Friday, September 14, 2007

Michael Blim Looks at Health Care (re-posted)

This was first posted in June.

I'm reposting it because it is relevant to what passes for "national debate" regarding available health care. As the presidential election race plods on every candidate seeks to look smart and tell less than the competition. We are snowed with meaningless soundbites, but through the storm an informed electorate is expected to select a candidate who will improve one of the country's most glaring shortcomings, how to distribute among ourselves a fair portion of the world's best health care.

Those who worship at the altar of market economics tell us with a straight face that everything will be okay and no one needs to mess with the world's best system of delivering good medicine and professional services. No need to mess with big pharma. No need to tinker with an inadequate supply of professionals. No need to mess with the insurance companies whose mission is to deselect those who most need to be insured with the goal of delivering attractive profits to investors. The best we can expect from that crowd is a cap on liability settlements..."tort reform" they call it. Those malpractice premiums are eating away at profits, so that is the best way to attack the problem. Riight. +

Oh, and the not-for-profit sector is in the game as well. While sucking virtually every dollar of revenue from the insurance industry by cooperating with billing practices derived from already-rationed health care (those with insurance are covered and those without are not covered) this subset of the industry simply writes off what passes for "community health," upwards of half to two-thirds of what would otherwise be tagged "profits." So, yes, non-profits are an important part of the problem. (A true non-profit would start by encouraging EVERYONE hurt or getting sick to seek immediate medical attention, not putting off needed care until their problems becomes untreatable or more expensive because of being uninsured. In the absence of universal health care, the only device available would have to be a means test...hello, market economics...but some baseline universal coverage could be devised that would eliminate even that.)

The world's most important economy should be embarrassed by the overall substandard health of its people. This conversation will not end any time soon. With this year's presidential election it is once again resuming.

Read what follows and think about it...


Today's "Below the Fold" feature from 3 Quarks should be read by everyone. I'm not a well-placed health-care professional or educator but I do work in a health-care system. Like the writer I have watched the trends he describes up close and personal for nearly five years. He's not so much complaining as looking around helplessly and asking what in the world should we do? He says clearly that the system is not only irrational but incapable of self-correction.

...self-preservation being keenly desired by many does not necessarily encourage rational choices. To the question of what is enough, for many, the answer is simply the egoistic reply of what is best for them. [Our two] choices – one to ration care by making it expensive, and the other to ration care by eliminating patients – are the unfortunate products of a system incapable of rationalizing itself.

A reader comment adds "If you want to live longer, stop going to doctors. because, given half a chance, they will kill you." I won't go that far, but my ninety year old mother still takes no prescription drugs and is in excellent health, despite the fact that she smoked unfiltered cigarettes for forty years before she finally quit. Go figure.

It is important to remember that this essay is not about specialists. It is about "family doctors" or, in insurance language, primary care physicians. Primary care physicians have two points in common with police officers. First, they're not always available when you need one. And second, those in the greatest need are often least likely to have access ...unless they have enough money.

Michael Blim teaches anthropology at the Graduate Center of the City University of New York. He writes about equality and global justice and is the author of Economy and Equality: The Global Challenge (2005).

I lost my family doctor last week. Or rather, he has decided to undertake a boutique practice, and I can’t afford the annual fee. So, in a way, he is leaving me, and I am not happy about it. Last week a friend of mine received a “Dear John” letter from her family physician. He is cutting 400 patients from his list, and he had selected her to be one of them. He is leaving her, and she is not happy either.

My friend and I are medically well connected. Both my partner and my friend work at a major research hospital in Boston. They know lots of doctors who know lots of doctors. And still, both of us are scrambling to find a family physician. Many have closed their practices to new patients, and even a well-placed word doesn’t always unlock their availability.

There must be primary care doctors who are not being overrun by patient demand, but in my quest to find a new doctor, I haven’t come across any with good track records in Boston that are not.
As the supply grows, so in turn does demand once more, fed by our unquenchable desire for more health and more well being. We return once again to the question: What is enough? The answer is presently unknowable for three reasons.

First, enough is defined now in terms of differential resources. If you have money or even proxy money such as insurance, private or federal, you can answer the question much more robustly. The lack of money or insurance for others defines in effect what is enough for them. The fact that persons making less than $20,000 a year spend 15% of their income on medical care and those making more than $70,000 spend just 3% of their income on medical care suggests how much more low income individuals are affected by medical costs than those with high incomes. I suspect, though I cannot prove it here, that high income individuals not only are better protected by insurance, but that they have more disposable income to devote to more health care consumption. This last might explain why hospitals are installing those hotel-like hospital wings complete with chefs and concierges, and thus making health care into a “quality experience.”

Second, the private system of medical care today is driven by the profit motive in which expanding our notion of what is enough in part creates greater demand for their products. For them, more is better, particularly as professional medical knowledge and ethics are being subjected to a business model. They can answer for their own interests, but their opinions of necessity are partial, and would probably boil down to the argument that we can never have enough, as health is more generally treated as an immeasurable human good.

Third, self-preservation being keenly desired by many does not necessarily encourage rational choices. To the question of what is enough, for many, the answer is simply the egoistic reply of what is best for them.

Read the whole thing. It will only take a few moments and will leave you with plenty to think about. Politicians are finally getting around to talking about health care. As the election season approaches I keep hearing that old joke line, "Hi! We are from the government and we're here to help you!" I'm already pulling on my boots.

There will be plenty of references to the "profit motive" in the coming months, suggesting that profits are somehow bad. This is a trap to be avoided. The fact is that non-profit (or as the fashionable locution so delicately articulates "not for profit" ) systems are just as bound by good business practices as their profit-making cousins. The difference is that the non-profit sector exists in order to furnish medical care to those in greatest need who either cannot afford to pay or come in the door larded with insurance. As a result billable sums that would otherwise flow into profits are written off in the interest of community health.


As an aside, since Obama mentioned health care there has been a noticeable spike in interest to my Obama post ...better than fifty percent of all hits for the last couple of days. I don't see this as an indicator of popularity of the candidate as much as interest in the topic. Michael Moore's film will also be like lighter fluid on the fire.

No comments: