollars; about three hundred dollars per stitch.

We don’t have medical insurance so we just set up a payment plan when as the need arises. We always pay our bills and appreciate the skills of the medical professionals who serve us. But the price just seems awfully high these days.

Maggie, you write: “But to live in a nation where there is so much poverty, so many people in need, through no fault of their own–including children–and still be able to say “I didn’t make them poor or sick. Why should I have to help them?” does suggest a real lack of compassion. ”

I ask, What percentage of the population says “I didn’t make them poor or sick. Why should I have to help them?” Did the statistics telling you that people feel this way show the methodology of the poll?

Also, Maggie, you write “Finally, libertarians are not likely to support single-payer becuausee single-payer systems require that everyone pay higher taxes (based on income) to support not only the poor, but foreigners who happen to be traveling in their country, immigrants, etc.”

Are you telling me that if we take the money out of medicine that it will cost more?

What statistics do you rely on that says single payor will cost society collectively more?

Nutrition Science Analyst & Ed

Nutrition Science Analyst–
Thank you for your comment.

$900 does seem a huge fee for a few stitches. But you have to realize, you’re not just paying for the time of the doctor who stitched her up, you are paying
for part of the hospital’s overhead–keeping the lights on in a huge complex.

The investments they have made in the whole complex are, to some degree, shared by everyone who is treated there (this includes the marble lobby, the art in the hallways the enormously expensive diagnostic testing equipment they have invested in, the new wing with all private rooms, etc. etc. )

You should also realize that, by going without insurance, you are taking a huge risk.

If your wife were in a very bad car accident, the hospital bills, surgeons’ bills, bills for rehab etc. wouldn’t be $900. They could be $90,000.

And a catastrophic accident can happen to anyone.

The good news is that, under current heatlh reform bills, if you have insurance and your wife is in an accident, you couldn’t be charged more than $10,000 (as a family) in a given year in out of pocket expenses.

In other words,you would only have to pay $10,000 of that $90,000 bill.

Y ou wouldn’t go bankrupt; you wouldn’t lose your house. And most doctors and hospitals would let you pay the $10,000 over time.

Of course, if you had insurance, you would also have to pay insurance premiums, but if you and your wife earn less than roughly $60,000-$65,000 a year jointly, you would qualify for subsidies to help pay the premiums. The amount you would have to pay out of pocket would also be lower.

Ed–

With single-payer, lower administrative costs would make a family plan about $2,000 less expensive–$11,000 instead of $13,000. (Numbers from the Commonwealth Fund.)

On the other hand, we would be covering the 15% of the population that has no insurance. Multiply that $11,000 by all of the uninsured households and you can see why, of course it would cost more.

The reason that healthcare is less expensive in “single-payer” countries (the UK and Canada) –as well as all of the European countries that have a hybrid system combining private sector and public sector health care– is becaue
in those countires, patients undergo far fewer surgeries, procedures and diagnostic tests.

Also when it comes to amenities, hopsitals also tend to be much more Spartan.

Nevertheless outcome often are just as good– sometimes better.

In Canada, for instance, patients suffering from heart disease are far less likely to undergo angioplasties or bypass surgery.

Instead of the “quick fix” of angioplasty, patients suffering from angina are more likely to be given medication and advice about changing their diet and exercising.

Ceasarians are much less common in Canada.

MRIs are far less common.

Yet outcomes are better in many areas.

The reason healthcare is so much less expensive in Canada than in the U.S is less because it is a single-payer country and more because patients don’t
receive every new treatment that comes down the pike, unless there is some medical proof that it is effective.

Unless we cut way back on the overtreatment that well-insured Americans are exposed to today–unnecessary surgeries (not just bypasses and angioplasties, but much back surgery), treatments that might give a cancer patient an extra 2 to 3 months (of poor quality life), pointless MRIs, PSA tests, etc–then we will never rein in the cost of health care.

But many Americans think they need these things– especially if their doctors or the hospital tells them that they do.

But cutting out the excess will take time–and much public education, as well as changing the financial incentives for hospitals and doctors.

