Health Care: GOP and Mark Levin are Both Wrong

Today on Meet the Press David Gregory was interviewing Gov Tim Kaine (D-VA) and the RNC Chairman Michael Steele about a broad range of topics. Health care is one of the most important issues facing America today and was presented just long enough for the summary of the opposing views. My summary follows: (here's the entire transcript):

Tim Kaine: 46 million at any given time do not have access to health care and that needs to be fixed. We need to figure out a way to pay for it. and also give people a choice between public and private plans.

Michael Steele: We have to look at tort reform and we have to make sure that pharmaceutical companies and insurance companies are at the table. (My addition: "huh?")

This is really the basic message that points out the priorities regarding health care and the place of the federal government. Conservatives, as embodied by the Republican party, do not even understand the problem. Their short view of the priorities shows that they really do not get it.

First of all, health care is a de facto right in the USA. Even the staunchest conservative (and I'll talk about him below) can write chapters on health care, but never do they even intimate that health care should be withheld based on some one's immediate ability to pay. It's not a question of mushy feelings of compassion or empathy, it's always about economics, i.e., the allocation of scarce resources and the conservatives do not want to make tough choices.

Hypothetical case (that plays out is some version every minute): Lydia is a 25 y/o waitress who has 2 kids and no health insurance. She has acute onset of left lower quadrant pain at 2 pm on a Saturday and her last menstrual period was six weeks ago. She has delayed seeking birth control because of the cost and waits to see if the current pain will subside on its own. At 8 pm she begins to feel dizzy and lightheaded and her friend from work encourages to leave work and go to the hospital. Lydia instead goes home to "sleep it off." The pain increases and she calls an ambulance at midnight and her neighbor come over to watch the kids.

At the hospital, the emergency protocols are triggered and she is seen immediately. A blood count shows she is acutely anemic and a stat ultrasound show a belly full of blood with the presumed diagnosis of a ruptured ectopic pregnancy. The gynecologic surgeon is called at 1:30 am, an operating room team is assembled, surgery is performed and she goes home two days later and back to work in 10 days.

The emergency physician, gynecologist, radiologist and anesthesiologist are never paid. Hospitals are required as a provision of getting federal Medicare money to provide emergency services. The hospital passes this requirement onto physicians by requiring emergency coverage for uninsured patients in order for the doctor to keep his or her hospital privileges. In practice, hospitals will often pay for such coverage with funds from other services, but not always.

Practical view: Nobody should die from a treatable illness. Provision should be made to pay for this care, and more importantly, provision should be made to prevent the need for the acute care of a life-threatening illness.

Current Republican platform: The system works the way it is and they give a long list of things that they will not do. They want to make sure that the doctors are not sued if they commit malpractice, which completely misses the point of the issue. Malpractice insurance premiums have not gone up significantly in recent years and tort reform has not been shown to improve quality or increase access for the indigent. GOP is off on a tangent here. I may dislike trial attorneys as much as the next guy, but the evidence shows that the costs of the current tort system is not the main driver of health care costs. If lawsuits were limiting access to care in particular situations, then federal risk pools could be set up to pay out for damages in extreme no-fault situations such as cerebral palsy or neurosurgical procedures. This has been done with vaccines with great success; but I hear no conservative thinkers presenting a case for another such federal program.

Libertarian conservative view (although I've never heard it actually voiced): Lydia is going to die. Nobody can be compelled to provide labor and expertise without compensation and since she has no ability to pay for the care, she will die.

Is this the optimal solution? Nobody would argue that it is. The provision of care to uninsured patients is a form of endenture. I would at least understand the conservative view on health care if they were consistent and said, you know on that fateful night the woman would die. She has no insurance and no means to pay for it, so I'm sorry, but nobody is available to treat her. In fact, even if a gynecologist is empathic enough to be willing to perform the operation, he would still need to assemble a team to also work for free and pay for the nursing care, pharmaceuticals, etc. Conservatives don't face that reality; instead they try to ignore the real circumstances.

Currently, at the urging of a conservative friend, I am reading the #1 bestseller, Liberty and Tyranny: A Conservative Manifesto (1), by radio personality and lawyer, Mark Levin. The book does not merit a more lengthy review, but I will point out now that he never mentions a solutions to the health care problem, the foremost economic and social problem of our day, in his entire book. In his chapter titled On the Welfare State, Levin goes on about all the problems inherent in the economics of health care and the federal bureaucracies involved. He mentions the supposed deficiencies of the British system, as well as the US' Medicare and Medicaid plans, but he fails to solve the fundamental problem with the current US model.

History tells us that Medicare and Medicaid were instituted in 1965 to fill a need, but regardless of why these programs are here, we are stuck and we have to deal with them. If Edmund Burke, a true conservative, were alive today he would admonish pundits like Levin and political parties to act pragmatically instead of expounding theoretically. Without these programs, countless elderly, poor and disabled would have been without health care over the past 40 years and they are not going to go away so we may as well try to figure out a solution. The GOP, with all their complaining about Obama's so-called "socialism", were the architects of Medicare Part D which is the largest social program of my lifetime, dwarfing the original Medicare program and estimated to cost three-quarters of a trillion dollars over the next decade. Small government conservatism? Not.

