current mood: medical
current music: Nina Simone – Sinnerman (Remix)
(or, primum non nocere)
First, do no harm.
The guiding principal of all medicine is encapsulated in the Latin phrase “Primum non nocere” – “First, do no harm.”. This precept, which has guided physicians for centuries, is one of the most basic concepts in medicine: given an existing problem, do nothing that will make it worse. It is a fundamental principal in the field of medicine.
It is also not how our1 modern healthcare system works.
In the healthcare system of the United States, there is a disconnect between this principle and the various organizations, bureaucracies, companies, and entities whose job it is to provide medical care to a population at large. Health insurance companies, in particular, have a nasty habit of rescinding insurance2, 3 whenever it suits them, (completely coincidentally) the people whose insurance tends to be rescinded happen to be the sickest among us, those with long-term illnesses like cancer that are expensive to treat.
To borrow an overused phrase, “the system is broken”. Indeed it is. Fixing it will not be easy. But it is, I believe, an ethical imperative.
The Ethics of Universal Healthcare
A lot of people find the idea of “universal healthcare as a right” to be disquieting on a number of levels. To many it seems like slavery; the masses of slobs who contribute nothing to society forcing them into servitude. Talking about healthcare as a “right” sounds demanding and shrill, and then of course somebody pipes up “with rights come responsibilities!”. The whole argument devolves turns into a debate about healthcare as a “right” vs healthcare as a matter of “personal responsibility”.
The problem with emphasizing “personal responsibility” is that, in the arena of providing medical care to people, it shifts the burden of responsibility onto the sickest and poorest. “Learn to take care of yourselves!” is their cry, assuming that some amorphous charitable entity will take care of those who can’t take care of themselves, and if not…well, they don’t think about that. Out of sight, out of mind.
Instead, I find it must more effective to talk about healthcare in the language of an ethical responsibility for an industrialized nation that can afford it4.
I believe we should start from the premise that health is a basic human need, and I believe few people would disagree with this. Further, if we can do something good to improve access to that basic need of society as a whole, we should – and we can therefore conclude that providing reasonable means for the people in our country to receive healthcare is a responsibility for all of us. Even beyond the warm fuzzy emotional feelings of altruism, there are logical benefits for a population whose health is being taken care of: a healthy workforce is a productive workforce, and a productive workforce has obvious economic benefits. A healthy consumer population helps drive the economic engine as well – when you’re not paying through the nose for health insurance, you can spend money on other things. We need a very strong, unified focus on preventative medicine, so we can start to move people into the system before their illnesses become exponentially more difficult (and expensive) to treat. We will all use this system during our lifetimes, therefore the benefits of paying into it are clear, despite the libertarian cry of “Slavery!”. Yes, it’s socialized medicine – the same way you drive on socialized roads, use the (extremely efficient) socialized mail delivery system, enjoy the socialized snow-removal services, and live under the protection of the socialized fire department and police.
The current system of employer-provided insurance isn’t doing much, and there a few big reasons for this. People are (generally) limited to what their company offers, and the choice of care is made by somebody without any vested interest in the outcome. When insurance companies focus on selling to companies rather than to individuals, they have no incentive to keep the individual happy. As long as the company is happy, the employees have no say. And of course it goes without saying that insurance companies don’t give a flying flip about the people they insure. Their actions clearly indicate a mentality of accumulating profit to the point of systematically failing and / or refusing to provide the care they’re supposed to.
To put it nicely, the private insurance industry is failing to deliver a service they’re being paid massive amounts to do.
A Brief History
This is not to say that a government-provided solution is necessarily the best solution. For instance, I would not be in favor of the government being the main provider of television programs or being required to buy my food from a state-run grocery store. (“Enjoy your Victory Gin, sir.”) Privatization of commercial goods and services can encourage competition, drive market innovation, and provide a greater range of services. Governments don’t have the luxury of innovating fast or often with large programs; taxpayers will (fairly) cry foul if they see their money being wasted.
But this is what leads us to our dilemma, and the crux of my argument: there is no market solution for the chronically and / or mentally ill among us. The private market has failed, utterly, to deliver a necessary service to the society it serves.
In the first half of the 20th century, most people got their insurance from non-profit Blue Cross / Blue Shield programs, which based their premiums on a community rating system. To calculate their premiums, they took the costs of their enrollees, added a reasonable overhead contribution, and divided that by the number of enrollees.5 Under this system, the young and healthy paid more of the cost than the more chronically ill ones. This isn’t really unfair, because if the younger ones lived long enough, they’d become old. (Duh.) Such an arrangement is fundamental to the definition of health insurance.