In the meantime, you should realize that in European countries, the average middle-class family is expected to pay 10% of gross income for health care before getting any help from the government–that is how the middle-class covers working-class people. (Switzerland is just one example of the 10% rule.

In the U.S. we pay substantially lower total taxes than in other developed countries because we don’t fund a social safety net (universal health care, guaranteed pensions, high quality public education k-12 for everyone etc.)

To fund all of that, European pay not only income taxes, but substantially higher inheritance taxes and VAT taxes (a national sales tax.)

Because we don’t fund a social safety net, we have much higher levels of poverty than in other developed countries–especially among children.

We tend to believe that people should take care of themselves.

As for the libertarian (and conservative) view on whether we are responsbilt for taking care of the poor.

A great many polls show that in the U.S. when you talk to people earning over $75,000,
universal coverage is not their first priority.

Google polls, healthcare and “by income.” For the libertrian argument, try googling “not by brother’s keeper” and healthcare and libertarian.

For the conservative argument, see the Cato Institute and the Heritage Foundation on universal heatlhcare. (They both have blogs.)

If there are no savings in a single payor or mixed public-private healthcare reform plan, then we missed the mark entirely. Certainly if you look at this as only “health insurance reform” then perhaps you are right and we are adding money to the money driven medicine problem we are trying to fix.

I’d prefer a more full featured healthcare reform that addresses the causes of the high cost of healthcare as well. Without that its no reform at all, just another round of food in the trough of the existing money driven medicine culture.

If I follow you logic, then adding more money will solve the problem of money driven medicine. Huh?

So I reject the notion that this will cost more and that adding more money is the answer.

And I do not believe that everyone who isn’t a progressive is heartless and cruel. I have never seen such a statistic no matter what web address people put up or how they spin or push poll.

Nor do I believe that every progressive is an “I know better than you” elite.

But the polarization evident in this and other areas of the discussion are counter productive. They divide us rather than bring us together to solve a common problem.

I just wish it would stop.

Ed–

Pehaps I haven’t been clear.

The reason that heath care in the U.S. is so expensive is because we over use medical technologies (which includes not just equipment and devices but new drugs, tests, procedures and surgeries.)

Often, a small group of patients who fit a particular medical profile would benefit.

But the new technologies are hyped and we use them on a much larger group of patients–who don’t benefit.

Meanwhile, we all pay the cost in higher premiums , higher taxes, higher Medicare co-pays.

Addressing the high cost of healthcare means eliminating the overtreatment.

This post is fascinating and resonates deeply with me, having only recently recovered from volunteering on a 4-year failed attempt to amend the Massachusetts State Constitution and recognize comprehensive health care as a right. This was attempted after a statewide ballot for universal health care lost 48-52% after health insurers outspent us 100-1.

We undertook the constitutional amendment in the hopes that leading with the values of health care for all would help build social solidarity around the issue and if we achieved the amendment, it would provide a legal platform to advance policymaking that would be somewhat more protected from the insidious reach of moneyed interests that now largely control policymaking in the health sector. The outcome was beyond belief and if you care to read about it look here http://www.healthcareformass.org

Ed and Maggie are bringing out important details on national reform that just yesterday I was discussing with another nurse and longtime health reform activist. He happens to be a die-hard single payer/improved Medicare-for-All activist, while I share that goal I’m willing to work toward it in large steps (e.g. strong public option using Medicare Rates, open to all in short order, etc etc). This is what I was saying that applies to the conversation here:

BOTH of the major components of health system reform are needed now, and they have inter-related components but can be thought about as standing side-by-side: 1. The Financing piece, how we pay for health insurance (single-payer aims at taking out the wasteful abuses of the private, market-driven insurance sector) and
2. the Delivery of care piece (reining in over-treatment by changing the fee structure by putting docs on salary, utilizing Comparative Effectiveness Research, etc).

It seems like more often than not these 2 major components of reform get talked about seperately and in different circles, when both are essential and must be undertaken in tandem if we are ever to achieve fundamental, justice-based, and effective healthcare system reform!