Mark Levin, who for his part has been critical of both Republicans and Democrats, offers no concrete solution to access. He takes issue with the number of uninsured, and while he does not dispute the total of 47 million, he implies that this overstates the problem. Levin says that of the 47 million, "9.5 million are not United states citizens." So? They still require health care. Even with the best immigration enforcement conceivable some illegals will find their way here. Perhaps Lydia is a migrant worker here on visa, or even an illegal alien. Do we let her die? What's your solution, Dr. Levin?

He continues, "Another 17 million lived in households with incomes exceeding $50,000 a year and could, presumably, purchase their own health care coverage." Presumably? Sure, Lydia could very well be a waitress at Lawry's of Chicago dragging down six-figures, but she still has failed to secure insurance. Do the ER physicians withhold care until she can secure a home equity loan?

Levin goes on, "Eighteen million of the 46.6 million uninsured are between the ages of 18 and 34, most of whom are in good health and not necessarily in need of health-care coverage or chose not to purchase it" (italics mine). Most of whom are healthy? How do we decide who will necessarily need coverage this week and will they be able to buy a good health insurance on their way to the hospital? Was Lydia on the schedule to purchase a health insurance policy this week or next? Maybe the ambulance drivers can moonlight as insurance salesmen. Seriously, this is just more ivory tower bullshit from someone with no practical experience in economics or health care.

He continues: "Moreover, only 30% of the nonelderly population who became uninsured in a given year remained uninsured for more than 12 months. Almost 50% regained their health insurance within four months." Which means that 50% to 70% of these apparently healthy people are playing Russian roulette at any given time. But it's not a gamble with their own health necessarily or even their own money; instead it's Russian roulette with the scarce resources of the health care delivery system, the precious time of the trained professionals who are compelled to work for free and the other people's money who are insured and whose premiums subsidize the uninsured when they get sick.

Levin's prescription is that workers, instead of having payroll deductions, should be allowed to make the financial decisions for themselves. The market place should be allowed to work to lower the costs of insurance and health care. He says, "Perhaps they could find less expensive alternatives, invest the taxes deducted from their income to improve their overall financial situation... Most individuals know best how to use their money which they earned from their own labor. And most individuals are not self-destructive (p. 111)." Perhaps?

Really, Dr. Levin, you had me at perhaps. Are you sure you're not a comedian? What evidence does Dr. Levin have for any of these claims? My observations see 18 year-olds who do not use contraception, 22 year-olds who drive drunk, 35 year-olds who beat their spouses, 53 year-olds who smoke and drink to excess, 61 year-olds who fail to treat their hypertension or get mammograms. And don't even get me started on other economic time-bombs that we all ignored, like sub-prime mortgages and outrageous household debt. Even if "most individuals are not self-destructive", which is debatable, many are at least negligent... but when they get sick these people will still exercise their de facto right to health care when it is absolutely needed. That's the real world, Dr. Levin.

Humans have two innate tendencies: they look out for their immediate self-interest, and they fear the unknown of death. A healthy nonelderly adult will often buy a boat or go on vacation if they have the money in their pocket, or they will eschew school or work for other fun things, because that is in their immediate self-interest. They often don't desire to buy an expensive health insurance policy that is perceived as unnecessary at the time. But when they have an "event", such as Lydia had, the second universal innate tendency kicks in and they run to the health care system to pull their cookies out of the fire. Is Levin true to his libertarian view? If he were he would candidly state that the hospital and doctors should be allowed, nee required, to say, "no, you did not know how to allocate your funds, you have failed to provide a source of payment for the scarce resources for which you are asking, therefore, you are going to die." Nope, Levin says no such thing. Instead, he says nothing.

Well, he does quote Edmund Burke (one of my favorite 18th century conservatives): "What is the use of discussing man's abstract right to food or to medicine? The question is upon the method of procuring and administering them. In that deliberation I shall always devise to call upon the farmer and the physician, rather than the professor of metaphysics." Burke thought that merely recognizing "abstract" rights was silly, rather he pursued a practical solution that involved charity on a society-wide scale, not mandated by law, but voluntary (2). If Levin is advocating this scenario, then I would expect a chapter requesting that physicians, lab techs, ultrasound techs, nurses, hospital administrators, drug companies, building maintenance engineers, housekeepers, nurse's aides, etc, continue to provide their products and labor for free to the increasing number of uninsured. Or, Levin should come out and say that the Lydias of the world will die at the curb of the hospital building.

Burke, for his part, was truthfully practical and did state unequivocally that participants in society had an Aristotelian moral imperative to voluntarily give back the fruits of their labor and he advocated a pragmatic system of charity giving. There is no evidence that our current society is willing or able to provide the largess necessary for the current mandate. Do today's conservatives recognize the gaping need? While charity programs are available, they are woefully inadequate to provide for the increasing numbers of needy and elderly. Guys like Levin want it both ways: they don't want to lower themselves to ask doctors and other skilled workers to provide charity that they themselves are unwilling to do, yet they will not level with us about the consequences of withholding life-saving care.

