Will We Eventually Insist on Medicare for Everyone?

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I highly recommend for your reading a slim 72 page volume written by Dr. Tim Johnson, ABC News Senior Medical Contributor, titled The Truth About Getting Sick in America: The Real Problems with Health Care and What We Can Do (Hyperion: 2010).

In addition to his impressive medical credentials, Dr. Johnson is an ordained Protestant Clergyman (I had the privilege of worshipping for 14 years in the Evangelical Covenant Church in West Peabody, MA where he has served as an associate pastor for many years). As a “follower of Jesus,” he draws on the Parables of the Good Samaritan (Luke 10) and the Final Judgment (Matthew 25) to argue that “it is impossible to be both a true follower of Jesus (or many other religious leaders and prophets) without also advocating basic health care for all” (p. 57).

But, in that light, the Affordable Care Act gets mixed reviews; “The good news is that the newly passed health care bill should eventually provide some kind of health insurance … to more than 30 million Americans now uninsured. The bad news is that the bill does not provide any assured way of controlling costs and guaranteeing quality” (p. 71).

Johnson does present some common sense proposals for control of medical costs. His most cogent proposal, in my estimation, is that the health care system needs to get away from an “ultimately disastrous financial incentive,” whereby “the more you do [as a doctor or hospital] the more you make” (p. 15). For example, he believes “we must pay all our doctors by salary … and a key component of that salary should be outcomes [not the number of procedures and tests that are ordered],” citing the fact that “some of our best health care facilities, such as the Mayo and Cleveland clinics, pay their doctors by salary in order to free them up from making decisions based on how much more money they could make” (pp. 18-19).

Dr. Johnson proposes some other cost-cutting measures, such as the creation of national information technology standards (p. 64). But in the end, Dr. Johnson is not optimistic as to the large-scale possibility of the cost-cutting measures that he proposes gaining much traction because “the political and economic pressures (for jobs and profits) from the medical-industrial complex will override truly significant cost control” (p. 71).

So, what to do? Johnson proposes that “there is no way to get costs and quality under control without a strong role for the federal government” (p. 31), by creating “a sensible partnership …[with] private industry” (p. xii). He cites the “congressional plan” that members of Congress participate in as example of such a partnership, since it “strikes a balance between choice and oversight” by means of an “insurance exchange” program (pp. 33-34). Johnson therefore applauds the “insurance exchange” aspect of the Affordable Care Act, scheduled to be established at the state level by 2014, since “health insurance companies will be competing for your business,” which “Conservatives” will like, and the Federal Government will “play a strong role in order to guarantee that all insurance companies play by the same rules and standards,” which “Liberals” will like. Johnson only bemoans the fact that these state exchanges are not scheduled to be operative until 2014; and he strongly urges “government planners to push up that starting date as much as possible” (p. 69).

But, after making what I take to be some excellent proposals, Johnson does not envision adequate implementation in the near future in light of the current political and economic climate. Hence he concludes his book with an extremely provocative “Big Prediction”: “No matter what legislation Congress develops this year or in the years to come, health care costs will continue to rise. Within five to ten years, health care costs will be so out of control that we – the public – will demand that the government bail us out. At that point, the easiest and quickest action will be to expand Medicare to cover everyone” (p. 60); a “public option as the only insurance choice for everyone” (p. 47).

I can’t imagine a more controversial prediction as to the future of health care in the United States. I welcome your comments.

 

 

 

Health Care and Judgement Day (Part 2)

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March 18, 2010 the American health care debate had reached its fever pitch as our Congress stood poised to pass or reject one of the most consequential pieces of legislation to trudge through its halls since the Civil Rights Act of 1964 and the Voting Rights act of 1965. On that day, I published Health Care and Judgement Day on the Huffington Post. In that article, I focused in on the Tea Party’s mantra of the time, “Small Government!” and traced the mantra back to its roots in the Antebellum South’s cry for “State’s rights!”

Two years later as pundits projected how the Supreme Court would rule, they confirmed the heart of the opposition’s arguments; “State’s rights“, but they miscalculated the level of ideological loyalty within the nation’s highest court.

The Supreme Court ruled that the federal government does hold the constitutional power to mandate that most American’s purchase health insurance or pay a penalty. This power is maintained in Congresses ability to levy taxes. It also ruled that the federal government does hold the constitutional power to expand Medicaid, making more people eligible to receive the benefit, but, like the original Medicaid law of 1965, states can opt out of the expansion if they choose to.