Maggie said, “$900 does seem a huge fee for a few stitches. But you have to realize, you’re not just paying for the time of the doctor who stitched her up, you are paying for part of the hospital’s overhead–keeping the lights on in a huge complex.”

Actually, we’re aware of hospital overhead. That $900 fee did not include the physician’s charge for stitching up the wound. My point is, it is insanely expensive to utilize an emergency care facility for even the slightest injury. And it is insanely expensive to purchase health care insurance.

As far as accidents are concerned, universal health care accident insurance would not cost the taxpayer much. It’s chronic illness and medical screening for same that are sucking unimaginable amounts of taxpayer dollars into a black hole. And it’s the government’s agricultural and nutrition education policies that are behind the massive increase in many chronic medical conditions. http://nutritionscienceanalyst.blogspot.com/2009/10/letter-to-president-obama.html

Maggie writes: “Pehaps I haven’t been clear. The reason that heath care in the U.S. is so expensive is because we over use medical technologies … Often, a small group of patients who fit a particular medical profile would benefit.
But the new technologies are hyped and we use them on a much larger group of patients–who don’t benefit.”

Ed Says: I think you have been very clear about that. Your next statement however gets very close to blaming the people with insurance. Is the major problem here these selfish non-poor folks being over users, searching for their next fix of the life enhancing and extending drugs and treatments?

Maggie
I appreciate your reminders about the corrosive nature of self-ceteredness, selfishness, greed. Two generations going that way surely have taken a tool on the soul of America.
My concern is political — pulling people together to win. In health care, better for society means better for you and for me, and just about everybody else. The opponents want you (and me) to believe that better for society means taking things away from you and me and giving them to someone else. And they also want people to believe that the cultural elite thinks you and I are selfish for not wanting to have things taken (forcibly) from us.
That is a recipe for defeat, for reaction, for right-wing, even racist populism. What the tea-baggers are trying to do.
Your distinction between rights inalienable and rights constitutional applies here. To make health care part of the birthright of all in America we need to answer both questions — what’s in it for me and mine, and what’s in it for all of us.
My concern is that denigrating or ignoring the former question guarantees the wrong answer to the latter.
Thanks for sparking this discussion.
nick

Healthcare costs are high because 31% of our costs are insurance industry waste, and that could be cut to 11% were it not for the cash dollars in campaign bribes. A single-payer system would do that overnight, but it’s not the only fix needed. We must reform the medical malpractice process with a three-judge panel rather than 12 man jury, and apply any punitive damages to the health care fund rather than giving them to the patient and attorney, who have already been compensated. we must also eliminate the unnecessary expansion of hospitals and turn them back to non-profit status. And eliminate the fee-for-service arrangement which incentivizes more testing rather than less.
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The last thing in the world we need are mandates. The insurance industry should be eliminated, not expanded to 100% of the population.

And incidentally, on the subject of single-payer, for the same amount of dollars we are spending today (16.5% of GDP) we could provide first-class Cheney-care to 100% of our population. Including those in BadgerCare and Medicaid, and those who are uninsured and under-insured.
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It’d be a Medicare-for-all system that would eliminate the insurance bureaucracy waste (31% of our costs) and we’d spend it on patient care instead. We’d pay for the system through our national infrastructure (taxes) and eliminate this cost for businesses. They could spend the savings on keeping jobs in the US instead of outsourcing to countries already with universal healthcare. A bailout for 100% of our businesses, not just the banks and car manufacturers.
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But instead, we are spending more time and money trying to avoid doing it the right way, than it would cost to do it correctly up front.
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But as I mention above, a lot of cash is changing hands to avoid the obvious fix.

Ann

Ann– Thanks very much for your wise thoughtful comment. Yes, we need to do both simultaneously.

Ed–As I have indicated many times, while supply drives demand for health care (doctors and hospitals tell us what we need), patients also need to begin to try to husband our resources, so that in the future, we all (the poor, the middle-class, the upper-middle-class ) will have care.

The time has come to realize that we are all in this together, and we will thrive and prosper only if we work together.