Michael Steele says to do nothing, and Mark Levin says to let the free market sort it out. The fact is that while these two yahoos twiddle their thumbs, the health care system is not going to allow Lydia to die because to do so would abrogate their human moral contract and so we go on with the burden being borne disproportionately by one segment of society and the moral hazard is never addressed. The problem is that the Lydias are crippling the system because her expensive surgery could have been avoided with a few dollars worth of contraceptive counseling and/or medication, but there is no organized system in place. Lydias fall through the cracks. Multiply this lack of preventive care by all the untreated hypertensives and diabetics whose arteries are being destroyed daily, the breast cancers growing without mammogram surveillance and the asymptomatic women who do not get Pap smears due to lack of insurance. They will all be consuming health care at some point, only by then it will cost more and have less optimal results.

Ignoring the problem of access and cost worked okay when there was fat in the system that could be boiled off, but now hospitals' budgets are tighter, doctors' reimbursement is lower and overhead costs are higher, and the numbers of under-insured and uninsured is growing. It cannot be ignored any more.

Insurance is based on the size and diversity of the risk pool. Currently, private insurers have the perfect situation: they cherry-pick the healthiest and wealthiest of the risk pool for their products, leaving the poor and infirm to be on the public plans. No wonder Medicare and Medicaid are in tough financial straits. In fact, since they provide care for the sickest, oldest, and least compliant patients on the tightest budget, it's really a testament to the efficiency of these federal and state systems that they are functioning at all.

Medicare actually works quite well with relatively low administrative costs, certainly no worse than private insurance for comparable patient populations. In addition, Medicare pays 100% of the educational expense for all residents in training. If the Medicare risk pool included healthy nonelderly people in addition to the current pool of elderly and sick, the system would work even better. In short, it would be immediately solvent and sustainable. Private insurers, for their part, offer no value to the product of health care: no training, no valuable guidelines, no new information; same doctors, same CT scanners, same hospitals; but insurers do skim 12% or so in profit. Private insurance does nothing but act as a middle-man, collecting premiums and paying out (or denying) claims. A federal utility can do that just as well, and without extracting a large profit.

Guys like Steele and Levin appeal to the majority of citizens who love simple answers to complicated problems. But health care is one of the most complicated issues we face in regard to our economic stability. As Levin pointed out, we spend 17% of our GDP on health care, while other industrialized nations get by on half that expense. The US' employer based health insurance model is a huge drag on the economy where employers are reluctant to hire workers due to the burgeoning cost of insurance. Companies are reluctant to build plants here because of this cost. The Detroit-based auto industry has been decimated largely because of the cost of retiree health care. Sure, the younger, non-union Honda and Toyota US workers are willing to work at age 30 without the promise of health care when they are 60 because, referring to my previous premise, this is consistent with their immediate self-interest. When they are 55 or 60 years-old, after working 30 years at a laborious job, how will they pay for health care? Answer: they will either still be working full-time (doubtful) or they will not have insurance (possible)... or they will be on some public plan (most probable). I would argue that a large number will be on some public plan. Sure, they could be allowed to make decisions now about providing health care for themselves later, but how many will actually do it? It only takes a small percentage of Lydias to bring the system down.

Levin cites a Gallup poll that shows that 57% of Americans are satisfied with their health care coverage, and Levin concludes that we should not change the private insurance system. The problem with Levin's interpretation is that 33% of the participants in the poll had Medicare or Medicaid! And since the poll did not differentiate between privately insured people and those in public plans, no such conclusion can be drawn. In fact, a large five nation study shows that US patients are the least satisfied of similar industrialized nations.

Elections recently have been a referendum on the dissatisfatction with the Republican leadership on a whole host of issues, but health care reform is near the top in polls that ask a reason for a person's vote. My thesis is that polls show that Republicans as a group are less worried about health care reform because these numbers are skewed with over-65 voters who are more likely to identify as Republican. They are satisfied with their health care because they have Medicare!

In conclusion, the US health care system suffers from poor access, increasingly high costs, and it is not sustainable in its current form. Without a solution, the structure will start to fragment as employers are increasingly burdened with costs and hospitals and physicians are forced to deal with an increasing number of the uninsured and lower reimbursement from the poorly insured. Market forces can be implemented to control costs, but the bottom line is that the risk pool needs to include everybody: the healthy as well as the sick. All citizens should be required to have insurance and cover premiums based on their ability to pay. Disengage insurance from employers; my boss doesn't pay for my auto insurance, why should he pay for my health insurance? Private policies should be required to cover the same things as Medicare and Medicaid and follow the same standards of allowable services.

The least imperfect solution was Hillarycare as presented last year. Obama's is next best, but his lack of a mandate for health insurance is a weakness. Neither Levin nor the GOP offer a solution that has any meat or merit.

(1) Liberty and Tyranny: A Conservative Manifesto, Mark Levin, 2009.

(2) Edmund Burke, Volume II (biography), by F. P. Lock, p.318-9