Because most philosophies that frown on reproduction don't survive.

Wednesday, February 13, 2008

Diseases Make People Sick

I wonder if one can say with without sounding like some sort of complete Scrooge...

There's a turn of phrase which has been bothering me a lot lately, and given that many predict health care will be a big issue in the coming election, I suspect I'll be hearing it a lot more.

"I think there's something wrong with a world where parents have to watch their child get sick because they don't have health insurance."

I understand what people mean to say, but: Not having health insurance is not itself a health problem. Indeed, 95% of the time, not having health care is not a health problem. The trick is, the other 5% can really get you.

Most of the time people are healthy. Our kids haven't been to a doctor for anything other than yearly checkups and vaccinations in about a year and a half. (And the last time we actually did take a kid in, we were told, "Yep. Looks like a virus. Get her plenty of rest and fluids.")

Now, I don't deny that not having health insurance is scarry, and at times costly. When we first moved to Texas, we found ourselves between coverage for a couple of months, during which time everyone got massive cases of strep throat and sinus infections. Just that cleaned us out a good $500 worth of money we didn't have, though what had really worried me was what would happen if we got in a massive car wreck or something and racked up tens of thousands in medical bills. (On the flip side, the $500 in actual medical bills was about the same as I was having witheld every month from my check to pay for insurance at the job I'd left in California.)

So my point is not necessarily to say that not having health insurance is no big deal. But I do think that it represents an emotional and unhelpful way to discuss the problem to imagine that simply being without health insurance itself makes people sick or makes people die.

Health insurance is one way, in our modern world of powerful but expensive medical care, to pay for health care. And paying for medical care is sometimes necessary when someone is sick or injured. However, it's the medical care which is sometimes necessary to health, not the insurance. Thinking inside the box of, "Lack of insurance equals sickness and death" limits our collective ability to consider all possible solutions to the "health care crisis".

Insurance has never made anyone healthy, nor does lacking insurance make people sick. Insurance is just a method of paying for things.


j. christian said...

The RAND Health Insurance Experiment showed that, among the general population, greater health insurance coverage does not lead to better health outcomes. It does help those with chronic illnesses who have regular and/or heavy medical bills, but for the average healthy person, it's not the cure-all some people think it is.

It's health outcomes that we should be worried about, not the method of paying for medical care. That's just a means to an end.

Rebekka said...

I wonder though about a difference in access to screenings or early diagnostics? I have seriously no data on this, but it seems to me that someone without insurance would wait longer before going to a doctor. With something like cancer, that could be the difference between an early diagnosis and too late.

Kyle R. Cupp said...

I've read that 18,000 Americans die each year due to lack of health insurance.

To my mind, a right to healthcare is an inseparable part of the right to life. That's the Church's position too.

Now, that doesn't mean that universal insurance is necessarily the best means of securing that right in society. As Darwin points out, insurance is a method. If it's not the best, then we should be actively seeking alternatives.

Darwin said...

I've heard that 18k statistic as well, which appears to go back to a AMA study in '02. Basically, they estimate that if people who had no insurance had had insurance that they would have had their diseases diagnosed earlier and would have sought treatment. It's not necessarily a bad rationale, but I'd be curious if there's a way to know, by the same rationale, how many people die each year from being too busy or from not liking doctors. In a country with 300 million people and lots of national statistics, even the number of children who drown in buckets is huge -- and so its hard to know what constitutes an empidemic and what's the normal friction of society, where people often don't do what experts believe they should do.

I'll admit, I am not clear what it means to talk about a "right to healthcare". I've read it in a few Church documents (more from the USCCB than from the Vatican, but I believe from both) but in some ways I find the phrase regrettable because of its imprecision.

Certainly, it seems clear to me that if vaccines and antibiotics were being poured into some desperately poor country, whose dictator then destroyed them all to exert pressure on the other side in an ongoing civil war, that this would constitute a grave violation of human rights.

And yet it seems strange to me to talk about a "right" to modern medical care, when it has existed less than 200 years.

Christ told us to care for the sick, and it does seem clear to me that we have the duty to care for the sick in whatever means we have available to us. I don't like phrasing that as a "right to healthcare" though. It seems to me too close to the thinking that leads people like Christopher Hitchens and Penn & Teller to condemn Mother Theresa for providing only basic care and not high tech hospitals and modern medicines.

Had she gone to the world and demanded a billion dollars to build and supply modern hospitals in Calcutta, I'm sure she could have got it. Instead she chose to teach her sisters to provide human care, not medical care.

And while I don't want to devalue the life-saving potential of medical care, it seems clear to me that it is not the only or the highest good in town.