This means that rather than insisting that you should have an MRI for back pain (because your brother-in-law had one) or pressing your doctor to precribe the new drug you saw advertised on televison, patients need to learn that “more does not necessarily mean better”– more care does not mean better care.

There is no single villain in our broken heath care system. We’re all involved, just as we should all be involved in trying to reduce waste in the system.

Nick– You write:
“The opponents want you (and me) to believe that better for society means taking things away from you and me and giving them to someone else”

Nick: The opponents who worry about “losing something” remind me of the wealth suburban matron who had been a life-long Democrat, but before the election, told a friend of mine: “I’m not going to vote for Obama. He wants to take “our” money and give it to ‘the poor people.’”

(By “our money” she meant Bushs’ tax cuts for the wealthy.)

Nevertheless, Obama won.

That woman, and people who ooppose covering the poor because they fear it might mena have to give up something (that MRI for back pain), the expansion of a near-by suburban hospital with hotel-like amenities)are part of a shrinking minority.

Less than 20% of all Americans identify themsleves as Republicans. (Polls show that a majority of Republicans are more concerned about their own healthcare than whether everyone has heatlhcare. Many of then simply prefer the status quo, don’t want reform,and will never be persuaded, as the White House has discovered.)

A certain percentage of middle-class Americans didn’t vote for Obama–and are fearful of healthcare reform–because they fear that they, and their families, will lose something.

But the growing demographic that elected Obama– low-income Americans, African-American, Latinos and Asian Americans, as well as many better-educated (and often higher-income) American Of All Races tipped the scales so that Obama won the election.

And they are also the people who, polls show are more concerned about universal coverage, and less concerned about what “me and my family” will lose.

In this last election, they discovered they their votes count. I suspect that they will be coming out to the polls in larger numbers.

As a result, I suspect that this new, heterogeneous majority may well become more powerful.

The president has tried to reach out and assuage the fears of the right-wingers, the tea-baggers, the people who ask first, “what’s in it for me and mine.” But now , the time for for so-called “bipartian” compromise is over.

At a certain point, LBJ realized that he could no longer worry about those who opposed civil rights legislation because they feared they would lose something if “other people” have equal rights.

A new majority is emerging, which includes people of many races and classes, who realize that our only hope lies in sharing our resources.

Today, a friend who is Jewish told me: “Of course, Hillel was putting the emphasis on the second part of that statement: ‘If I am only for myself, what am I?” You first responsibility is not to your self and your family. That is what the Rabbis always taught us.”

(Since I am not Jewish –as you may have gathered from the name– I felt I may have overstepped my areas of expertise my trying to explicate what a Rabbi was saying. This is why I asked my friend how he interpreted Hillel)

He added: it’s Margaret Thatcher who said “There is no such thing is society, only individual men and womena, and their families.”

Thatcher and Ronald Reagan share this belief. And, of course, Reagan ushered in the Greed decade that would undermine social solidarity and collective thinking in the U.S. as the gaps between the poor, the middle-class, the upper-middle-class and the very rich widened.

Health care reform means reversing that trend.

Oh my, its hopless trying to reason with you, and I generally agree with you too!

Somewhere along the line the idea of refroming money driven medicine has changed into something more like social engineering.

Reforming medicine I can agree with, government enforced social engineering I can not stomach.

Stick to the issue at hand please and we may end up successful getting a better health care system. Make this a right bashing excercise, and its bound to fail.

Can’t you see that obvious truth?

Ed–

In your first post on this thread you wrote: “Sarah Palin isn’t a bad person. . . I believe Glenn Beck means well.”

This suggests a degree of tolerance for conservative fear-mongering, and outright right-wing racism that I don’t possess.

I can’t subscribe to moral relativism. Some ideas are simply wrong and part of talking about health care and values means standing up for equallity, justice and solidarity.

Maggie writes: “I can’t subscribe to moral relativism. Some ideas are simply wrong and part of talking about health care and values means standing up for equallity, justice and solidarity.”

I say: The people you mention might say the same thing about your position. You have inadvertently made my point for me, which indicates you don’t understand my point at all. I’m dissapointed too, because it marginalizes your potential impact.

