Health Care For All Americans, Part 3: UPDATED

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Over the past few days, Dr. John and I have been having a fascinating discussion about this post from September 2008.  It is one of the first pieces I wrote for Extreme Thinkover,  before President Obama was elected, as well as at least a year before the serious work on what would become the Patient Protection and Affordable Care Act, known as “Obamacare” (but which I prefer to refer as “the ACA”) was being worked on.  It was also before Dr. John and I met and got acquainted.

I deliberately haven’t edited the post below, so our comments will make sense in the context in which they were written will make sense.  I think my readers will enjoy the back and forth between us, and I invite you to add your own comments, should you feel so inclined.

IMPORTANT: Read the comments starting from the bottom of the thread. It is where the discussion starts. And you may have to move up and down a few comments for our replies because of the way WordPress publishes them: by the time stamp of the comment/reply and not directly associated with a given submission.  Sorry for the inconvenience.

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Health Care for All Americans: Part 3

In Parts 1 and 2,  I discussed first, the assumptions needed from a medical perspective, particularly with respect  to the scope of treatment plans that would lead to optimizing the health of Americans, and second, how those assumptions would create a radical transformation in the health of Americans that would work its way through all aspects of daily life.  In Part 3, I now want to describe the logic that shows how the country would benefit.

We’ll start using my first assumption: Preventable diseases are prevented.

We could use any number of examples, but the format of the blog does requires some brevity, rather than a detailed White Paper or journal article.  I also acknowledge that the ideas I  present here have all been suggested by others, but this is how I choose to organize them.

For purposes of our discussion let’s call our example citizen, Larry.  Larry works full time for minimum wage, does not have  health insurance, and cannot afford to buy private insurance.  He also does not qualify for any government health care benefits.  Larry’s wife also works for minimum wage, but only 24 hours per week.

As long as his health holds, Larry can work and he has no medical needs.  He pays local, federal and state taxes and uses no special government services.

But let’s say that Larry gets pneumonia.  It is a very common viral strain, and can be treated successfully with antibiotics, and could have been avoided entirely if Larry had had a pneumonia vaccination.  Now he’s faced with a dilemma.  At first he thinks he just has a chest cold and he can wait it out.  Being a conscientious worker, he toughs it out and goes to work, but exposes his coworkers to the bug through his worsening cough.

By the weekend, Larry is really sick.  Over the counter cough medicines provide almost no relief, and on top of that, his cough is becoming increasingly productive.  He cannot sleep because of the cough and not being able to find a position in bed where he can breathe without effort and  pain.  Larry knows he needs to see a doctor, but having no insurance, he does not have a primary care physician, so he has no idea who to call.  Finally his breathing becomes so difficult that his wife calls  911.  Larry is taken to an emergency room by ambulance, but one on the far side of the city because the hospital closest does not like to take patients without insurance.

By the time Larry gets to an emergency room that will accept him as a patient he is nearly in respiratory arrest.   The ER doctor quickly diagnoses the pneumonia, but that it is so advanced that Larry’s life is in danger.  She intubates him immediately and transfers him to the hospital’s intensive care unit. It is four days before Larry’s condition has improved enough to send him to a “step-down” unit and two more days before he can be admitted to a medical unit room, and he is discharged two days after that.

Larry is fortunate that the hospital he is at has Certified RN and MSW Care Managers.  They work with him and his wife throughout  the hospitalization, develop a treatment plan and a discharge plan, set Larry up with a local medical clinic that treats patients without insurance, and provide his wife with food  vouchers and bus tokens so she can make the long trip back and forth to the hospital.

Despite all this, when Larry is wheeled out to the taxi to take him home, he has a hospital bill that is $250,000.  Since Larry and his wife together make too much money to qualify for Medicare, that bill rests squarely on their shoulders. He has no way to pay it back.  He will not be strong enough to work for at least another three weeks.  He will have not earned a dollar since he got sick, and won’t until he returns to work.  His wife’s income is not sufficient to cover all their bills,  and if they pay the rent, they will not have enough money to buy food.  The hospital sent home a week’s supply of medications, but after that, he will have to pay for them himself, and due to the damage to his lungs, he will need regular medications for at least six months.  Those prescriptions will cost over $800 per month.  Through the free medical clinic he can apply for medication cost support , but that can take up to four weeks to be approved assuming he qualifies.

