Terry Schiavo and US Healthcare

For us to continue to pretend that we aren't paying for health care for all is absurd.

For us to continue to ignore that we are getting very little bang for very big bucks is foolish.

People are not going hat in hand to ask for help and being turned away - they are falling through the doors of emergency rooms all over America and they are being treated at the expense of taxpayers and insurance buyers.

I read an article the other day about the links between gum disease and heart attack, stroke, diabeties, premature birth and on and on and on.

My family pays about $600 each month for health insurance that doesn't cover dental care. We pay for dental out of our own pockets - about $500 each year for regular dental cleanings.

If we know that having your teeth cleaned can ward off so much expensive illness it seems ridiculous that adding such a cheap service to our insurance policy would double our premiums.

In my opinion, my inusrance company is penny wise and pound foolish.

As a society we are guilty of the same thing.

We are footing the bill for very expensive treatments and hospitalizations for health issues that could be prevented or treated early for very little cost.

My take is that, given that the health budget is limited - here, especially, where our birth rate is very low, and we have an ageing population - that we do need to make some tough decisions.

Actualy, they are being made all the time, quietly, in hospitals.

For instance, the neo-natal unit I once worked in, after it got over the "who can keep the smallest wee scrap of humanity alive" contest between the two NICU's here, quite clearly discusses with parents the prognosis for very unwell babies and, if the prognosis is extremely poor, and the parents wish, heroic measures will be stopped. Most parents, sooner or later, will feel that they do not wish their tiny baby to suffer for a long period, and gently say goodbye.

Of course, they continue to fight for the wee babes for whom it appears possible that a reasonable outcome may be achievable.

People with advanced and painful illnesses in the terminal stages are given pain relief up to and beyond the limit that will cause death, if that is what it takes to relieve pain.

Very elderly people, with no hope of recovery, are not treated heroically for severe strokes etc. This is with family discussion - and discussion with the patient, if possible.

These are just small examples.

Most of us use the most health dollars in our last two years of life.

Speaking for myself, I do not wish my final illness dragged out. If there is no prospect of heroics giving me a reasonable quality of life - please do not do them. I would rather the money be used on the early intervention/health promotion/research on medical issues where there is a real chance to give people life - and a good quality of life.

That being said - a hip replacement on a reasonably healthy 90 year old is clearly justifiable on my criteria, because it will give improved quality of life.

A hip replacement on a 90 year old patient who is bedbound for another reason is nuts, in my view.

Do people catch the rationale?

What do you think?

tired this approach already Deb, noone interested
http://www.able2know.com/forums/viewtopic.php?t=47947&postdays=0&postorder=asc&start=0

Oh - but I thought it was a different level of discussion here?

The plan I am limning is actually FROM the US - it is a well worked out one based on points for things like likelihood of raising quality of life and for how long.

I just wish I could remember where! It was being very seriously discussed as a model here a few years ago (and I suspect has been quietly informing decisions ever since).

Dys, it was your thread that inspired me to start this one. And dlowan, your ideas sound pretty close to the model that boomer brought up, the now battered Oregon Health Plan.

Hmmm - could be too.

Oregon sounds like a good plan, poorly implemented. At least what dlowan describes acknowledges the fact that the public is paying a major part of health care costs. I have yet to decide whether we should, but we may be way ahead in avoiding the pretense that we are not.

boomerang,

I just finished examining John A. Kitzhaber's talk at the Risk Management Conference of 18 Feb 2005.


He brings up some salient points and his retrograde drafting of our current health care system titled The Health Care Equity and Empowerment Act of 2005 is amusing and poignant. Yet, his claim that the "[Oregon Health Plan] has offered national leadership on this issue in the past..." rings hollow when we then find that the OHP: "...lies in shambles." and "Some 50,000 Oregonians have lost coverage and more will follow."

But what is responsible for this failure? Well, Kitzhaber informs us what is not. Its downfall "was not simply the depression, the budget deficit and the lack of funding". So, what brought this noble social experiment so low? "It was brought down by the larger system in which it existed - by the fact that we were trying to bring about meaningful reform within the constraints and contradictions of a fatally flawed system". Oh...but, somehow, my appetite for a clear explanation of cause is not satiated.