Ed and Maggie – sounds like ya’ll (and the movement for health justice) could benefit from a sit-down between the two of you to hash things out. I agree with Ed’s observation that Maggie and Ed are likely in agreement with other much more than in dissent. Do you live near each other?…

This work needs you both, and working together has much more power than the two of any of us working independently. Make a date for coffee (or tea), please.

Inded I agree Ann, we all need to think collectively about healthcare reform.

I attended a group meeting in favor of health reform and was struck by the lack of realistic thinking. In some ways those favoring reform are as impractical and perhaps naive as those strongly opposing. This in turn got me to think about false assumptions and expectations.

1. Rationing– (the R word) Somehow our conservative friends don’t think there is rationing of care now and that there will be with health reform. In fact health care is now explicitly rationed by cost. It’s a little like the supreme court’s concept that money=free speech (campaign contributions). If you’ve more money you have more speech, and in health care………. In neither case is it appropriate.

The challenge of health reform is to “ration” care by appropriateness and efficacy, a concept opposed by our conservative friends.

2. Have access to everything: The evil twin of rationing. Many available interventions are minimally effective and prohibitively expensive. Neither the consumer nor the health industrial complex fully appreciates either of these truths. Until they do we are doomed to have double digit increases in health expenditures as we do “everything” for everyone.

We need comparison and cost efficacy studies to guide us. Wouldn’t you know this is opposed both by drug companies and our conservative brethren.

3. Socialized Medicine–Medicine has long been “socialized”. We have around 100 million citizens receiving government sponsored health care. Our soldiers serve and retire, guess what one of their benefits is………. Our elderly priced out of the market by “private industry” have been well served by medicare. Those without insurance who are cared for for “free” at emergency rooms are indeed receiving a the most expensive and inefficient socialized medical service–paid for by someone else. Ironically or perhaps hypocritically the ER access rule is cited by our conservative friends as the answer to health care access.

4. Don’t want Government making decisions about health care (a variant of #3)– Instead we have profit driven insurance companies controlling our access and charging excessive premiums to maintain their profits. In an ideal world there would be neither. And indeed for the wealthy no such limitation exists. They simply pay whatever is necessary.

By accepting the need for third party payers we cede our “complete” control and are to some extent dependent on the good offices of the insurer–government or private. That’s life.

5. Health Savings Accounts are the answer: The question is the answer to what? If you said a means of the wealthy to shelter money for their health care I’d agree. If you think it’s an answer to the health insurance problems of the great majority you’d be mistaken. (as noted here and here)

Do you have any false health Gods?

http://www.medicyic.com

That was a very illuminating post. It may be unrealistic to expect the elite to accept anything but the best possible. I guess we’d better give them a straight path to getting it while the rest of us get “good enough.”

Is a two tier system really the only solution? One for the rich or influential and one for the citizens. And if so, I guess we have too many folks in the top tier.

I would like to comment on two key points in the original post: the point about health care as a right and the point about the need to think about health care collectively.

Maggie asserts that if we think of health care as a right in the proper way, we think of it as an inalienable right, which is superior to a constitutional right. Inalienable rights are seen as “natural rights” that we deserve imply by virtue of being human, so that we can be free to pursue life, liberty and happiness. These are affirmative right which empowers us to become part of society.”