Now multiply this basic scenario by twenty or thirty million Larrys a year. Every year. That is health care in America.

Here’s what happens.  The only good news is that Larry has survived a brush with death, ironically from a completely preventable disease.

Larry and his wife now owe the hospital $250,000.  They have no assets.  Even though they signed a promissory note with the hospital, no one is under the illusion that he will be able to pay back more than a few thousand dollars if he is a very conscientious person.

Larry and his wife owe the ambulance service perhaps $3,000.  They cannot pay it, or they will have to try to pay it off in very small amounts per year at a probably high interest rate.

Larry will lose at least a month’s income, and perhaps more if his recovery is longer than expected.  If he is very fortunate, his employer will hold his job until he can return.  In the meantime, his wife’s income is not large enough to cover their essential bills, starting with rent and food.  If Larry’s wife cannot get more hours from her current work, her only realistic option is to get another part time job, likely at minimum wage.  Whether that will at least let them pay for their basics is not certain.  It is also uncertain how flexible their landlord will be to let them catch up with their current rent.

It should be clear by now, that one simple, preventable illness has created a cascade of events that affects the economy, are extraordinarily expensive and completely unnecessary.  Yet, this is the true consequence of the current American health care system.

The hospital will have to write off the $250,000.  To compensate they will have to pass this loss, as well as hundreds of others per year, to their patients with insurance.

The ambulance company will have to spend a lot to try and recover their fee from Larry, and will pass those added expenses along to their other customers who can pay, either privately or with insurance.  If Larry doesn’t keep up with the payments, they may turn him over to collection, which will damage his credit.

Larry’s employer loses productivity from a good worker.  The company may have to hire temporary labor to fill Larry’s absence, which will be more expensive.

Larry and his wife lose essential income, which at minimum wage is marginal to begin with, and may jeopardize their ability to even house and feed themselves.

Every day that Larry does not work means that his wages do not generate taxes, local, county and federal, as well as FICA withholdings.  Multiply that by twenty or thirty million Larrys year after year and the loss is well into billions.  The impact of this loss of tax revenue and productivity is staggering on the national economy.

All this from a preventable disease that could have been stopped before it was started if Larry had had access to the most basic medical care.  Everybody loses.  The nation is weakened through attrition in ways no external threat could impose on us.   This national “epidemic” is progressive, it is close to end-stage, and we could all too easily end up with a terminal prognosis.  We may reach a point that we literally will be too unhealthy to survive as a nation.

We still have a choice.  Until the epidemic takes that away.

VINDICATED! Today a New Dawn Rose for a Healthier America

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CONSTITUTIONAL!

It is a day that even I wondered would ever come.  I began Extreme Thinkover with posts on the topic of comprehensive health care for all Americans.  I wrote in September of 2008:

The typical arguments for or against universal health care always focus on what the government will have to spend, what taxes will have to be raised to finance it at any level, or providing health care to consumers, i.e., virtually the whole population, has been, from my perspective, approached from the wrong frame of reference.

I put forth the argument on numerous occasions.  The Affordable Care Act, from my perspective, is a just solution to a miserably broken health care non-system.  It is just in the sense that this law creates a new level of access to medical assistance that Americans have never enjoyed, but that virtually every other First World country (and a number of smaller nations) has offered its citizens for decades.

The Affordable Care Act is the cornerstone of an inalienable right that makes possible in a tangible manner the chance for every person in the country to be healthier, and consequently enjoy the Blessings of Liberty. Yes, I can imagine the eyes rolling over that assertion.  But though it will take a generation, maybe more, to make that difference, doing nothing, that is, to go back to the pre-ACA situation, Americans would continue to be less healthy, costing perhaps trillions of dollars in avoidable care.  Now, at least we have a law, a system, that can turn that trend around.