Originally, the for-profit companies considered health insurance too risky because of uncontrolled costs or the adverse risk that health insurance carries. To get around that, they eventually came up with the idea of “pre-existing conditions” to exclude the sick from insurance coverage. They also applied a “risk rating” to health insurance premiums – which reduced the premiums for the young while making insurance unaffordable for the older population – which handily eliminates the risk that an older population inherently carries.6
The risk-based approach is appropriate for, say, automobile insurance, because clearly people are responsible for the way they drive. But risk rating is totally inappropriate for human beings who cannot control their genetic inheritance, which plays a large role in their overall health. (Clearly, there are lifestyle choices that make a huge difference, too – smoking, which caused some 5.4 million deaths in 20087, comes immediately to mind.)
Risk rating was immediately problematic for the Blue Cross / Blue Shield plans, became if they continued the community rating system they would end up with all the sick, and all the young healthy people would flock to the cheaper rates of the for-profit risk based premium system. This forced the non-profits to switch to the risk rating system and act like the for-profits. Today, there is virtually no difference between CIGNA and Blue Cross / Blue Shield.
Private insurance has failed the American public. It didn’t have to be so. But between the inane numbers of administrative personnel, a lack of regulation to ensure that plans are adequate to cover the needs of the people who have them, and absurd use of risk rating, we have a system designed to maximize profit while systematically eliminating the covering of the sickest. The huge number of available plans provides a challenge for doctors and hospitals to figure out what services are covered by what plans. Despite the insurance industry trying to portray itself as terribly interested in the health of the nation, their actions tell a different story8.
The Horror of a Government Solution
And so we come to the unenviable position of needing to do something drastic to ensure delivery of healthcare to those who need it, and (seemingly) not having any private market solutions to turn to. Of course we all know that the government will not be any help – the healthcare system of England is bureaucratic mess, and in Canada, you’re likely to die before you get the help you need.
Right?
One of the things I hear people criticize the healthcare systems of Canada and England for (I mention these two specifically because they’re two of the largest, and most successful.) is the rationing of care and the waiting times. But the point that many people miss is that the United States already rations care, only instead of meting out care based on urgency and need, we do it almost exclusively on one’s ability to pay. (Almost, because emergency care and a few other services are guaranteed. I for one am glad ambulances do not come equipped with a bank uplink to do a credit check before getting out a stethoscope.)
These systems certainly have their problems, but they are far from the bureaucratic nightmare that some popular media makes them out to be. And the simple fact is that you have to ration healthcare at some point. One of the most fundamental concepts in economics is supply and demand. The trick, regardless of the economic model, is finding that equilibrium between the potentially unlimited demand for a given product or service, and the limited supply of same. And this need not even be related to money – everybody needs air to breathe, but there’s only so much oxygen to go around. Cars or aerosol deodorant or Chanel No. 5 can generate stuff that decreases the supply of breathable air. In some parts of planet Earth, folks go to oxygen bars and pay hard-earned cash just to get a few hits of the good stuff.
Further, I think many people despise the government solution merely because its “The Government”. But how is the government running (and rationing) health care particularly worse than the plethora of private companies running (and rationing – and that is exactly what they do.) these days? In America, we tend to look to the private sector to provide our needs before we turn to a governmental agency – it’s part of who we are as a society. But the private market hasn’t done what needs to be done – provide a reasonably affordable solution or solutions so that most (if not all) of people who need healthcare can get it. If the private sector failed to provide affordable, say, Tamagotchis to the public, well, that’s fine – people can live without annoying egg-shaped electronic pets. But access to healthcare is is a basic need, and in America, almost 17% of Americans are without health insurance.
How to Save the World and Still Feel Good About Yourself
Modern medicine is perhaps the most magical (In the Aurthur C. Clark sense) of all the technology that human beings possess. We can do some truly astounding things – we can take organs from a dead person and put them, still working, into someone else. We have effective cures or treatments for some truly hideous diseases – the simple drug penicillin has saved a nearly incalculable number of lives.
But there are only so many transplantable organs to go around, and some of the more exotic diseases cost a great deal to treat. So who gets that donor heart? Who gets that oxacillin? Who gets the laser eye surgery or the career-enhancing pectoral augmentation?
In a purely capitalistic society, the answer is easy: throw it on eBay and see who coughs up the most cash for it. But is the person with the most cash always the best person to get a precious and rare resource?
There are lots of different ways to determine Who Should Get It, and one answer is not necessarily better than the other. Do you give it to whomever needs it most? If so, how do you determine that? What about giving it to the person who will have the most benefit to society? If so, how do you go about calculating something like that? Is it better to give it to the young and full of potential or the old and proven? Should lifestyle choices make a difference? Would you give your liver to someone who drank theirs to a pickled case of cirrhosis? Because the hard fact is that you have to ration anytime supply exceeds demand.