There is much confusion here on the relative merits of constitutional rights compared with inalienable rights. Ms. Mahar appears to believe that the latter trumps the former and provides firmer grounds for arguing that health care is a right for all Americans. This is a strange reading of history in the sense that the authors of the Declaration of Independence knew perfectly well that inalienable rights in the absence of adequate constitutional arrangements which limited the authority of the government were useful only as rallying points but that they lacked real substance unless fought for and earned. This is the ironic aspect of the matter. At no point in the constitutional formation did inalienable rights prevail over constitutional rights. The former never lead automatically to the latter. In fact the very purpose of the Bill of Rights was to provide the legal foundations that the so call inalienable rights required.
The argument for the inherent value of inalienable rights is weakened further by the course of American history which demonstrated time and time again that rights without governmental protections by actions of the judiciary and the Congress, and in some cases even the executive, are declaratory and without force.
This suggests that any effort to make health care a right needs to focus on the body politic and not on the society. It needs to find an argument that will lead to changes in law and perhaps even in the constitution to sufficient to establish health care as a right. It may very well be the case that this will require a change in values at the societal level, but only as the first step in a long process by which inalienable rights get elevated to constitutionally protected rights.(This should not be construed as an argument in favor of a right to health care. How we might establish one is not an argument for establishing one.)
On the matter of thinking about health care collectively appears to overestimate the ability of individuals and groups to think about the common good. My own sense is that most American families have great difficulties in providing reliable and consistent answers to the question of what reform will mean for them, let alone what it will mean for the nation or the society. We are operating in the dark most of the time and the relationship between our values and our interests, on the one hand, and our decisions on the other, are tenuous at best. We should mistrust anyone who claims to know what is in the common good, or what drives history forward. Our best option is to muddle through and to let the interplay of diverse narrow interests in competition, conflict and rare convergence rule the day. Democratically based decisions should not be base upon the mythological common good. Efforts to accomplish such decisions are fertile grounds for the autocrat.

Rights have been discussed extensively here, but what about responsibilities?

It’s a forgone conclusion that most people will eventually develop one or more chronic conditions that will require treatment either early or late in life. If early in life, the expense can mount over time. Later in life, heroic medical interventions can result in astronomical medical bills in a rather short time. Whatever the scenario, chronic diseases are ubiquitous and costly to treat. Far better to prevent them so that health span and lifespan coincide.

Longevity research has demonstrated that when healthy humans (and animals) die from old age, it’s due to almost simultaneous failure of all organs.(1) No intervention can postpone the inevitable so no treatment is indicated. It’s an inexpensive death that all of us would be wise to aim for.(2) Problem is, the quality of food available and the kind of dietary advice we’re constantly exposed to pretty much guarantees the onset of debilitating chronic disease a decade or more before ones normal lifespan plays out.

1.http://www.indianexpress.com/news/old-age-cannot-be-a-cause-of-death/211346/

2.http://aje.oxfordjournals.org/cgi/reprint/149/7/654.pdf

David,

David–
You are entirely correct that the cost of chronic diseases account for much of our health care spending.

But the one thing that you don’t mention is that chronic diseaes are much more prevalent among the poor.

If we really want to manage chronic disease, we need to focus on public health–and healthier conditions for the poor.

This means, as you say, better nutrition (much healther lunches and even breakfasts in poor public schools,) affordable nutrional food (fresh fruit and fish) available in ghetto grocery stores) safe places for poor people to exercise, much better air quality. (Asthma and other respiratory diseases are far more common in poor neighborhoods.)

In our society, if you are born into poverty, it is very hard to get out. Over the past 30 years, social mobility in the US has shrunk drastically.

We can’t hold the poor “responsible” for being poor.

But we do need to hold society resopnsibilty for tolerating so much poverty–especially among
children. Levels of poverty among children in the US are now much higher than in any other developed country.

Ms Mahar
Please explain how one can hold a society responsible for tolerating so much poverty. Society is the highest level of aggregation in our collective life. It is society that has the power to make us responsible not the other way around. Do you mean that an entity such as the government or a religious body that functions within the society should hold the society responsible. I am at a loss to know what this idea means and how it might work. It seems to me that you might speak of individuals through their actions holding the government responsible, but that is hardly the society.

John Eley,

You are right that the Founding Fathers did not, ultimately, reocgnize “inalienable rights”, rights that we deserve simply by being human.

But ultimately this country would recognize those “inalienable right” –when we decided that slavery is unacceptable.

Whatever a person’s race, their origin, or the color of their skin, they have an inalietnable right to “life, liberty and the pursuit of happiness.”

In your comment, you write: “Our best option is to muddle through and to let the interplay of diverse narrow interests in competition, conflict and rare convergence rule the day. Democratically based decisions should not be base upon the mythological common good”

I’m sorry to hear you refer to the “common good” as a myth.