Anonymous said...

Well ... Mother Teresa is an admirable example, but her emphasis was on care of the dying.

Insurance seems to work when a huge number of people buy into a system, so catastrophic mishaps by a few can be covered by the sheer numbers of contributors.

The problems start when the profit motive overrides the basic common sense of the insurance system. Health care seems too important for it to be a for-profit business. I don't see that corporations have an inherent advantage over a government or a not-for-profit system.

Oh wait, yes I do: they make tons of money on it, and invest a lot of this money to bribe politicians to help them make more.


Rebekka said...

I think "right to healthcare" is shorthand for "right to healthcare according to one's needs". Who decides what one's medical needs are? The doctor and the patient together. Not the insurance company.

Hospice can be as legitimate a choice as intensive care.

Darwin said...

Mother Teresa is an admirable example, but her emphasis was on care of the dying.

I think the argument from her critics is basically that a lot of those people didn't have to be "dying" if they got full, modern, high tech medical care.

My point on that one is not so much whether insurance companies are right or wrong, or should exist or shouldn't (that would have to be another post) but that it's not necessarily medical technology or "medical outcomes" that are the moral imperative so much as that we take care of our fellow creatures by whatever means we have available to us.

Rick Lugari said...

I really hate commenting on the health care issue because I have no real answers - all I have is the benefit of hindsight. It seems to me that the whole discussion is a mess on a number of levels. I'll try to encapsulate my thoughts though.

Blaming for-profit insurance companies for excessive health care costs seems to be way too simplistic and misguided. One, while not knowing the actual figures, I wouldn't be surprised if the majority of insured are insured by non-profit companies like Blue Cross - Blue Shield. As someone who has had BC/BS for over 15 years and is losing it (it costs $1800/month and my deductible $2500 annual deductible) for a small local HMO ($800/month with no deductible, but a $15 co-pay) I can attest that non-profit insurance companies aren't necessarily a more economical solution. But here's the real point on that matter: Let's say an insurance company is making a profit, even what anyone would consider an extremely healthy profit of 10% - so what? Let's say the average insurance policy for a family runs $1200 a month, eliminate the 10% profit and you're still talking about an $1100 a month bill. I don't take much comfort in that.

Another thing directly relating to the insurance companies (and I'm not an apologist for them, I just think we should acknowledge facts, otherwise we won't find solutions), is that they have actually served a valuable service in helping to control costs. I'll explain.

See, profit motives are certainly a big part of the problem with health care. When we examine the cost of health insurance, we're really examining a.) the genuine cost of health care and b.) people's economic decisions. Take away any profit from insurance companies and you will still see huge costs. Those costs contain layers upon layers of profit taken. The medical field is quite lucrative. Doctors are incredibly well paid. Nurses and other staff generally do fairly well. Pharmaceutical companies pay very well and make large profits, build costs in to fund further R&D. Hospitals make profits. Manufacturers of medical equipment pay well and make good profit. The list goes on and on. Insurance companies have to base their charges on what the costs are...those costs reflect a huge amount of profit taking across the layers. At least insurance companies usually make agreements with doctors and facilities to limit the costs of procedures, etc. If they didn't do that, who knows what HC would cost?

I think it's simple economics that the reason we have such great health care and technology is because of the profit motive and that insurance has been viewed as a cash cow. As GKC would say it's one of those things that turns on itself like a snowball. Thing is at some point (already there?) it will become an immovable boulder.

IMHO it would have been best to have foresaken so many truly wonderful advances and retained a more fundamental and charitable approach to health care. Not sure I'm stating that right. Had health care remained more in the sphere of corporal works of mercy - a vocation that people chose to do more as a call to help others rather than a job or career AND that health insurance never became anything more than a co-op pool of money for certain catastrophes rather than a perk that makes it so you don't have to pay a doctor's bill, etc. I think we wouldn't be in this situation.

And no, I don't think the government could do any better. If the government ran things, we would still have the same or worse problems at the provider end and the consumer end. If the government became the only insurance company in town, which is what many propose, it would do nothing to address the root issues and it would have to do the same things insurance companies do, like determining what will be covered and what won't...but the thing is you're stuck with whatever decision some bureaucrat made - you won't be able to say, okay, for the same money I can go to company B and get better coverage. On top of all that, at least for-profit companies have an incentive to keep operating costs down. GovCo has no such incentive, in fact, it's pretty fundamental that it is predisposed to growth, bureaucracy, and waste.

See? I have no answers - but neither does anyone else as far as I can tell.