Having worked in a hospital for over a decade and a half with daily patient contact, I can attest to the misery and personal suffering that those who have no insurance are forced to bear.  Add to that, my hospital is Catholic, with a mission to serve the poor and uninsured, and I have seen the incredible stress this very broken way of providing medical care has placed on my organization, restricting our capacity to plan for the future because tens of millions of dollars annually are required to subsidize those with no insurance.

I fully realize that the success of this change depends on individuals taking personal responsibility for their health.  I would contend, however, based on my experience with chronically ill patients who are poor or unemployed, they are caught in a vicious circle that all too often results in their getting the short end of the stick economically, for which access to medical care for wellness simply does not exist.

I could also put it this way, with the Supreme Court’s decision today, health care in America has finally stepped into the 20th Century.  The challenge now to us living in the 21st Century is fend off those who would overturn the law and plant us firmly back into the 19th Century.

People.  Real, live people with real live medical needs.  That is what the ACA is really about.  That is why for nearly four years, I’ve objected to the argument put forth by the law’s opponents that it was all about money and government.  I rejected that argument on both moral and ethical grounds.  Those who grouse that they are only paying for others bad habits are short-sighted, and in my opinion, fundamentally selfish.  To me, that argument is both highly ironic and paradoxical, because my experience with my neighbors has uniformly been that Americans possess a natural selflessness and generosity to help anyone in need.  But somehow getting the connection tied between to the two has been an uphill battle and continues to be.

For example, I have no doubt that if Sen. Mitch McConnell, Rep. John Boehner, Rep. Michelle Bachmann, or Sarah Palin were in a setting in which total strangers were injured and needed immediate emergency medical care, that every one of them would step up and wade in to help.  But all of them today condemned this law, despite the fact it acts on their behalf as well, so that their fellow citizens will receive that care as a matter of course.  And those patients won’t be nearly as likely to end up bankrupt as a result of seeking out that care.

Simply put, I don’t get it why they don’t get it. (I’ve got a pretty good notion why they think they don’t want to get it, however). Because of that great contradiction, conservatives like those mentioned above still want to overturn it legislatively.  I will continue to write to defend it.

(Yee-haw!)

A Recession Forty Years in the Making–Updated

This Great Recession  Didn’t Happen by Magic…My Rant

The Sniffer Returns. Photo Courtesy: Smith Detection UK

When last the Sniffer’s image appeared here on Extreme Thinkover, he (well, I think he’s a he) was celebrating the passage the the health care reform act, having sniffed out the “radiation” of American Health Insurance Providers and other members of Big Medicine’s failed assault against the legislation, spending undoubtedly hundreds of millions of their subscribers’ dollars in the process.  That money was intended by those who paid it, whether it was the funds directly from the insured or their employers, to pay for health care not to pay lobbyists and advertising to defeat every effort and piece of legislation devised to make it better.  Fortunes spent without consent.  A cruel form of taxation without representation.

We will probably never know how much money Big Medicine squandered in their complete and total defeat, as the benefits of health care for all Americans already taking effect, item by item, promises a future of access to medical care that for over two centuries we have never had the right and many have been denied by sheer accident of their socioeconomic status or a simple preexisting condition.

Now we have the right.  Obviously, we should be celebrating, right?  Right?

Political Memory Distortion

Some of our citizen sisters and brothers continue to snort and paw like an angry bull over the fact that they now have to participate in a society that cares for the medical needs of  all its citizens (joining finally nearly every other First World nation and many others), not just as country that rewards those who would hoard their worldly goods as if none of those around them had any role in the accumulation of that wealth.  In their anger, from distorted recollections of an earlier geopolitical battles, they call it socialism, an incoherent misunderstanding of that term in the history of political systems.  It is not socialism.