No matter, for "It is time to take those lessons and move the debate to the next level." How? By "develop[ing] a clinically and politically defensible priority list and to use that list to establish a covered benefit". Additionally, we find "...that it is possible to confront the reality of fiscal limits and to assume accountability for the difficult choices which those limits make inevitable". But are not the depression, the budget deficit, and lack of funding the very fiscal limits that so constrain and prevent such lofty ambitions of Universal Health Care? Note the Dr.'s reference to limits and roger's "There just have to be limits".

However, admitting limits and fiscal responsibility is a far cry from admitting and fulfilling obligations. Dr. Kitzhaber then compares the ideal Health Care system by equating this social "obligation" with, of all things, our public education system. He feels, apparently, that both are an obligation to all citizens, a promise to be kept for the good of society. Sounds delightful, but does he really want to use the latter as a shining example to which we should aspire when designing a universal health care system? Some might, instead, use this to argue for vouchers and even the dissolution of the public education system altogether. But even in this comparison he admits to budgetary and other real world constraints:

Getting to the point he says: "What we do not debate is eligibility. We do not say that, in order to balance the budget, we will eliminate grades 11 and 12 for the next school year or that we will turn away children over the age of 16. In other words, we never question our commitment to universal coverage."

We may not question our commitment but real world forces demand practical considerations. Hidden in his comparison we find just such constraints in the very fact that we do not debate something that is assumed in the public education system: Public education is not forever. The assumption is that only younger individuals are considered. The time span is 12 years only, eligibility does come into play and adults are excluded, an age category suddenly appears, a limit is born. Not so with the "cradle to grave" promise of Universal Health Care, but the education system accounts, at most, for only 1/7 or about 14% of any given individual's life span not its entirety.

Dr. Kitzhaber would have us believe that our health system would benefit from the concept of universal obligation, as opposed to "categorical eligibility", but with the caveat of fiscal responsibility. He then proceeds to lament our present system and its lack of "social responsibility". This is a trap that one falls into when assuming for the care of others who, for whatever reason, do not assume this basic individual responsibility themselves. But, when building a fiscally responsible health care system that assumes universal responsibility and accepts "limits" and the real world ability to pay factor on an individual basis, one cannot help but divide the total population into groups that share an equal ability to pay. But when we divide and classify these groups, in the effort to create practical payment schedules, don't we end up putting such people into various categories?

My point: It is best that we forego this concept of state obligation to provide any good or service because "morality" deems it necessary. This concept as the basis for arguing for state handouts fails on the moral ground that it must be supported by involuntary income redistribution. Further, in practical terms, it is impossible to envision a universal healthcare system that gives equal and fair treatment to all. After all, how fair is a system that demands the support of those who cannot contribute to the system in any way? It is better to assume individual responsibility with the hope that, if it can, the state (i.e. all of us) will do what we can to help the unfortunate when we can. Does this remove us from the responsibility to care from others? Perhaps so, but there is little morality involved when legal plunder is used to force such actions upon those who have no such interests. This method also robs those who might help voluntarily of the same morality by lumping them into a large group known only as taxpayers. Should we help the unfortunate? Yes, but both the definition of and the level of support should come from each individual. We would do well to also tailor the support so given to unfortunates on an individual basis.


JM

If we are going to limit ourselves to Terry Schiavo, then moral necessity has to be the issue. If we're discussing health care and public health care, I'm not sure that's the issue at all. Are we providing some level of public welfare because of some moral imparative, or do we just find it distastful to read of how many in our own little towns starved to death last week. Okay, that's dramatic. I could have come up with worse examples from health care or public education. My thought is that if we're going to develope consistant policies, we should really determine the motives and beliefs behind the policies.

If the basis is to be moral principles, we got trouble. Whose principles, for starters, and is it moral to impose those principles on someone else's tax burden?

