Mere Medical Insurance Won’t Fix Our Problems   6 comments

Hi. This is Rick. I’m a research doctor, which means that I work on salary for a major medical center. I won’t name it here, but you’ll probably figure it out by what I’m about to write. That I work on a salary meant that I made the exact same amount of money before Obamacare was enacted that I made after. In other words, I can’t be accused of trying to line my own pockets. My concern is the care my patients receive, not how much it costs them … but, I should say that we’ve offered ample evidence that it cost them more under Obamacare. But I want to suggest that medical insurance is not going to fix our health care problems because coverage is not the problem. We are!

For the first time in my adult life, I voted Libertarian in 2016. I started out as a somewhat liberal Democrat, son of working-class folks who’d always voted Democrat until the Party was hijacked in 1972. I voted for Carter both times, then for Reagan’s second term (so did a lot of moderate Democrats). I was in Europe for Bush 1’s election, so missed it entirely, then went back to voting Democrat for Clinton’s first term. But Hillarycare REALLY bothered me. As a doctor, I knew it was a very dangerous thing for patient care. I’d worked in Europe for several years and I can tell you that universal health care doesn’t work as advertised. So I voted against Clinton’s second term, then found myself agreeing with the Contract with America (yeah, I was surprised too). I voted for GW Bush the first time, was out of country and forgot to vote the second time, voted for Barack Obama the first time and then stopped being a Democrat entirely and stayed home in protest of his truly terrible policies (and not just Obamacare) the second time. I was planning to stay home last fall too when Lela said she was voting for Gary Johnson out of protest for the devil’s choice the Clinton-Trump face-off made for us. I actually heard Johnson speak a couple of times. He would have been a good choice for president, though he never had a chance.

The Trump presidency is kind of a scientific marvel to me. There are diseases I’ve studied that are a curse that also impart some brilliant advantages. That’s sort of my view of the Trump presidency. Lela likens it to watching a horror film through your fingers. I guess that’s my reaction too. The repeal and replacement of Obamacare is, for me, the most important domestic issue of the year … possibly the century, followed closely by the Supreme Court nominations.

With Republicans set to control the federal legislative and executive branches next year, the hyperbole of the last six years has soared to new heights. You’ve got suppossedly reputable media outlets insisting that 21 million … or 40 million … or 300 million people will lose coverage if Obamacare is replaced.

Others have tried to ground the discussion in reality, focusing on the details of the most comprehensive replacement plans floated to date: that’s what Lela and I have been doing. Speaker Paul Ryan’s “A Better Way,” and Avik Roy’s “Transcending Obamacare.” both provide market-based approaches to comprehensively overhauling the health care system in America, while also addressing the numerous (and now abundantly-clear) problems of Obamacare.

While avoiding many of the defects of Obamacare, Ryan and Roy’s plans both have two fundamental and interrelated flaws: first, they focus on health insurance

  1. they focus on health insurance coverage rather than medical care.
  2. they fail to take into account that a large number of Americans are too dysfunctional to benefit significantly from the proposals.

Providing truly affordable health insurance coverage might equate to obtaining health care, but any proposed reform to our health care system must take account of the limitations of the populace it will serve.

Politicians and policy wonks are often too far removed from true dysfunction to understand how pervasive it is, and how it prevents even the most perfectly devised plan from succeeding as intended. Politicians residing in the D.C. bubble are unlikely to have seen the lives of the truly dysfunctional – those suffering from severe mental illness, drug or alcohol addicts, or just run-of-the-mill adults who lack basic skills to manage their own affairs and that of their families. They usually have no idea how to reach out to a politician and so them the reality of their world.

I grew up in an average working-middle-class home in Washington State. I didn’t know these people existed until I went off to medical school, living in an apartment I could afford, and started spending weekends in that same lower-income neighborhood’s “free clinic”. There I got a close-up view of urban poverty. Later I would spend two years in rural Wisconsin and find out that the same dysfunctionality exists all over.

 

An appropriate health care plan, whether fully or nearly fully subsidized, will be beyond these people’s capabilities. Providing tax credits to offset the cost of privately purchased insurance will be lost on the transient worker who already lacks the knowledge and wherewithal to claim the Earned Income Tax Credit. Signing up for Medicaid might be easier, but that does not translate into health care. There is an extremely limited number of doctors willing to accept the low reimbursement rates, for one. And, then Medicaid recipients actually seek out and find those doctors.

Many cannot or wish not to, which is why they do not regularly obtain preventative care and why, when sick, they end up in the emergency room. In reality, 25% of children in foster care do not receive the required check-ups. These children are in the care of “professional” parents cleared by the government as appropriate caregivers and their medical coverage is government provided. Do you think their dysfunctional birth parents could do better?

I am absolutely in favor of repealing Obamacare and replacing it with something that makes sense, or better yet, with a low-income medical care system that makes sense. Don’t judge the success of replacement legislation on the number of people with health insurance coverage, whether private or governmental. It tells us nothing about medical care or health outcomes. Until we address the lack of medical care as evidenced by poor health outcomes, we aren’t fixing our health care crisis.  Medical care is a separate issue and outside of the insurance and Medicaid structure. Here are a few ways to do so.