PS. This didn't post when I click publish, and that gave me a moment to recall that I didn't address in any detail how "having insurance" influences our decisions, often in a careless or wasteful manner - I'm certainly guilty of it myself - but surely you can imagine what widespread "third-party deep pockets" have contributed to the snowball of costs.

Anonymous said...

Rick, I don't know the details of your new health care plan. But for-profit insurance companies have the profit incentive to drop high-risk people, including the elderly, from their insurance rolls. They make insurance overall a better-paying proposition for the young and healthy.

If you're over sixty and have been permitted to have your pre-existing conditions tag along with you to your new plan, then all the better for you. But if your new insurance doesn't provide for old people or sick people, or those with other medical conditions that need expensive care, you (and your insurance/new employer, or whomever) has just screwed sick Americans a little bit more deeply.

Getting back to Darwin's point, if systemic evils incompatible with Christian ethics are part of any health care system, then yes, we can say a certain system with these evils is immoral.


Kyle R. Cupp said...

I think we should do what is in our power, authority, and vocation to do for the healthcare needs of others. We have a social obligation to care for life, for health. How we meet this obligation is a matter of debate, and it doesn't mean every single person does the same thing. Mother Teresa had a particular calling, one that she may not have been able to live had her focus been otherwise than it was.

Rebekka said...

"If the government became the only insurance company in town, which is what many propose, it would do nothing to address the root issues and it would have to do the same things insurance companies do, like determining what will be covered and what won't...but the thing is you're stuck with whatever decision some bureaucrat made - you won't be able to say, okay, for the same money I can go to company B and get better coverage."

As someone who lives in a country with universal health care (Denmark) and who works in the health care sector (nursing) I can say that things not being covered is not a problem. At all.

If your doctor decides that you need something really expensive like a full-body PET scan, because you maybe have a metastasized cancer and they don't know where the focus is, you get scanned. End of story. There's no bureaucrat sitting around getting paid extra because they can find some completely spurious reason for why you don't need that scan. If you need an operation, you get the operation. If you need some really expensive medicine, you get it, and the state pays 85% of the costs, and if you use more than 10000 kroner a year on medication (right now that's US$2000) you get 100% coverage.

Non-coverage is for stuff like cosmetic surgery, unless you have a medical reason (mastectomy, burns, cleft palate, etc.).

Denmark spends 8.6% of its GNP on health care. A lot of people actually complain because that's less than the countries we usually compare ourselves to (the rest of Scandinavia is around 9-10%). The US spends 15% on health care. (WHO)

The US uses 31% of its health care costs on administration. Canada uses 16,7%. (NEJM 349 (8) Woolhandler et al) What a waste!

Rebekka said...

Oh, and there is private insurance here, if you want it. And private hospitals. Not to mention that you have free choice of the public doctors and hospitals.

Even the elderly get to choose between county home nursing services and private companies--and it doesn't cost extra. And they also get to choose between care facilities when / if the time comes for that.

Rick Lugari said...


I think your point about certain insurance companies dropping or refusing coverage speaks of a different aspect of the health care problem as things are now structured. Maybe as a society we should vote in legislators who craft a law that says insurance companies must cover anyone who is willing to pay, that the rate should be structured to factor in that risk rather than be increased for the high risk client - maybe not - personally, I could go along with such regulation. However, that still misses the point about excessive health care costs not being due to the act of having insurance companies paying the bills. In fact, whether desirable or not, policies like that prove the point - even while not covering the very sick the price of health care remains extremely high.


Thanks for pointing out Denmark's system. As you probably know, many people here point to your system as a model system. I'm not sure I know enough about it to make a judgment as to whether I would like it or not, but there are some factors that need to be considered. Some things work with some people and cultures but not others. This may or may not be a bad thing, but it is a real thing. I'll rattle off a few initial thoughts that may or may not be very coherent.

First, and getting back to my original point, is that I think the root of our problem is medicine as a business. I don't ignore sound economics. I'll be the first to admit that health care technology and understanding is as advanced as it is today because of the monetary incentives that exist. It's a great thing, but it has come at a cost. But viewing this thing that should be (and really is) a huge benefit for the family, it has come at a great cost. At some point the cost is going to be so great that the family cannot afford to take advantage of it - that the family won't be able to afford the kind of medical care that I would consider fundamental (first aid type stuff, clearing up infections, pain relief and care for the dying, etc.) I think it would be better to not have things like the latest advances in chemotherapy that may or may not save a life, or may or may not extend a life 6 months rather than providing tender care for all who are afflicted. That may sound crass, but I really see such things as a choice. It doesn't matter whether me or my employer pays for insurance to cover a session of chemo at $25,000 or the government confiscates my wages to pay for it - as things are it still cost $25,000. Take out the layers of profit and regulation built into developing and administering the treatment and would be a fraction of that cost. But when we do that, not many people will have incentive to innovate, resulting in a reduction in advancements. I don't think that's necessarily a bad thing, but I don't think the majority of my society feels the same way.