I just finished watching MSNBC with Joe Scarborough. No reflection on him but the media has displayed an inordinate fondness not for beetles but for those of the religious right that condemn everybody for, well, not following their agenda. The last spokesman on Congressman Scarborough's show condemns the system. He points out our 3 branches of government and the value of its systems of checks and balances. Further, using faith based reasoning he points out the validity of G.W Bush (signing onto) and the U.S Congress' initiative and commitment of end runs around the system, but then proceeds to vilify the very court system that has rejected Terri Schiavo's parents. It seems the system of checks and balances is valid to him as long as the result validates his personal values and his desired outcome. The fact that the effort to support his pre-conclusions has failed via, at least 3 round trips up to and down from the, U.S. Supreme Court seems nothing more than a failure of one of the branches of government that he originally invested seems his opinion only. The court system, to these people, is now merely a rogue entity and therefore deserving of scorn and irrelevance since it has (repeatedly) come to a decision which has been continually upheld within the very system Terri's parents have looked for vindication. This very system, from which they would have gratefully accepted a favorable decision, is now marginalized, disdained and invalidated. But, given the acceptance of this American system, negating one branch or the other simply because it does not fall inline with one's reasoning and, more importantly, picking and choosing those that do agree, seems, well, simply childish at best and extortionist at worst.

The parents of Terri are subject to charitable forgiveness, indeed I wish all God's blessings upon them. The President, Thomas Delay, and numerous others whose obvious pandering for purely political motives is shameful. Jessie Jackson's motives are almost French-like and therefore simply mystical.

Respectfully,

JM

Yes, the Terry Schiavo case, which was a motivator in the creation of this thread, is full of contradiction. According to the panderers, there is a moral obligation to support life. According to many of the same, we shouldn't have to pay for it. The fact that many of those who sought to do an end run around the courts with "waste of time" federal legislation are the same who are proposing cuts in Medicaid (among other programs) which has been helping to pay for the care of this person they wish to keep alive is not lost on many.

But essentially, I think the root of it is this:


The fact is that, right now at least, there are laws in place making it illegal to refuse emergency medical care based on ability to pay. Presumably, these laws were inacted because of some moral agreement that poor people shouldn't die for being poor.

Where we go from there is open to debate. JM's pointing out that public education is provided only for some 13 or 14 years of a person's life is well-taken. However, a limit on age is really not so different from a limit on benefit, is it? A limit is a limit, no? After all, when do most of us require the most health care? Though we might be covered for life, even with insurance, do we require constant high levels of care? Not most of us. And as to the point of requiring people to contribut to the system who have no interest in doing so, we freely agree to do this in other cases. Public education being one. The transportation system being another. Perhaps I don't drive or perhaps I have no children or send them to private school. I still pay into both benefits and, whether I know it or not, I still benefit from both. My grocery store is stocked with goods from far away because the government built roads to carry the trucks that brought them. My business can hire literate workers because the education system taught them to read and to count money.

I certainly believe in the principles of a free market system. However, there is a direct conflict, in the case of health care, between profit and benefit. Wherever there is a moral imperative to provide a service, introducing the profit motive can only distract from the purpose. I noted elsewhere the existence and benefits of non-profit insurance companies. I wonder how a state benefit might differ from such.

Their seems to be a consensus that the main case for either camp's views towards Schiavo's right to die or right to live forever, no matter what, is based, ultimately, upon morals. But rogerroger's concern of the plurality of morals obfuscating the decision making process in such cases as these can rightly be overcome by the reagent of our legal and constitutional systems reacting with divers competing moral positions that seemingly cloud our vision, the resultant precipitation of superfluous and irrelevant moral positions resulting in a clear legal solution to the problem. Let the Constitution be our guide. But, what about the religious/moral beliefs of others, are these to be ignored altogether? Not at all, as has been said before, our laws, legal system, and even our Constitution has been constructed with these contributing various influences in mind, but even the extremely religious Christian founding fathers used Greek, Judaic, and Roman legal concepts merging them with that of British jurisprudence, Common Law, and other sources to produce the synthesis we know as the U.S. Constitution.

FreeDuck in his post # 1252671 cites a seemingly troubling issue (given my perspective) regarding public works funding.