A Republic’s Highest Value

To the contrary, it is the highest value of a democratic republic: Sharing.  It is that simple.  In a democratic republic, one of the blessings of liberty is sharing.  To treat another as you would want to be treated.  We are now a large nation, over 300 million people and growing.  The day of a flat birth rate has passed.  It takes a lot of organizational structure to insure that the ideals and the order of a democratic republic are nourished over time.  It cannot be done by stinginess, or by isolationism.  The age of the Rugged Individualist has passed.  We now are connected in ways even those of us in our middle age could not dream of.  We now live in a shared world, a shared connectivity at the speed of light, the evolution of human ingenuity turned up on high, the 20th Century a platform for the 21st.

Equality consists in the same treatment of similar persons–Aristotle, 384-322 BCE.

Most of all it cannot be done by refusing to share in such a way that those with the most are continuously provided with more through no merit of their own, denying the dreams of those in the middle to improve their lot in life, it too a blessing of liberty, and effectively squelching the chance of those at the lowest rungs of life from ever daring to dream that those above them might welcome them to take those steps and dream those dreams out of their poverty.

The right to achieve prosperity in a democratic republic is not the exclusive right of those who have already achieved it through their own effort or inheritance.  At the same time, those who have achieved prosperity have no right to hoard their prosperity so that those who are trying to achieve it as well are denied their right to share in its blessings, regardless of their beginning station in life.  With all due diligence those who are prosperous must ensure that the efforts of those who desire to be so as well are rewarded and their growing prosperity welcomed.  But because human beings all have differing gifts, desires, capacities, and health, a democratic republic can exist living by its highest ideals when the prosperity of the whole also ensures the rights of the whole.

Rant complete.

An Unexpected Proof of Concept: 40 Billionaires’ Pledge

What I wrote in the previous paragraph is not just a flight of fancy or a theoretical construct that never would be tried by the very most prosperous people in our country.  On August 4, 2010, the foundation begun by billionaires Warren Buffet and Bill Gates announced that 40 billionaires have so far pledged to give away at least half of their fortunes during their lives or at their death.  Called The Giving Pledge, the list is available publicly online and, according to Buffet and Gates, this is only the beginning of their project.  For instance, the Wall Street Journal reported one of the pledger’s rational:

In an interview, Tom Steyer, founder of hedge fund Farallon Capital Management LLC in San Francisco, said he and his wife had planned to give away their wealth but decided to go public after Mr. Buffett called.

Mr. Steyer made the pledge to support what he sees as an effort by Mr. Buffett to show how those who profit from capitalism can help improve society.  “We want him to succeed in reshaping the way people think about the private enterprise system,” Mr. Steyer said.

MSNBC reported that the United States has about 400 billionaires, some 40% of the world’s total, and their net worth is estimated at $1.2 trillion.

Some of the billionaires have a very specific goal in mind for their pledge.  George Lucas, filmmaker and creator of the vast Star Wars empire stated,

“My pledge is to the process; as long as I have the resources at my disposal, I will seek to raise the bar for future generations of students of all ages,” filmmaker George Lucas said. “I am dedicating the majority of my wealth to improving education.”

Finally, Warren Buffett co-founder, remains ever the optimistic example for First Citizen in our democratic republic:

“We contacted between 70 and 80 people to get the 40. A few were unavailable. We don’t give up on them. Every saint has a past, every sinner has a future. We’ll keep on working,” Buffett said.

Thank you, Mr. Buffett and Mr. Gates.  You get it.  But we are not done here…

So What Next: A Recession Four Decades in the Making

How bad is it?  Ironically, out of the past a major player has come to the horrified realization that the policies of the past forty years, in which he played a major role, beginning with the disgraced Richard Nixon, set in motion the recessionary calamity we are trying to survive.

David Stockman, who was the director of the Office of Management and Budget under the evangelist of  “trickle down economics” and the fomenter of the doctrine that all government is essentially bad, Ronald Reagan, wrote these words published in the New York Times:

Republican pretense that its new monetarist and supply-side doctrines are rooted in its traditional financial philosophy. Republicans used to believe that prosperity depended upon the regular balancing of accounts — in government, in international trade, on the ledgers of central banks and in the financial affairs of private households and businesses, too. But the new catechism, as practiced by Republican policymakers for decades now, has amounted to little more than money printing and deficit finance — vulgar Keynesianism robed in the ideological vestments of the prosperous classes.

