Jay Lake (jaylake) wrote,
Jay Lake

[culture] The politics of American healthcare

Having a bit of a discussion on Facebook with my friend Bryan Schmidt. We don't agree on much politically, but we manage to get along just fine, and remain happily civil when we get into political interchanges. My response to his remarks from overnight was such that I've decided to promote it to a blog post.

Jay, I have a friend in England who hs been denied surgery by their public healthcare several times for surgery the govt claims is non-essential but his doctor says is. In fact more than one doctor because he got multiple opinions hoping to influence the govt decision.

Unlimited government healthcare can be great stuff.

As the case may be, though I'd hardly describe the UK system as "unlimited" anything. I'll point out also that no system is perfect, but the UK has the virtue of nearly universal coverage without significant compromise in social outcomes measured by infant mortality, average life expectancy, etc., where in many cases their system provides superior outcomes to the American system.

Also, though you did not raise this point as such, I'd like to highlight the fact that many Americans don't understand the difference between "single payer" and "single provider" systems. This is largely because the GOP, the AMA and the insurance industry have spent the years since WWII throwing up a deliberate cloud of confusion about "socialized medicine" in order to short-circuit any reasonable discussion of these concepts.

The UK has a single provider system. Canada has a single payer system. In the US, the VA medical system is an example of single provider. Medicare is an example of single payer. Oddly, most people in both those systems like them quite a bit, and would be appalled to discover they are victims of socialized medicine.

The issue is not privatization, it's capitalism. HMOs and drug companies and our culture of greed have created a health care environment where the rich get the best and everyone else settles.

I don't think we disagree much here. Healthcare is a market segment where the profit motive is fundamentally at odds with the nominal mission, which creates a permanent tension.

The government can't run health care any better than any other of its failed, mismanaged programs, espc. In this culture of greed.

Now you're falling into empty conservative rhetoric. Ronald Reagan's greatest, most successful lie was "Government is the problem." Government is no more automatically prone to failure than the private sector is automatically prone to success. The private sector fails all the time. Look at the statistics on the number of private sector mergers and acquisitions that meet their stated financial and business goals. It's abysmally low. Likewise, look at the statistics on how many major IT projects are cancelled or truncated. If the market were the magic conservatives like to think it is, companies would never go out of business.

Similarly, plenty of government programs work very well. Emergency services, for example. Virtually every community in the United States has a publicly-operated fire department, which generally enjoy sufficient funding and little political opposition. And fire departments tend to poll very well. How well would private sector fire departments function?

When you make a baseline assumption that everything government does will be a mismanaged failure, you'll find plenty of evidence for that due to observational bias.

For whatever it's worth, I don't presumptively assume that government healthcare is the answer. As it happens, Medicare is by far the most efficient healthcare funder in this country, measuring by overhead. That is to say, Medicare spends a larger percentage of every dollar on healthcare than any private sector insurance provider. It also polls very well in customer satisfaction. Hardly a failed, mismanaged program.

What government's proper role here is in regulation. That's how our system is established, right there in the Constitution, Article I, Section 8, Clause 3 — Congress is given the responsibility "To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes".

The conservative panacea of industry self-regulation is a laughable myth. This has been demonstrated over and over again through our history, from the Gilded Age to Enron to the Wall Street derivatives nonsense of recent years. For-profit companies are by design and law intended to maximize both revenue and profit. Our current system evaluates this on a quarterly basis, with the "long view" being a year or two. There are explicit structural incentives for private health insurance providers to limit payouts, and reduce or eliminate coverage for expensive insureds. Like, say, me.

So whether government enters the coverage business directly (say, by expanding Medicare) or simply regulates the behavior of insurance providers, it must have a role.

Also, for more on my response to Ronald Reagan's anti-government rhetoric, see this post of mine.

If we want to change health care, we need to redefine it as about "Care" and "Health," not a family's egos. When the Schiavos can waste hundreds of thousands of dollars and resources keeping alive their dead daughter, money and resources better spent on someone with the hope of a quality of life, while other people die of diseases and injuries we long ago learned how to easily treat, the system is broken not from conservatism but from its heart. It's not about what it's supposed to be about, but the soft, bleeding heart Americans can't give up, can't let people go, can't allow our loved ones to die. Fine if those poor people do, but not our families.

The Schiavo case is a very odd example to cite in making a conservative argument, given the specifics of it. Her life was prolonged (at great expense, as you point out) against the wishes of her husband through the effort of significant conservative legal and political muscle, given that her parents had rallied the Right-to-Life movement. That was pretty much the opposite of bleeding heart liberalism, forcing government intervention into a private family matter and seeking to remove the decision from the hands of her husband, where it legally and morally rested. Conservative action prolonged Terri Schiavo's life, extended the expense for years, and made a political and media circus out of the tragedy of her death.

Speaking as someone who's been at death's door more than once in the past two and a half years (I came within about two minutes of death at the time of my original ER admission that led to the primary cancer diagnosis), I'd strongly prefer my loved ones not let go and allow me to die. I don't think it's a simple as people being willing to let go, and I don't think that's a "bleeding heart" issue.

It's a sick, corrupting philosophy which government control doesn't change. I've been around the health industry all my life. My dad's a doctor, mom's a nurse, dad trained paramedics and techs, uncle developed ultrasound tech and died of cancer for his effort -- it's a bigger problem than "limited government." It's an attitude.

Again, I don't think the American dysfunction around end-of-life issues is an inherently political issue, though it is certainly subject to politicization. Palin's mendacious "death panels" meme is a very good example of conservatives explicitly undermining efforts to make end-of-life care reasonable, for example. The dysfunction is much deeper in our national psyche than that.

Tags: cancer, culture, health, healthcare, politics

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