I find little moral or constitutional problem with this concept. The problem always seems to lie in the real life extremes and not the concept of public good. These are all good examples of how tax dollars can be spent for the good of all despite the fact that they allow the federal government a large club regarding fund dispensation to be contingent upon moralistic values such as civil rights and education requirements (good) or speed limit requirements on all highways, state or federal (bad). But is it OK for some to request, because of disability or whatever they feel are special circumstances, that interstate 95 and an on ramp be built right next to their home and then moved when they do? How far does the imperative of 12 years of secondary school accreditation go? Can one continue to try for that goal, at state expense, until 30 years of age, 40, or 50 is reached? For the extreme example of heath care one need only be familiar with the subject of this thread. Yes, we pretty much agree there must be "limits".

Regarding the free market system, FreeDuck finds "there is a direct conflict, in the case of health care, between profit and benefit" but this assumes "there is a moral imperative to provide a service". As I have said before, it is when we assume a moral imperative to what I believe is really an individual responsibility we then bump into arguments as to how much "the state" should pay for.

"Moral imperative" suggests heroic efforts are called for in accomplishing the desired goal. A "moral imperative" of the U.S. Marines demands that no member is left behind on the field of conflict, dead or, certainly, otherwise. This decision is also informed by any number of obvious practical considerations. But with health care what is the obvious practical consideration that impels us to perpetuate the condition of those in such PVS's (Persistent Vegetative State) that defined Terry's condition?

Further, if universal health care is demanded by a "moral imperative", the free market is not a consideration at all and we must simply fulfill the obligation, the free market being damned. This can be done but requires extreme cost cutting measures that would not only decrease the quality of health care, as seen in other socialistic systems, but put the medical insurance industry out of business as we now know it. So we see that FreeDuck's inclusion of the market system has a legitimate place in any future synthesis of a U.S. health care system. Any American system would include some competition for individual's business. But questions still present. Should we loosen medical school requirements to increase the supply of their product or cut down on intern hours? Further, how about, the cost of drugs? Should we disallow the drug companies "detail men" (salesmen) and free stuff (including trips) to doctors? No, this is the drug companies' decision to make freely. However, if the federal government became involved in the health care system it might want to decrease its costs by using its considerable buying power as a bargaining chip (some might say club). Then if the drug companies feel they must cut costs in the name of competition and profitability, it would remain their decision on how this would be best accomplished. But the American system would also hold the feet of the demand side of the market to the fire with choices of increasing levels of health care (with correspondent increased cost) and deductibles.

This is a terribly thorny problem but I am convinced social medicine is not the answer and is inherently un-American. Up until recently the free market has reigned supreme in this area but the maturity of the baby boomers has brought the drug and medical care industry under increasing pressure to cut costs. Roger's post has rightly pointed to the fact that we must first define the problem as it relates to exactly what we want to accomplish with the proposed American Health Care System. FreeDuck and his "moral imperative" explicitly points to some sort of need that must be met. My "Individualistic responsibility" concept is an attempt to keep the resultant system morally honest and therefore impart validity and legitimacy to the final product. The result, given it actually appears, will be a real world compromise hopefully encompassing all these elements. It will be, unmistakably, American.


JM

P.S. for those I have mentioned and perhaps insulted by assuming gender I apologize, but I feel that my possible mistake and their gender are both of little or no consequence to our purposes in this or any other thread.

Re: Terry Schiavo and US Healthcare

Let's assume that there is.


Problematically so. Look at the current situation with health care in the US. The primary problem we have is run-away costs. What has driven that problem? Government intrusion into the health care market. By attempting to set artificial price ceilings for health care the government has driven providers to inflate their charges over time in expectation of receiving only some percentage of those charges when the government is the payer. Absent this effect, health care might be considerably more affordable for the very people the government seeks to help.


A) Criticality of need. (Triage.)
B) Ability to pay.


Absolutely. Should we pay for someone's nitroglycerin tablets? Sure. Should we pay for someone's Viagra? No. Emergency appendectomy? Yes. Tummy tuck? No. Well baby care? Sure. Fertility treatments? No fracking way.


I am not currently aware of any statutory "right to die". (I believe we all have an obligation to do so at some point, but that's a different thing altogether.) ;-)

Re: Terry Schiavo and US Healthcare
Hiya Scrat, thanks for dropping by.