What does this mean? 100 years ago, in 1912, Theodore Roosevelt advocated for a national health insurance program. 1935 President Franklin D. Roosevelt tried to include a national health insurance program in Social Security, but was thwarted. 1945 President Harry S. Truman proposed the nation’s first “single payer” program, but was eviscerated by the American Medical Association, who feared the program would cut into their profits. Then in 1965, President Lyndon B. Johnson amended FDR’s Social Security Act to include Medicare and 19 million senior citizens gained access to health care that year. 1974 President Richard Nixon proposed the Comprehensive Health Insurance Act. This program would have expanded Medicare and Medicaid to cover all Americans, but political jocking on the left stalled that legislation. Then, 1993, President Bill Clinton put forward a bill that would retain the best of the market, while offering universal coverage. It was defeated. Finally, 2010, in one of the most dramatic congressional fights ever, the U.S. House and Senate passed the Patient Protection and Affordable Care Act, which expanded coverage to 30 million more Americans. President Obama signed the bill into law on March 23, 2010. Two years later–100 hundred years after Teddy Roosevelt pressed for a national health care program the Supreme Court has levied it’s judgment: States can opt out, but cannot prevent the nation from offering its citizens the health and care worthy of every human being made in the image of God.

What does this mean for Jesus followers? In my book, Left, Right, and Christ: Evangelical Faith in Politics, I ended my chapter on Health Reform with a reflection on Matthew 6:24 where Jesus said: “No slave can serve two masters; for a slave will either hate the one and love the other, or be devoted to the one and despise the other. You cannot serve God and wealth.”

In the same way that Justice John G. Roberts served the constitution and forsook ideological loyalty to the states rights mantra, followers of Jesus are called to bow to God and forsake our ideologies.

Jesus reminds us that our creator requires supreme loyalty. If we claim to follow Jesus, then we are to be slaves to the God who “made heaven and earth, the sea, and all that is in them; who keeps faith forever; who executes justice for the oppressed; who gives food to the hungry” (Psalm 146:6-7). If we claim to be followers of Jesus, then we must be slaves to the God who protects and cultivates the lives of people made in his image as he “opens the eyes of the blind” and “lifts up those who are bowed down” (Psalm 146:8)–slaves not only in our individual morality, but also in our vote.

 

There are still 12 million uninsured and underinsured lives in the United States. Now it is time to fight for them.

Health Care: The Road to Real Reform

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The Supreme Court will rule tomorrow on the constitutionality of major provisions of the Affordable Care Act, the health care reform package crafted by President Obama and Congressional Democrats. As we await the ruling on this legislation, let me offer a few thoughts on the economics and spiraling costs of health care in the United States, the kind of health care reform we really need, and what we as Christians can do to help meet needs now.

The Economics of Health Care

In my first economics class in college, I was introduced to the concepts of supply, demand, and elasticity. Elastic goods are most sensitive to price changes; if a price goes up, demand goes down because consumers will substitute something else in its place. Inelastic goods are not affected by price changes; consumers will pay whatever price because such goods and services are necessities and have no substitutes.

The professor used health care as an example of something with a near inelastic demand curve. When choosing a physician, surgeon, or course of treatment, most of us ask first about quality and expected outcomes. Cost is low on the list (or not even considered) when someone’s life hangs in the balance. Those who do want or need to compare prices find it difficult, and at times, impossible.

We hear a lot of talk about market-based solutions to health care, but too few of these discussions take into account the particular qualities that make the market for medicine so different from that for most consumer goods.

A Good Return on the Investment?

The United States spends more money on health care per capita than any other country, and the rates of spending are growing faster than anywhere else. In 2008, the U.S. spent $7,538 per person. Norway was second highest, spending $5,003. The U.K. spent $3,129, Germany spent $3,737. In 2010, total health care spending in the U.S. was an astounding $2.6 trillion.

It is not always clear if we get what we pay for. On the one hand, the United States is the undisputed center of medical innovation that paves the way for new drugs and devices. People travel from all over the world to receive medical care in the United States. On the other hand, we don’t rank as high in positive health outcomes. In 2006, for example, the U.S. ranked 39th for infant mortality and 36th for overall life expectancy.

The numbers tell a clear and compelling story. Health care costs are rising much more quickly than wages and inflation. The spiraling costs are unsustainable for government and for the private sector. Health insurance premiums have risen more than 100% in the past decade, increasing costs for employers and employees while also dampening wages. Health care costs are the largest piece of the current federal budget and will consume even more of our limited dollars as costs rise.