I’ll borrow an example from Jim9: You’re the surgeon general of the great state of S.O.L., the Socialist Order of Lobbyists. Your budget for pharmaceutical disbursement is 50,000 krapees per year. In this particular year, the medical establishment develops cures for three longstanding, fatal diseases. For 50,000 krapees, you can save ten people suffering from the virulent Bromidrosis, which if left unchecked could infect half the population–particularly those who wear the occasional python boot, which includes most of the major employers in the nation, any one of which would put tens of thousands of people out of work by their deaths. Or, save 100 people from a terminal case of Yanni Fever, which strikes only people who make 75,000 krapees per year (which places them in the top 10% of all wage earners in S.O.L., and who form the upper-middle-class taxpaying and consumer backbone of the state.) Or, you could save 10,000 low-income people whose only contribution to society is keeping your favorite horndog El Presidente in office from seeing the re-release of The Exorcist without having a sufficient number of antacids on hand to prevent a fatal onset of acid reflux the day before the big impeachment vote – and without the huddled masses, El Presidente is toast.
Whom do you save?
Perhaps now you see the dilemma.
Now let’s add a complicating factor. Let’s say one of the big problems on this state is that they’ve got great medical supplies, but they suffer from overpopulation. Disease used to thin the herd enough to maintain equilibrium, but advances in health sciences now means there’s a shortage of everything – food, water, habitable land, breathable air – because folks who would normally have kicked the bucket by disease are now drains on society. Most of them working in corporate middle management and the mainstream media.
There was an episode in the original series of Star Trek (I forget the title) where Kirk was kidnapped and compelled to get busy with a beautiful woman for the express purpose of giving her a deadly illness, in order to solve their horrible overpopulation problems. Some folks might call this brilliant social engineering. But the doctors forced to treat the dying might feel differently.9
My point is that rationing is the inevitable outcome of any system where supply exceeds demand – and we’re already doing it. But other countries do it better – and ultimately treat more people well than we do.10.
Solutions and Problems
What most people are actually talking about when they talk about “healthcare reform” is actually “insurance reform”, but the conclusions remain the same: the current system needs to go. Any approach that keeps present for-profit and not-for-profit insurance companies with their plethora of insurance plans alive makes it impossible to control cost and free the billions of dollars that today go to administrative cost and make these funds available for patient care.
There isn’t necessarily one approach that is “right”, but there are certainly approaches that work better than what we have now. I believe strongly we should move to a single-payer insurance system that covers every person in the country for medical, mental and dental healthcare. The cost of the system should be funded by income taxes paid by each adult/family in the country. It should provide universal access to care no matter where you are in the country, with equal quality and quantity and without regard to your wealth. Pooling should be eliminated, and insurance companies should be non-profit, community-based entities under the direct control of a national insurance entity. The system must be attractive enough to encourage bright young people to get into the medical profession, and prevent the older doctors and nurses and providers from getting fed up and leaving. One of our medical system’s strengths is the extremely advanced technology that we’ve developed, and the remarkable treatments we’ve devised. Any system we come up with should preserve this valuable aspect of what we already have.
That said, the present insurance system is ethically11 bankrupt and should not be sustained. Making the massive changes necessary, and deciding on what the best changes are will not be easy, but I believe the direction we should take is clear – away from for-profit companies too interested in themselves to do their job, and toward an insurance system that we all pay into. Because ultimately, we’ll all have to use it.
Exit, stage left.
Sparks
1: I refer here to the United States. Most other industrialized nations have moved on.
2: http://tauntermedia.com/2009/07/28/unconscionable-math/
3: http://www.npr.org/templates/story/story.php?storyId=105680875&ft=1&f=1001
4: inspiration: http://allbleedingstops.blogspot.com/2008/10/healthcare-is-not-right.html
5: Blue Cross and Blue Shield – A Historical Compilation [PDF document]
6: A related term for this is “pooling”.
7: WHO global burden of disease report 2008 [PDF document]
8: For an insider’s view of the insurance industry, watch this interview with Wendell Potter, former insurance industry executive: Part 1, Part 2.
9: Jim at Delta Blues was extensively plagiarized for much of this section.
10: I am aware that this is a blanket statement that disregards a lot of things, like the discrepancy between cancer survival rates between Canada and the United States – but these aren’t issues so bad they can’t be overcome.
11: “Ethics” does NOT equate to “morals”. They are related, but very distinct, and not interchangeable.