Competition among “narrow interests” has led us to the current situation where, in too many cases, youth is pitted against age (and age against youth) men vs. women, Gays vs. Straights, African Americans, Latinos, recent immigrants and whites all divided against each other . .

Read the history of some other countries. Such divisions usually foreshadow the fall of a nation.

John–

In response to your most recent comment–”Please explain how one can hold a society responsible . .”

I have a feeling that you don’t really believe that there is such a thing as society–

This reminds me of Margaret Thatcher who also denied the existance of society saying that there is no such thing “only inidiviudal men and women. . and families.”

I suspect that Thatcher never felt part of society, never felt a communal connection with others by virtue of being in the same boat–all human.

I think Margaret Thatcher meant well too. But I think Gordon Brown means well too, as did Tony Blair. This poster John above likely means well too, has feelings, and meaningful connections with other people.

Why suspect that they are heartless? Does that help us to think collectively?

Maggie,

My take on the cost of health care problem is that ill conceived government policies, especially in the agriculture sector, have contributed greatly to the degradation of the food supply. There is considerable grass roots effort aimed at educating consumers and improving the quality of the food supply. Unfortunately, our government has yet to take much notice notice of our efforts. And the public health sector all too often fights against efforts to promote local food production and distribution, especially where raw dairy is concerned.

As for the poor suffering disproportionately from chronic illness and obesity, a toxic food environment is certainly a large part of the problem. But there are appallingly high rates of chronic disease and obesity in all strata of society due to, as I mentioned earlier, the government’s terrible dietary advice. Nearly every institution in the country that serves up food (schools, prisons, hospitals) utilizes the expertise of registered dietitians to plan menus. Unfortunately, dietitians are trained to recommend reduced fat foods as a means of preventing excessive caloric intake. But low-fat diets tend to derange the appetite regulating mechanisms in many of the insulin resistant portion of the population causing them to overeat. Hate to keep harping on this but improving the quality of the food supply needs far more attention than it currently gets.

Maggie before I respond to your comment about my attitude toward society, I think that it would be good to introduce myself, especially since I jumped right into the conversation, based on an open invitation to do so. I am a retired consultant with considerable experience in policy analysis and program planning. I am a political scientist by training and a conservative by predisposition. I am suspicious of efforts to transform the society in fundamental ways and painfully aware of a long history of government policies with unintended consequences. I will challenge all signs of idealism and its companion known as romanticism whenever I see it raise its head. This may not make me very popular with those of you who intend to reform the system in the name of humanity. I hope, however, that my comments will give you something to think about.

I believe in society in much the same way as do sociologists, as an abstraction that enables them to have something with boundaries that they can study. I do not believe in society as a romantic valued-laden concept that can be used to summon the masses behind a common good, the public weal, the national purpose, etc. I find that extremely dangerous and fertile fields for the rise of demagoguery of all types, be it conservative or liberal.

You seem to disparage Margaret Thatcher for her failure to grasp the idea of society. How strange that you do so given your idea that society needs to assume responsibility for correcting a serious problem. I know of no other European leader who more effectively and courageously assumed leadership and brought her nation, via the government into the post cold-war world. Perhaps she makes my case better than you realize. Thatcher was the ultimate realist and her accomplishments speak for themselves.

One final point, you say that the US finally recognized an inalienable right when it abolished slavery. I have problems with the use of recognition here, as in virtually all cases because it conveys to me at least the idea that there are values, principles, Platonic forms, etc., out there waiting for us to recognize them. I am a social constructionist and I simply do not think that such entities exist. As for your example of slavery, I think that Americans opposed it managed to persuade those in control of the government that a war that was originally fought to keep the nation together needed to become a war that abolished slavery. Those in control of the government constructed a new justification for the civil war and developed a number of measures that brought this about. Since the US had the power to do so, it used its might to construct a right, which it never treated as inalienable. This act seems like a recognition only in retrospect. The core question is how this developed? Answering that might help all intent on major reforms.

This is an excellent post with an incredible comment section.

