The Nubbin



One need think about the implications of this video only for a moment to understand the essential issue: a system that depends on private insurance is potentially no system at all. That insurers routinely deny coverage for any number of reasons means that, in addition to the forty-seven million who have no insurance, there are potentially millions more who only think they do, despite paying premiums.

Insurance companies do not provide medical care. They collect money, invest it, dole it out when they have no way not to. Even for the so-called "non-profits," it's a money-making business, the basis of which is taking money intended for health care, keeping as much of it as possible for as long as possible, returning to the system as little as possible. If it can also be said of physicians and hospitals that they profit from the ill health of others, at least those entities are providing actual care. If we're serious about real health care reform (and it's evident that the "we" is the populace, but not its elected officials), it ought to be the case that any citizen who gets sick can receive care, regardless of the timing of their illness or where it falls in the fine print. Period. And, of course, the same ought to apply to well-care (assuming we know what interventions actually add to health. As opposed to prophylactic spine manipulations, homeopathy, and other forms of woo.) The criterion for coverage: you exist. Other countries do it; why not us?

This is the central idea, the raison d'etre, of a single payer plan. Same rules for everyone. Guaranteed coverage. No wondering, no legions of people spending dollars intended for health care trying to find ways out of spending dollars intended for health care.

And, taking it all the way, what if this care were not only guaranteed but free (or nearly free) of premiums? So what if certain taxes were raised to pay for it? Wouldn't that be more than offset (or at least evenly offset) by freedom from those premiums? And by the fact that there'd no longer be an unnecessary and very expensive intermediary between people and the care they get?

To me it's obvious. Inevitable, even. Although watching Congress I conclude it won't happen for a few more decades, assuming we still exist by then; and only after a complete failure of the current system. The opposition continues to parade their hand-crafted talking points, designed to scare and distract. There simply are no salient arguments I've heard that make a case for maintaining the intermediary of hundreds of insurance companies, other than what amounts to "we need them because we have them." What good are they adding? What particular and essential need do they fill? For the billions and billions of dollars, intended for health care, that insurance companies make, take, and keep, what do consumers get that justifies their existence? The "public option," they tell us, "is just a way to get rid of insurance companies." And that would be bad, how?

Seriously. Somebody tell me. I can't think of a thing.

And yet, if you listen to our Congresscrowd -- practically all of 'em -- you'd think it's the insurance companies that are responsible for everything that's good about American health care. "The best health care the world has ever known," as one of them recently said, ignoring the price we're paying compared to the rest of the world, the millions with limited access to it, and the fact that we are at the bottom end of most measurable health criteria.

This might be a good time to insert a cartoon that Ellen sent me:

I think it is the essence of the contrary argument. Although, as I've said, were we to go all the way to provide universal coverage under a single payer, taxes would be offset. For those who love insurance companies, there ought to be a way to provide them the option.

Or, if they want the same result without all the paper work, whenever they get sick they could run into their bathrooms and do this.

Res Ipsa Loquitur

Having nothing but time on his hands like any law student, esteemed reader Patrick sent me a link to a pdf containing the arbitration brief of a recent and widely publicized case. Far be it from me to beat a dead horse, but it seems a tidy argument for finding a way to provide health care without the need for dozens and scores of insurance companies. (And as an aside, a look at why, to some degree anyway, I've always been sort-of attracted to law as a profession: the orderliness, the linearity, the need for factual and logical thinking. Sometimes.)

The case is that of a woman who, despite having perfectly good health insurance, was approached by a (predatory?) guy wanting to sell her a less-expensive policy. Forms were filled out. She evidently thought it was going to be some sort of automatic transfer, rather than an application. At some point, the number for her weight had been changed on the form; the change was initialed by the agent, not by the woman. The form went forward, the insurance company reviewers noted the change but did not raise questions at the time, at least not to the woman. The old insurance dropped, the new policy established. Then she got breast cancer. Ostensibly because of the weight-change shenanigans, the insurance was canceled. Claims and counter-claims were made, and the case went to arbitration by a retired judge. (My dad was a judge, and when he retired, he was a much sought-after arbitrator.) (There's no real point to that interjection other than the fact that I always enjoyed hearing him discuss the process and the issues.) The result was a decision in favor of the woman, to the tune of several million dollars.

One might see the case as less about bad old insurers than about fine points of insurance law. In the brief, there was much about "due consideration" and "good faith" and various quite particular minutiae, from which one might or might not generalize. But one fact struck me as very important beyond the case at hand: employees of the insurer are paid, in part, based on how many claims they DENY; how much money they save for the company. They get bonuses for that. (Outrage mine.)

Just good business, some would say; and at some level they'd have a point. But that's exactly the problem. Having insurers sitting between providers and patients, taking money from both -- inserting the business of business and creating a whole profit-making/money-sucking ("non-profit" or not) enterprise that has nothing to do with providing actual care -- seems an obvious and unnecessary waste of health care dollars. Particularly when the business thus inserted clearly -- because its business is business, not healthcare -- has the aim of authorizing the least amount of care that is possible.

Most doctors hate the idea of a single-payer health care system, and for many good reasons, most of which have to do with concerns about loss of control. Of care decisions, of pay. I share them. But there can be no doubt that the system as now constructed in the US diverts huge amounts of dollars to companies that have nothing to do with actual care, and even -- as we see here -- to funding their efforts not to pay for it; and the amount is way more than would occur with a single payer and a single set of rules, aimed at paying for care rather than trying not to.