One thing I like about the Denmark system is that physicians are salaried (something which keeps the overall cost down). As a principle, I like the freedom afforded a man to be able to work and be compensated according to his work, but like I said earlier I think some things should primarily be in the realm of charity and service rather than profit. I think the money involved draws some great minds to the field and we benefit from that, but I'd be fine with having the field of doctors who are adequate and practicing their art out of service.

Other things I'd note is that I don't have experience with Denmark's governmental bodies. It's entirely plausible that they suffer from many of the limitations inherent in governments, but are more resistant to abuse and complacency than the governmental bodies in the US. Point being, your HC system may function fairly well in your government, but it doesn't mean it will in ours.

I would also note that while your system is popular, it doesn't mean it's necessarily better, nor that measure of it's effectiveness hasn't been dropping. Also, it's funded by taxation on income and property AND has a 15% co-pay. Not saying that funding health care is ever pretty business, but I'd hardly call that a panacea. The funding of it is always coming out of the pocket of the common man, but certain forms of taxation can be more abusive to the family than having the family foot the bill directly or throughout added costs in the economic system. The co-pay means that if someone has a $150,000 procedure (not uncommon here) they would have to cough up $22,500 in cash. Not something the average family has laying around here. I certainly don't, however, with our system as it exists, I could have that procedure and it cost me $15 out of pocket and $15 for each of the follow-up visits.

All those words...sorry...but having to reply to these things have further convinced me of my thinking...that the problem is not who pays the bills (excluding the principle that when a third-party pays - people consume carelessly and providers gouge accordingly (strong word, not necessarily accurate, but you get the idea), but that the actual cost is inflated.

BTW, lets not forget the costs of regulation and liability inherent in our system. Doctors pay liability insurance to cover them from excessive litigation and pass on the cost. Government regulation, licenses, etc. while much may be proper and necessary for the common good, actually add to the cost. i.e. I cut my finger and it gets infected. I know what an infection is, I know that 500 mg of amoxicillin for ten days will clear it up. It's cheap too, $5 for the cycle. But because the government mandates that a doctor prescribe it, I must go into the doctors office and pay (or my insurance company - or the government if that were the case) $50 for the doctor to look at it and say, "yep, it's infected" and write a prescription for a $5 bottle of pills. Not saying that we shouldn't have such regulation, but it comes at a huge cost, and that cost will not go away if the government foots the bill rather than an insurance company (and note, if I didn't have insurance, most doctors would most likely only charge half their rate).

Rebekka said...

Hi Rick,

Thanks for the response.

The 15% co-pay is not really a co-pay in American terms. It's only for medications and certain kinds of therapy. Purchase of medications is tracked electronically (by SSN) over the course of a year. You pay the first 500 kroner ($100) out of pocket, and then move your way up a scale from 50% co-pay to 15% and eventually 0% if you use a lot of medication. That's only for medications you purchase at a pharmacy though. If you are at a hospital you do not pay for the meds.

If you need an operation that costs $150,000, you pay $0. You don't even get a bill.

It costs nothing to see your doctor or a specialist, or to have diagnostic tests or blood tests or... Some sorts of therapy have co-pays, like physical therapy (unless you have a chronic illness that requires physical therapy like MS or something).

Where I worked we had a strange experience in that a man from the Middle East wanted to come to Denmark to have a cerebral tumor removed. He had also contacted a hospital in the Boston area, and the estimates lay in his medical records. The estimate for the operation + 30 days hospital stay in the US was $100,000. The estimate for the exact same in Denmark was something like $27,000. Maybe because we don't have malpractice lawsuits here? (If you have a complaint, you send it to the Patient Complaint Council and they figure it out and if you're right you do get a certain amount of compensation -- but not hundreds of millions of dollars.)

Actually, one of the reasons that I live in Denmark at all is because my husband has Crohn's disease. I'm sure that I, as a nurse, could get some sort of health coverage for him through my job if we lived in the US. It would still be expensive though. He's had a bunch of operations, diagnostics, insane amounts of blood tests, and takes all kinds of medication. It hasn't cost us more than a few hundred kroner a year at the pharmacy and that's it. (Not even lost wages, because that's covered too.)