I agree with the first two sentences and maybe a little bit with the third. I don't think that the government alone is to blame for over-inflated costs. Insurance companies also pay 50% or less of provider charges. The problem with both government paid and insurance paid care is the cost of the middle man. I would say that the cost of the middle man in the case of insurance companies is high because of the profit motive. The cost of the middle man with the government is high because of beaurocracy and waste. If the government got completely out of medicaid and medicare, would the crisis solve itself? Somehow I don't think it would.



Right. I believe the "legal" right to die is signified by things like "do not resuscitate" orders and the like. Basically, if we are sick enough to die, you can't force us to stay alive. My reason for mentioning Terry Schiavo is that, for better or worse, if the government were paying for her care she would not have stayed on life support as long as did.

I agree with your other points.

Re: Terry Schiavo and US Healthcare

Who or what sets the prices?


:-)

Re: Terry Schiavo and US Healthcare


There are no regulated prices. The government (through medicaid and medicare), like insurance companies, agrees to pay providers a certain price for certain services. I am unaware of any laws or regulations that dictate what prices can be charged for medical care.

Re: Terry Schiavo and US Healthcare

With respect, you're wrong. The government requires doctors to accept Medicaid and Medicare, then dictates what it will pay. This sets the price. Market forces are taken out of the equation, and providers are forced to consistently over-inflate the stated cost of services in order to get something close to what they actually need from the government and insurance companies.

The more directly individuals pay for health care, the more market forces will drive prices down.

Re: Terry Schiavo and US Healthcare

With respect, this is quite different from government regulations. You have a point in that they are forcing providers to accept Medicaid and Medicare, which I did not know. But insurance companies also dictate what they will pay, and because they represent millions of patients, doctors have a greater incentive to sign on with them. To their way of thinking, the assurance of partial payment form insurance is better than the uncertainty of any payment at all from individuals. There is also the promise of more patients coming to them because they are now in-network. Otherwise, why would so many medical establishments sign on for all the extra paperwork and processing just to get a fraction of the costs.



I agree that market forces are taken out of the equation, but I disagree that the price is set. The number of patients who qualify for the two government funded programs is relatively small. The rest of us are paying a different price. Indeed, those of us without insurance don't get the medicaid/care price or even the insurance company price. We get the fully inflated price.



I'm actually inclined to somewhat agree. I think that having the costs of a third party payer inflate health care costs. But, obviously, if we all had to pay directly, a great many of us would go without, and there are entire states that would have little or no health care facilities. After all, why do business there if there was no money to be made? And then we're back to square one.

Re: Terry Schiavo and US Healthcare
Free - You're getting bogged down in semantics. The feds don't have to control prices through regulation, when they have the power to force providers to accept whatever price the government dictates. That sets the price. Period. The feds never set a national maximum speed limit of 55 miles and hour, either. They just tied receipt of federal highway funds to states adopting same and, voilà, everywhere you went in the US the max highway speed was 55.

Insurance companies aren't setting their prices in a free market, they are playing in a market influenced by upward pressures due to the intrusion of government policies. Of course, insurance companies are part of the problem too. Am I more or less likely to go to the doctor when it only costs me $10 for that visit? More, of course. But it doesn't actually only cost me $10, does it? It costs me that plus whatever I'm paying monthly for the privilege of that $10 fee. Would the overall cost to me be lower if we all paid as we went? Almost surely.


Yes, we get the price that became inflated by virtue of having to find a level at which the percentage the government was willing to pay would be sufficient. See? The "full price" is set as it is in order to ensure that what they really get from govt and insurers is enough. This puts upward pressure on prices where market decisions would do the opposite.

Scrat, the government is only part of this equation. Tell me, if medicaid and medicare went away today, would the system fix itself? Medicaid and Medicare are nothing more than government sponsored insurance companies. They are doing what insurance companies do. And they don't cover everything. What about the huge supplemental market? What about the prices for things medicaid doesn't pay for? Who's fixing those? You see where I'm going.

It is incredibly convenient to label the government the problem and it's consistent with some ideologies, but in this case, it just isn't that simple. At least, not in the way that you are suggesting.

I'm surprised you haven't mentioned the way we subsidize employer provided health insurance as a further erosion of market principals by the government? You're right that it's not a free market, but that's not just because of medicaid and medicare. Maybe we just have to accept that it isn't a free market system and try to fix it.