I've made it clear how disastrous I think is the trend, especially in Medicare and Medicaid, to pay providers less and less; how it will lead to huge access problems and changes in the sort of people who choose to become doctors. About that I have no illusions. But I don't think "single payer" and "cutting pay" and "onerous rules" need to be synonymous. For one, there'd be more money to work with. And it simply can't be totally impossible to find an operating model that would include providers in a meaningful way to set up and govern the execution. Improbable, maybe, but not impossible; unless politics as usual remains politics as usual.

Rationale

I've written in this blog, and in a certain book I've been known to hype, about the pleasures of doing an operation when it all comes together. I've compared it to music: the transcendent feeling that derives from the sense that the team is flowing together, from being able to ply the craft with no distractions. No need to wait for an instrument, to ask for something you always use; having people assembled who know you, and what your intent is and who can nearly wordlessly join the orchestration of effort, uplifted by the knowledge that you have been invited into the essence of another human being. Because, for many reasons, it's rare to work with the same team over and over, achieving that kind of soaring synergy is uncommon -- when it happens it's invigorating beyond words. When it doesn't, the lack is ruefully noted at best; deeply disturbing at worst. That an operation is carried out by a team is an understatement, which brings me to the off-the-wall point of this post. As much as I love it when able to do surgery in a way that I consider some sort of artistry, and as much as I realize that being able to do so is the result of the efforts of nearly countless people, there are times when I've had a moment of disconnection (or is it clarity perhaps?) and have wondered if it's all insanity.

For an operation of anything more than the most minimal magnitude, the team consists of at least five people -- and often more: anesthetist, surgeon, assistant, scrub nurse or tech, and circulator (meaning the person who runs around getting stuff, more or less) but it's always in fact way more than that: anesthesia tech, people in the sterile core, in the pre-op holding area, admitting, in the recovery room. Central supply techs, assistants to set up and turn the rooms over between cases. Schedulers, people at the front desk keeping the day in synch. And these are just some of the folks surrounding the operation itself. One-on-one or one-on-two nursing in the intensive care unit, around the clock. Nurses, aides, assistants on the surgical floor; physical therapists, social workers, unit managers and clerks. Pharmacists, lab techs. The number of people involved in supporting an operation on any individual is staggering. Clearly, for the patient and his/her family, it seems worth it. But is it crazy to wonder if it makes sense, economically? Or even, given limited resources, ethically? Thinking of so many people involved in the care of a single individual makes me wonder, sometimes, if societies would be better off if that effort and treasure were directed in ways that would benefit more people. Is surgery an example of our fundamental instincts to help one another; or a sign of misguided priorities? Do we allow such lop-sided economics because, at bottom, we want that effort when it's our turn, damn the cost? I'm no philosopher, nor an economist. I don't suppose societies ought to behave only on the basis of cost-effectiveness: some values are reflected in ways that don't fit bottom-line thinking. Still, there are times when I look at all the effort involved in supporting what I do, and it gives me pause. Funny thing is, I've never regarded any patient -- famous or infamous, wealthy or destitute, brilliant or slow -- as unworthy of that effort. It's only when I think of myself lying on an OR table, and of all the people called upon to do whatever they'd be doing to accomplish whatever operation I'd be getting, that I think of it as somehow unseemly. But that's just me, I guess.

* * * * * *

Well now, as luck would have it, while I'm putting the finishing touches on this post, there appears an article in the local paper about an eight-year-old boy receiving an intestinal transplant. So maybe it's destiny that this becomes about something larger (as I implied in a recent post, we're not in charge of our thoughts anyway.) The pictures show it: he's a really cute kid, and he's looking forward to being able to eat. It's heartwarming; it really is. And yet. The operations that gave me pause above are in the most minor of leagues compared to this sort of thing. Dozens of OR personnel, people involved in the harvesting, the maintenance of the organ; lab folks. The immediate post-operative care is highly labor-intensive; the drugs, the after-care. And oh, the dollars.

I recall watching Ronald Reagan many years ago, as he made a very public show of donating to the fund for a liver transplant for some cute little kid, during a time in his presidency when he'd been loudly decrying the costs of health care. There's a huge disconnect: who isn't moved by this beautiful child, who would admit to begrudging him whatever it takes? And who, if in a darkened room away from prying eyes and ears, if not given the particulars of any individual, if crunching numbers trying to balance budgets, would argue for paying a million bucks or more for a procedure whose long-term survival is discussed in terms of three-year alloquots? But if it were their child...?

It seems inevitable that at some point the US will join the rest of the western world and provide some form of universal healthcare. I wonder when, in the process of discussing it, the R-word will finally be raised and addressed head on? Unless there's agreement that healthcare is the sort of priority that gets all the money it takes to provide all the care possible to everyone in need no matter the details, sooner or later "RATIONING" (call it whatever you prefer) has to be part of the mix. Somewhere along the line, we will have to say THIS is how much or our federal budget we're willing to spend on healthcare; THESE are the things we're willing to pay for; and HERE is how we'll pay it. It's way too important to leave to the insurance companies, and it's way too difficult to think politicians would tackle it seriously, let alone with an eye to finding actual solutions. (They're all too busy electing themselves and playing power games -- and have been for several years.) If anyone asks me, I'll tell them we need to convene a dedicated group of economists, health-care experts, maybe toss in a politician or two if any can be found willing to out-stick their necks, business folk, consumers. Maybe lock 'em in a room with hardtack and water, don't let them out until they come up with a plan and a price; maybe a couple of them. And then let everyone think about it for awhile, and put it to a vote. It's long overdue. Meanwhile, out of concern for your money, I promise not to have an intestinal transplant.