I really, really believe in this system. Yeah, we pay high-ish taxes. (35% income (60% "top-tax" if you go over a certain really high amount, and then only the part that goes over is taxed at that rate) + 25% sales tax) But we have no health care costs at all, we had free schooling plus a monthly stipend to live off as students. In spite of the high taxes we aren't financially burdened. Yeah, if we were a single income family of 8 it would be different--maybe we would have to get out of downtown Copenhagen and buy a crockpot.

I am GLAD to pay these taxes, because I truly believe that everyone should have the right to access all these goodies according to their needs. As far as I'm concerned, it's the same as the 1% church tax I pay to the Catholic church here.

Rick Lugari said...

Thank you, Rebekka. I'm sorry for incorrectly stating how the deductible works, I misunderstood considerably.

As I read your description of the coverage in your system and I find it agreeable to me. But that brings me back to what I find is the problem with our situation. It costs us $100,000 for the same procedure that costs you $27,000. It matters not who is actually paying the bill, private insurance or government. It still costs too much. The debate in our country is between framed as insurance vs. government, nobody is looking at the root of the problem. I think that root is part cultural (at the consumer level we put a premium on our freedom of choice) and that our system developed over generations to what it is now (and the wide-spread use of comprehensive insurance - a third party payer) fueled excessive costs across the board. The excessive costs simply will not change here by anything that has been proposed - it's built into the nature of what we have.

The taxation thing is another issue. Some will think my balking at that sort of a taxing scheme is reactionary and selfish, but I don't think so at all. What Denmark seems to be doing right is that there is a communal approach to the giving of health care - a mentality of service and charity that starts with the individuals involved. I'm not saying that our physicians and nurses, the technological field, etc. don't care about others or that they're only in it for the money, but the money IS a factor to a degree that I think is inconducive to the properly ordered view of health care (just my opinion of course).

See, when the family is taxed to such a degree, they lose autonomy - they have no way of cutting costs - of practicing economy (lost these days is the true notion of what economy really is, household management). Perhaps it's more important to me to put food on my table or buy a pair of shoes for my children than being taxed for "free health care". That's a real world situation for myself and a great number in the US. While my family is young and struggling, I'd rather ensure we can sit at the dinner table together with a healthy meal than eating ramen noodles with the comfort of knowing that 5 years from now when one of my children breaks an arm, I can have it set and put in a cast for free.

Rebekka said...

Hi again,

I agree that the $100,000 vs. $27,000 is one of the key issues. Personally I think that health care-for-profit (and here I'm not counting wages as profit!) is just not ethical. The whole malpractice issue is just totally bananas.

I think the idea behind insurance is to cover your behind in case of a real catastrophe. You may be willing to pay the costs at the ER for a cast, but what about a massive car accident with multiple serious traumas requiring operations, intensive care, long hospital stays and rehabilitation (God forbid)? Part of the problem is the whole insurance mentality. It's like buying homeowner's insurance so that you aren't left homeless in case of a fire, but using it to replace a window broken by a baseball. If the insurance wasn't used for every little thing, it wouldn't cost as much but would still be able to cover catastrophic situations.

Yet for some people a trip to the emergency room may be enough to tip their whole economy over.

I don't have all the answers (at all!) and the system here, in spite of what I've written, isn't perfect. I'm just glad it's there!

Rick Lugari said...

I think the idea behind insurance is to cover your behind in case of a real catastrophe. You may be willing to pay the costs at the ER for a cast, but what about a massive car accident with multiple serious traumas requiring operations, intensive care, long hospital stays and rehabilitation (God forbid)? Part of the problem is the whole insurance mentality. It's like buying homeowner's insurance so that you aren't left homeless in case of a fire, but using it to replace a window broken by a baseball. If the insurance wasn't used for every little thing, it wouldn't cost as much but would still be able to cover catastrophic situations.

Amen. Amen. Amen!

Foxfier, formerly Sailorette said...

Wasn't going to comment because this issue usually makes more heat than light...but I've got to add a voice of agreement that insurance is abused.

It SHOULD be used for a major crisis-- life-changing events. Instead, it's like using your car insurance to pay for oil-changes.

I'd like to add that, from what I recall, Denmark doesn't have around 15% of their population living there illegally and using the emergency room for slivers.

(Dear Mother, I wish I was joking-- my aunts are nurses, and they HAVE had folks with slivers, paper cuts-- although, admittedly, it was a pretty nasty papercut-- and other amazingly mild injuries come into the emergency room, and then saw the hospital have to foot the bill when they vanished into thin air, paper-wise.)