Experts disagree on the exact reasons for the high costs, but some of the contributing factors include the high cost of medical technology and prescription drugs, the expense of administering such a complex public-private hybrid system, overtreatment, and the increase in chronic illnesses.

Health Care for Everyone?

I am not particularly impressed with much of what I see in the Affordable Care Act. Although it will be several years before most of the provisions are in effect, the plan appears overly complex and deeply tied to our current system which most observers agree is broken.

Although I have many concerns about how this would work well, my current view is that we need to move toward some form of single-payer health care delivery system that provides basic medical services to all Americans. We need to start at the drawing board, creating a new system that compensates medical professionals fairly and guarantees basic standards of care for everyone.

Our current public health delivery programs, Medicaid and Medicare, are not wise models. The payment schedules are so low and the red tape is so complex that payments don’t always cover the costs. Many doctors, especially specialists, do not accept Medicaid and Medicare patients. Some doctors I know find it is more cost effective to set aside portions of their practice to treat Medicaid patients for free.

We need a bold initiative created in a transparent process by policy and medical experts, not negotiated in back rooms with pharmaceutical and insurance lobbyists. I don’t know exactly what that would look like, but I will suggest some useful principles to guide true reform.

Access to basic medical care is a right, not a privilege. Advanced industrial societies should provide a way to provide basic care to all of their citizens. I realize that the debate over “preventative care” can get murky very fast (as we are witnessing with the controversial HHS mandates announced earlier this year), but we need to work toward creating a system where any man, woman, or child has access to a doctor or dentist when they are ill or in need of periodic check-ups.

Medical personnel are highly-trained professionals who deserve reasonable compensation. Doctors devote many years to schooling and additional training. Our system needs to encourage, not discourage, promising students to pursue medical careers.

Seek alternatives to our current fee-for-service system that encourages unnecessary procedures and over-testing. Many procedures are essential, but many others are not. Medical research helps physicians develop best practices; patients should pay more for tests and procedures beyond that which is medically necessary.

Waiting for Results: Helping Now

Given the current political climate, I have little expectation that we will see comprehensive health care reform anytime soon. What can we be doing in the meantime?

One place to start is helping free and low-cost medical and dental clinics by volunteering time and/or donating funds. Community-based health clinics offer a range of services to care for those in need. Many Christian medical professionals also contribute by regularly seeing a few patients for free. Hospitals provide billions of dollars in free care each year, much (but not all) of this in compliance with government regulations.

We can also support those elected officials who have the political courage to pursue comprehensive health care reform. Scores of legislators and several presidents have made serious attempts at reform over the past half century, but voters have rarely rewarded such efforts. We need to encourage and reward those willing to take the political risks necessary to find a long term solution to the nation’s health care crisis.

The Hard Work of Health Care Policy

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Insurance is kind of a funny thing. When I decide to purchase life insurance I’m essentially saying to the lender, “I bet you I die.” The lender takes a look at me, considers the odds of my demise, sets a price accordingly, and responds, “I bet you don’t.”

All insurance works this way. And, when the market is functioning efficiently, insurance is a great deal for both lenders and purchasers. Consumers receive protection from emergencies at a price consistent with the chances of an event occurring. If I choose to live on the beach in Florida, hurricane insurance will cost more than if I lived in Colorado. Then again, life insurance is likely to be more expensive if you are regularly rock climbing in Colorado.

Insurers profit by “winning” their bets with policy purchasers. As all smart investors know, they increase their odds of coming out ahead by diluting risk. By insuring as many skiers and Florida homeowners as possible, insurance companies can make payments to the very few who actually make use of their coverage and remain profitable.

Health insurance functions in largely the same way as other forms of insurance. Consumers bet they will get sick, and insurers bet that they won’t. However, the health insurance market has characteristics that distinguish it from other insurance markets and make it quite complicated as a matter of public policy. Here are just five examples that demonstrate the complexity of public health:

  1. Though many choose not to live in hurricane zones or to ski, everyone needs health care at some point in their lives.
  2. Though individual behavior is a key component of health, sometimes health care is required regardless of choice, as with genetic disease or children born with a disability.
  3. Health is deeply personal. It can affect our whole lives and is often a matter of life or death.
  4. Health care is incredibly complex. Consumers often can’t understand the technical nature of disease diagnosis and treatment, and therefore must rely on others’ expertise when making decisions.  
  5. Health care is expensive. Advances in medicine and technological innovation have led to new cures, remedies and diagnostic techniques, and have greatly increased both the odds of survival and lifespan. All of this comes with a hefty price tag. When coupled with the costs of bureaucracy, regulation, malpractice lawsuits and the gulf between consumer and price, the sum mounts quickly.

