"Spreading the Wealth" for Health Care

Over at Bookworm room, she reports a conversation with he Kaiser Permanente Doctor.
The doctor had a very interesting take on the current uninsured. I said that a lot of people are opposed to the proposed plan because they recognize that those numbers being bandied about regarding uninsured are false. That is, the 45 million (or whatever) uninsured aren’t uninsured simply because of poverty. The vast majority are either illegal aliens (and you can see his views about those above) or voluntary uninsured. As to the latter, my friend thinks they’re the real problem. He understands that these people are voluntary uninsured because they are young and healthy. They’re gambling that they won’t need insurance. Or they might be marginally insured, in that they buy a $10 policy with a $10,000 deductible, just in case something really bad happens. They are not putting money into the system.

What this doctor likes about mandatory universal health care is that it forces the voluntary uninsured into the system. He thinks it grossly unfair that they are not paying into the system, while people who need insurance are paying. If there were more money in the system, the person with a preexisting condition would not be required to pay as much for his insurance. In other words, he thinks that the insurance system should be a cross between an uninsured motorist requirement and social security. He freely admits that this is a government mandated spread the wealth approach, and one of which he approves.

Because he has a philosophical approach that requires everyone to be in the health care market, whether they want to be or not, he is unperturbed by CBO numbers projecting vast increases in the cost of health care under the new plan. He thinks the CBO people, being accountants and not doctors, have no idea what they’re talking about. What he envisions is a brave new world in which the government simply provides more insured people who will use medical services. He finds it inconceivable that universal health care (which is a system by which all people are insured, but medical care providers continue to be privately owned) can shade into a single payer, government-owned system.

He does not believe that having the government as an insurance provider will change the system and drive out private insurance. Nor does he believe that, even if all private insurance is gone, with the government being the only bill-payer, that this will do anything other than purify the private medical system of the current social injustices that plague it. He also refused to believe that, in other countries that have socialized medicine, there are treatments that are denied to people, not because the treatments don’t work, but because the people are deemed (by government mandate) to be too old or too ill to be worthy of treatment. As for government lists of treatment, he says we have them already, because every care provider is in thrall to Medicare and related government programs. He did not see a difference between the fact that Medicare sets prices, but does not yet set age or health boundaries for providing treatments.

He is very disturbed by the opposition to the health care plan, which he sees as the product of Republican cabals who are shipping agitators into local town hall meetings. The absence of any concrete evidence of such busing (such as buses) does not change his mind.

I explained that people are also concerned that they’re being sold a bill of goods that is not as promised. The rush to pass a bill (three weeks “deliberation” to change a sixth of the economy) didn’t bother him at all. “That’s how things go.” When I raised specific concerns about the existing bill (the inability to stick with your insurance if you change jobs, the incentive for employers to dump insurance and drive people into the government system, the government decision boards re treatments, the enhanced access the government will have to our finances) he just didn’t care. He thought those were petty concerns and was sure I was wrong. He also discounted the hidden taxes in the bill. “Obama promised that he’d veto any taxes.”

The doctor also dismissed the fact that many of the bill’s proponents — including the president himself — are on record as supporting single-payer care (which is different from the universal care this doctor supports). He denies that Obama lied at the New Hampshire townhall when he when he said ““I have not said that I am a supporter of a single-payer system,” despite several past instances of his having said precisely that. “There’s no lie there,” said my doctor friend. “Obama did not say that he ‘never’ supported single payer care. He’s talking in the present tense. He doesn’t support it now.” I said that, if that’s what the great communicator meant, that’s what he should have said, including explaining why he’s changed his mind. “Nah,” said the doctor. It was clear.

The conversation ended there.

My response, with some additional comment not posted there in italic, is as follows.

1. Unnecessary tests rarely profits the doctor ordering it, whether it be lab tests or procedures. When a doctor sends a patient to get endoscopy, the gastroenterologist profits (if not on salary) from the procedure, not the referring physician. Yes the referring doctor could have just given you a trial treatment, as well as the gastroenterologist. Kaiser though also would not profited from the endoscopy it this was an in-network service. Kaiser predominantly profit from the subscription/insurance fee of its members by taking more in than they spend, by taking money from people who use less of kaiser services and spending some (but not all) of it on those who need and use more.

2. Health systems thus profit by taking money from those who subscribe for health services but do not use as much of it as they put in. If we look at our national health care system overall, the problem may seem that the uninsured are not putting money into the system and thus your doctor’s impression may seem correct but it is not. The uninsured do put money into the system already through taxes they pay to the local, state, and federal system. Those who choose to go uninsured likely believe that they would not need to be insured because they don’t expect to use health care should have that choice respected. In large part these are young people who really don’t need to. To think we should force them, or those who cannot afford insurance, to buy insurance or buy into the health care finance system seems coercive to me.

3. I have no problem with the doctor being agreeable to the government spreading the wealth in this regard for health care. If you think it is a form of taxation for the general well being of the nation, like that of national defense for instance, or border control, or disasters relief a health care tax might even seem reasonable. What is not reasonable is to think that as a democracy that rose party out of refusal to pay unfair taxes, that the doctor would take exceptions to people, whether it be a majority or a minority voice of protest. Isn't that the essence of the Tea Parties and the townhall protests currently underway regarding what the current government proposes. And should the majority decides against this tax should it be forced on them anyway?

4. For a learned person, the doctor still made several gross error in analysis and judgment. The first being a sampling error based on anecdotal experience. Just because the Kaiser system works does not mean a government managed system would. Yes clearly a “public” option will drive private plans out of business because the government plan will get income from everyone through taxation, even the already insured will pay them, thus the government’s “public” option plan will always have a higher ratio of pay-ins to pay-outs than any private plan could match. And since the government has the right to set health care standards for all, private health system cannot hope to compete. In addition, the government has never been known for being efficient financially or in service provided whether it be Amtrak, the post office, or Veterans Health Administration. What partly work now, or even what works well now, can work even less later. Not all reforms make things better.

5. The second error the doctor made is likely based on hubris of being an educated physician thinking he knows better for the patient than the patient himself. Though the current drive for health care reform is really about reforming to control costs rather than improve care access (though some will certainly benefit from improved access), when it comes to the ultimate and primary recipient of health care, it is about quality of care. The current anxiety and consternation among the majority of Americans center around the care they are currently getting as contrasted to the care they may or may not get with the reform. The doctor likely believe he can deliver the same (high?) level of care to his patients and are thus is dismissive of patients general concern over health care reform. He may not realize some patients may not think so highly of his delivery, and he certainly underestimate how someone smarter (or perhaps even less smart than he but has a better political pedigree) than he, another physician installed as a health care czar, may feel inclined to believe he is wasteful and starts to dictate how he could do better, placing him in a position to have to change his standards of practice to conform to someone else’s standards. When one is smart, there is a tendency to believe that one is right and that this right is self evident to anyone else with half a brain.

6. The third error the doctor made is allowing his own convictions and bias blind him to information challenging the veracity of his own beliefs.

I have frequently noted that when a doctor speaks out for or against in the current health care debate, they are given special status and what they say seems to gain greater significance. But shouldn't the truth and the justice of any argument be equally valid and valued regardless of the speaker? It is all really rather amusing.

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