To me, the fundamental question in health reform is “what ought we do to ensure that all members of our nation experience equal chances for health?” Once again I come back to the distinction between health and health CARE. Government programs aimed at insurance reform should not be confused with real actions aimed at improving health. Our obligation is not to ensure that people can buy insurance– insurance without real reform in health delivery, prevention, and public health is meaningless– but to ensure that people have a chance to experience health equally despite (perhaps in spite of) their individual circumstances.

My frustration in this debate tends to be with folks who confuse ANY government attempt to ensure the health of all citizens with an encroachment on their rights– frankly, I’m still unclear exactly what right ensuring health encroaches on.

Can we have a conversation about health if we see it through dramatically different “frames”? How do we arrive at a common frame? Do we need to?

A University of Michigan study found that 32 percent of Democrats believe that social factors — such as socioeconomic status, neighborhood safety and availability of healthy food — play an important role in health, compared to just 16 percent of Republicans. (http://www.scienceblog.com/cms/news-red-and-blue-messages-about-social-factors-and-health-can-backfire-26293.html) “If you are more liberally minded the ‘neighborhood explanation’ can be motivating, but for people who are more conservative politically, that message can backfire and make them even less interested,” says Peter A. Ubel, M.D., professor of internal medicine at the University of Michigan and director of the U-M Center for Behavioral and Decision Sciences in Medicine. “The same information can polarize people.”

In her dissertation, Robert Wood Johnson Foundation Health and Society Scholar at the University of Pennsylvania, Sarah E. Gollust, Ph.D., notes that the results challenge conventional wisdom that increasing publicity of the social determinants of health will lead to greater public support for health policies. Rather, advocates who want to mobilize the public might consider disseminating information about both social factors and individual behavioral causes to avoid triggering resistance.

And here we are reminded again that it is context, more than content, that makes healthy conversation possible.

Rick Brush
http://www.communitiesofhealth.org

Well I think we can all agree that the cost of healthcare is out of control and needs to be lowered.

To me, I think it would be best to concentrate on the cost issue rather than the coverage issue. So we get reduced cost and increased coverage.

Right now, it seems the cost part is way lost in the conversation. No government person seems to even mention it anymore except “bending the curve down” and then they go on to talk about higher costs and virtually nothing about reforming money-driven medicine.

Republocrat or Democlin we can all agree that the high cost side needs to be reformed.

Its like Wall Street, there are lots of good words about reducing the greed->risk->bailout thing but scant actions from DC. Too many monied interests on Wall Street and Healthcare I guess.

I was really hoping it would be different this time, and it wouldnt be all talk and no action. The jury is still out.

Ashley B. And Rick Brush

Thanks for your comments.

Ashley– I agree that guaranteeing access to health insurance
does not solve the problem.

We need to make structural changes in how we pay for health care –and how it is delivered.

Specifically, we should reward providers for the quality of care that they provide rather than quantity. And should use financial incentives to encourage collaborative care: doctors and hospitals working together while striving for more efficient care–better outcomes at a lower cost.

Finally, we need to invest in public health. To a very large degree, that means investing in public education k-12. Health, education and welfare are all one ball of wax (which is why we once had a federal Dept. of Health Education and Welfare.)

Why do some people argue that any attempt to guarantee health for all encroaches on their rights?

Often, they are concerned that providing care for all will mean in an increase in their taxes. For some, their right to accumulate and preserve capital is an individual economic “right” which trumps
the social goal of trying to create a society which stresses equality.

On the other side of the debate, health care economist Rashie Fein writes: “We live not just in an economy, but in a society.”

See also Dr. Steve Schroeder’s Shattuck lecture referenced below.

Rick–

I think we do need to agree on some values. One goal of a political movement is to move people’s minds from where they are to where they might be. . .

Understanding the role that “behaviors” play in determining our health– and the degree to which poverty influences behavior– is very
important.

On this issue, I strongly recommend Dr. Steve Schroeder’s Shattuck Lecture herehttp://content.nejm.org/cgi/content/full/357

I wrote about his lecture here
http://www.healthbeatblog.org/2008/05/whatever-happen.html