As a result of these and other factors, health care policy has been a primary cause of debate in American politics for years. In 2010, President Obama and Democrats in Congress were able to pass the Patient Protection and Affordable Care Act, commonly referred to as Obamacare. The administration’s intent was to solve the problem of coverage for those without access to insurance through existing means, such as through an employer, private insurance market, veteran’s benefits, Medicare or Medicaid.

For some, lack of insurance was due to a “pre-existing condition,” a medical scenario of some type that occurs while an individual is uninsured that prevents a company from providing coverage. For others, insurance was simply too expensive or deemed unnecessary.

The Affordable Care Act was a divisive one, a bill that did not receive a single vote from congressional Republicans. Public polling showed a majority disfavored the law at the time it passed. (The same holds true today.) The reasons for discontent were varied, but at the core of the debate was the role of government, specifically in a key provision called the individual mandate. 

The individual mandate requires Americans who aren’t receiving health care coverage to purchase health insurance. This is a key point: the mandate forces individuals to purchase a product they would otherwise choose not to buy. Additionally, it requires employers such as small businesses and not-for-profit organizations to provide a certain minimum level of coverage to their employees. Burdensome financial penalties are leveled against those who fail to comply.

On Thursday, the Supreme Court is expected to rule on the constitutionality of the law, with specific attention to the individual mandate. There are a number of possible results, but most believe the Court will decide one of three ways: uphold the law in its entirety; strike down the law in its entirety based on the unconstitutionality of the mandate; or strike down the mandate but allow that the other parts of the law may stand without it.

I believe the Court will — rightly — strike down the mandate. The president’s administration has argued the mandate falls well within the bounds of the commerce clause, the part of the Constitution that grants the federal government authority to regulate interstate commerce. The government has relied on the commerce clause as the basis for all kinds of regulation since the landmark Supreme Court decision Wickard v. Filburn, in which a farmer was denied the right to grow and consume wheat on his property because his actions were deemed to affect the national wheat industry.

Opponents of the Affordable Care Act have argued that unlike the active behavior of wheat growing addressed in Wickard, the individual mandate regulates inactivity. The law rests on the government’s power to regulate an industry in which an individual has chosen not to participate by electing not to purchase health insurance. Carrying this logic further, many have asked, “Can the government also require individuals to eat broccoli?”

Should the court rule against the Affordable Care Act, public health will return to the forefront of American policy debates. Problems of the cost of health care, the availability of affordable health care to the uninsured, and malpractice lawsuits must be addressed. Republicans in Congress have proposed numerous alternatives that speak to these crucial questions in various ways. Essentially, Republicans favor a market-based approach that offers more flexibility and options to consumers by allowing individuals to purchase insurance from any state, deregulating the industry, and incentivizing innovative insurance products like Health Savings Accounts.

Explaining the ins and outs of public health policy in a short space is difficult. I’ve been forced to leave out a lot. I wish I had space to explain the problem of distancing consumers from cost and the moral hazards created for doctors under current law. I had to almost entirely the consequences of personal behavior for health (obesity, for instance) and the morality of requiring society to subsidize costs associated with poor choices. I have also left out any discussion of end of life care, which accounts for a large percentage of total health care costs. I would love to have space to outline a dream vision for health care policy that removes employers from the equation and deregulates to allow individuals to choose from a variety of health products. Oh well.

I hope I have made clear that health care policy is complex, but important and worth the hard work of crafting quality public policy. I’ve argued (quite briefly) that the Affordable Care Act is unconstitutional and will need to be replaced. And I’ve outlined some broad guidelines for alternative legislation.

 

TOPIC # 8: Health Care

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Please consider the following potential leading questions

 

#1: The U. S. Supreme Court will soon pass judgment on whether the “individual mandate” requirement in President Obama’s Health Care initiative is constitutional. What are your views about this issue?

 

#2: If the “individual mandate” is declared unconstitutional, are there other workable and politically feasible means for providing adequate health care coverage for all Americans? 

 

#3: If you object to President Obama’s Health Care Initiative, what would you put in its place?

 

#4: The costs associated with health care continue to spiral. Are there workable and politically feasible means for reducing such costs? Can costs be contained without sacrificing the quality of or access to adequate health care services for all Americans?