This approach has not simply made a mockery of traditional party ideals. It has also led to the serial financial bubbles and Wall Street depredations that have crippled our economy. More specifically, the new policy doctrines have caused four great deformations of the national economy, and modern Republicans have turned a blind eye to each one.

Although I politely disagree with Mr. Stockman’s criticism of Keynes, arguing as would Paul Krugman, Nobel Prize winning economist, that had Keynes’ economics been followed, instead of Reagan’s supply side fantasy, we might have avoided some of the damage Mr. Stockman places right at the door of the Republicans, who claim they want more of the same.

As our nation moves along the unstoppable path of time toward the General Election in November of this year, Mr. Stockman’s accusations against his own party are even more troubling.  He continues:

But in the end it was a new cadre of ideological tax-cutters who killed the Republicans’ fiscal religion.  Through the 1984 election, the old guard earnestly tried to control the deficit, rolling back about 40 percent of the original Reagan tax cuts. But when, in the following years, the Federal Reserve chairman, Paul Volcker, finally crushed inflation, enabling a solid economic rebound, the new tax-cutters not only claimed victory for their supply-side strategy but hooked Republicans for good on the delusion that the economy will outgrow the deficit if plied with enough tax cuts. (Emphasis added)

Delusion or Voodoo Economics: Your Choice

Dr. Krugman, however, agrees with Mr. Stockman on one major point: tax cuts will not help our economy outgrow the deficit now, any more than they did by the time Ronald Reagan left office in 1989.  Earlier this  month, also in the New York Times, Dr. Krugman wrote:

Now there are many things one could call the Bush economy, an economy that, even before recession struck, was characterized by sluggish job growth and stagnant family incomes; “vibrant” isn’t one of them. But the real news here is the confirmation that Republicans remain committed to deep voodoo, the claim that cutting taxes actually increases revenues.

It’s not true, of course. Ronald Reagan said that his tax cuts would reduce deficits, then presided over a near-tripling of federal debt…

But we’re talking about voodoo economics here, so perhaps it’s not surprising that belief in the magical powers of tax cuts is a zombie doctrine: no matter how many times you kill it with facts, it just keeps coming back. And despite repeated failure in practice, it is, more than ever, the official view of the G.O.P. (Emphasis added).

Are we at an impass: Yes.  I have done a lot of counseling during my career and one thing I have seen dozens of times is that a person who is suffering a delusion is not aware of the distortion of reality that is affecting them.  Voodoo, and I will place it squarely in the Hollywood horror genre’ and not the religion of many who live in and around the Caribbean, and the image of zombies, plays on our deep fears of somehow having our dead bodies overtaken and made to do nasty things to, well, anyone, but, in this instance screaming attractive American teenagers.

In terms of economics, the accusation of either, is to say something is deeply wrong, but we know that.  What we are suffering from, is the gathering force of economic distortions that have gathered for forty years.  Forty years.  How many really smart people, in both parties, noticed this, and said exactly nothing?  Was it delusions or voodoo?  How could that be, though?  The delusional cannot recognize their delusions, and the zombie’s revivified by voodoo do not know they aren’t supposed to be in that very state.  Does that mean there are not any really smart people left in either party who can figure it out?  A tantalizing question to ponder, I admit, but the answer is no.

If the Answer is “No,” What was the Question, Again?

The question, in the end, is not whether there were smart people following the economy for the last forty years; there were.  The question is how over forty years did nobody get it?  Since Richard Nixon brought the Union to its knees politically and economically, hundreds of economic models have been built, hundreds rejected because they didn’t work.  Computer modeling has entered the 21st Century–Economists of all stripes have access to these computers and run probably terabits of data through them to test the accuracy of their latest theory.

And yet we wallow in the debris of a Recession still threatening our national prosperity and influence, whose roots are easily traced to forty years ago.  This is a topic that must be more closely examined in the months ahead as the election approaches.  I think the Sniffer has a new assignment.