Thursday, September 24, 2009

Death Panels? Puh-leeze!

In a great post on The Health Care Blog
Bob Wachter goes macro-politico with a title that sums it up all too chillingly: "Death Panels, Palliative Care, and the Dangers of Modern McCarthyism," and my spleen gets the best of me...

The health care reform debate has been turned into a fetid dumping ground not just for right-wing fanatics and the disgruntled fools who follow them, but for the sprawling, unconscious anxieties of people who know nothing about medicine or how health care financing and delivery really works. Death panels? Puh-leeze!

Aside from those transparently on the anti-Obama warpath, what is really driving the hysteria about the belated modernization of reimbursement for end-of-life care is nothing more complicated than fear: an unalloyed fear of death, a primordial revulsion at the gruesome reality that awaits all of us sooner or later and, more broadly, the infantile fear we all have regarding the loss of control of our bodies, minds, and lives.

Unfortunately, it's far easier to rage against government (or against health plans, or drug companies, if you're left-wing and equally unconscious) than it is to rage against mortality, or God's silence, or one's self for decades of smoking, eating garbage, and exercising nothing more than one's mouth. The "death panel" nutjobs seem to be laboring under the weird self-delusion that their categorical tirades against "government health care" might somehow mitigate the hardest fact of life, i.e., that life ends, no matter who we vote for, or what nonsense we choose to believe about health care and government's role in the system.

The government may or may not be able to fix a broken health insurance market with regulation even the health insurers now acknowledge is necessary. But in the end, government no matter how large, small or non-existent, will not be able to bail us out of the saddest fact of life. Instead of muddying up the reform debate, these folks need to grow up, see a therapist, take a philosophy course, or actually read their Bibles...

Monday, September 14, 2009

What Health Care "System?"

In the screaming match that passes for today's health care reform debate, fear and sanctimony are running the show, while rationality, data and decorum have left the building. Why does everyone seem hellbent on blaming everyone else for bad faith? Because we are ALL victims of a situation beyond anyone's control - and victims tend not to be rational, nor data-driven, nor decorous.

So let's see if we can agree on one simple fact: there is no US health care “system.” What we call our “system” is, in daily practice, a sprawling hodgepodge of historic accidents (e.g., job-based insurance); ideological conflict (e.g. government/corporations good/evil or vice versa); and competing economic schemes with enormous amounts of cash in play. Health care in America combines the tortured, politicized complexity of the U.S. tax code with a conundra of intractable political, cultural, and religious disagreements about personal rights and responsibilities.

This may not be news to us health care lifers, even if it is to the idealists in the Obama Administration or the opportunists on Wall Street, but every time policymakers, corporate health benefits purchasers, insurance companies, or entrepreneurs try to fix something in our health care system, they run smack into its central reality: the primary producers and consumers of medical care are uniquely, stubbornly self-serving as they chew through vast sums of other people’s money. Doctors and hospitals are driven by irresolvable conflicts between personal gain and ethical responsibilities; patients are driven by the acrimony and anguish that accompany life-and-death medical decisions; consumers, paying for the most part with everybody’s money but their own, demand that the system serve them with the immediacy and flexibility of other industries; and health insurers are trapped in the middle, trying to keep everybody happy. A group of highly imaginative, energetic people armed with the world’s largest Mark-n-Wipe board could not purposefully design a more complex, dysfunctional system if they tried. The result is a $2 trillion-per-year fiasco in slow motion, a bloody mess narrated with moral shrillness and played out one competing anecdote after another. Death panels? Puh-leeze. Read the actual bill, and you'll be forced to admit that what's really driving the hysteria is fear - of government, of death, of the loss of control - not anything written by anyone in Washington.

So where do we go from here? Quite simply: somewhere else. Now. Another decade of the status quo, and we will have squandered both the political moment for real change ushered in with the election of President Obama, and we will confront the inevitable collapse of our non-system, one that finally fails not just the un-insured and under-insured, but one that fails all of us, including those screaming loudest to protect the status quo. How else to explain why (1) most Americans think the health care "system" is a mess while (2) most Americans are scared to death of changing it. This paradox is rooted in the fact that our health care "system" is a disaster, while at the same time, our medical industrial complex still produces, year after year, the world's greatest medical miracles. If you don't think so, ask anyone old enough to remember the AIDS quilt, or what a breast cancer diagnosis used to mean, or how we used to treat chronic schizophrenia.

That's the $2 trillion question: how can we save American medicine while junking American health care? Maybe if we only stop screaming long enough to have a real discussion about it...

Employers & Health Care, Episode 19327

Consider this note from the CEO of a once-growing technology company in the midst, like too many these days, of a major restructuring.

"As you guys saw from the draft termination letter from [our current health plan], we have had this policy in place for only 13.75 months - 4.25 months short of the number that puts the HIPAA 'portability' guarantee into place for our people. As I understand it, under the law we are all eligible for that guarantee regardless, as we had coverage from [our previous health plan] in the months prior to 8/1. But adding a second look-back carrier to prove that to any third and subsequent carrier inserts one more node of potential administrative failure which the third carrier would fully exploit to deny somebody coverage for any big medical stuff. So regardless of any other administrative decisions re: our people, let's keep this restored coverage in place with [current health plan] until we pass the 18-month mark, in the interest of minimizing potential points of failure on the one thing that could ruin one of our people faster than anything else out there."

Unless we want to write this off as paranoia and/or micro-management, let's consider a really basic question: why should the CEO of a technology company be this knowledgeable - and this anxious in this much detail - about health insurance regulations and how they play out in the real world? Is this anyway to run an economy?

The right answer, as with so much in health care is political. Health insurance should be completely portable for all US citizens, among all licensed health plan carriers; if one element of the Obama health reform package survives the next political storm, this should be it - so that the busy people charged with growing the US economy out of this miserable hole can focus on their real jobs.

In the meanwhile, if you were reporting to or consulting with this CEO, would you agree with what he says his company should do?