A huge part of America’s health outcomes problem comes from lifestyle choices – drug addiction, smoking, high-fat diets, lack of nutritious eating, overeating, alcoholism. Many health conditions and illnesses are preventable. Congressman Paul Ryan highlighted this point in his predecessor legislative initiative, The Patients’ Choice Act, writing:

“[F]ive preventable chronic diseases (heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes) cause two-thirds of American deaths while 75 percent of total health expenditures are spent to treat chronic diseases that are largely preventable. In government programs, the problem is even worse with chronic disease spending consuming 96 cents of every Medicare dollar and 82 cents of every Medicaid dollar.”

Preventing disease by encouraging lifestyle choices and immunizations would greatly reduce medical care costs. Private insurers use “wellness programs” to promote preventative care, weight loss, and smoking cessation programs; they offer reduced premiums or other rewards when certain goals are met. That’s not feasible for Medicaid and relying on advertising campaigns designed by social marketing professionals that focus on health promotion and disease prevention don’t work.

All the advertising in the world will not provide access to healthier food options and even if it did, that will not change eating behaviors. Lower-class Americans do not need more marketing. They need more markets. “America’s Worst 9 Urban Food Deserts” highlighted this problem:

[T]he United States Department of Agriculture reports that about 23.5 million Americans currently live in food deserts, including 6.5 million children. Typically, food deserts are defined by:

  1. the lack or absence of large grocery stores and supermarkets that sell fresh produce and health food options; and
  2. low-income populations living on tight budgets.

These food deserts are also signified by high levels of obesity, diabetes and cardiovascular disease in the community, which result from residents buying their food from corner stores that sell processed foods, and plentiful fast food options.

The solution is to create health oases. Unfortunately, Democratic control of large cities has often led to resistance to “big-box” retailers. That’s code for non-union superstores, such as Wal-Mart. These Democratic governments throw up barriers that prevent large grocery stores from opening in urban areas. Detroit has recently done adopted business-friendly policies to encourage grocery stores to enter the inner city, attracting the regional super-store Meijers, which is now looking to open a third store within the city. Not only does this provide access to healthy food options, it also provides employment opportunities that are lacking in the inner city.

Promoting the expansion of large grocery stores within the inner city will also greatly reduce the rampant fraud in the government food stamp (SNAP benefits) and WIC programs. Large corporate-run grocery stores have internal controls in place that prevent cashiers from trading government benefits for cash, ineligible items (alcohol, cigarettes), and even counterfeit apparel. Corner stores, owned and run by individuals and families and with unmonitored access to cash, have the means to misappropriate government funds. Check out the Chicago Tribune article “Why Food Stamp Fraud is ‘Fairly Rampant’ at Corner Stores in Some Chicago Neighborhoods.”

Large grocery stores often have in-store pharmacies, which have the capability to provide vaccinations. Some states also allow nurse practitioners working out of pharmacies to prescribe basic antibiotics for common conditions, such as ear infections and strep throat. Further legislation to encourage the expansion of store-run pharmacies and access to nurse practitioners will further assure medical care access, making such super-stores truly health oases.

I am personally opposed to abortion, so my next suggestion should not be misunderstood. Fund crisis pregnancy centers. Pro-“choice” advocates regularly accuse pro-lifers of caring only about the baby—not the mother—and then only until the baby is born. While that might make a pithy talking point, it bears no resemblance to reality. Most crisis pregnancy centers offer a wide-range of services, from pregnancy testing, ultrasounds, counseling, goal setting, prenatal care or referrals, parenting classes, and “reward” programs by which moms can earn necessary baby and household items. Oftentimes, counselors end up serving as birth coaches for women abandoned by the father and their family. And these relationship and services continue long after the baby is born.

What better place, then, to assure women and children obtain preventative care and nutritional guidance? Rather than dump more money into the Medicaid system, which has shown no better results for recipients than the uninsured have, we should shift funding to states and experiment with providing grants to crisis pregnancy centers.

These grants could fund hiring nurse practitioners, who could see children while parents work with goal counselors. Parents could earn “points” or rewards for meeting certain targets, such as obtaining routine vaccinations or smoking cessation. Stop funding more government public service announcements, and instead fund nutritional education, smoking cessation, and “rewards” implemented during parenting classes. And fund smoking cessation programs out of the centers. Many centers are already doing some of these things, with great results.

The Women’s Care Center is one such center. Formed in 1984 in South Bend, Indiana by Dr. Janet Smith, the Women’s Care Center now serves women in eight states. (I served on the Women’s Care Center Board of Directors and as the Treasurer for seven years.) A recent newsletter showcases one example of how crisis pregnancy centers can achieve what the government cannot:

The Federalist highlighted a pro-life center, Turning Point, in this piece by Jay Hobbs. As Hobbs explained, “Started in October 2010, Turning Point opened as a fully medical clinic, with ultrasound and STD/STI testing, in addition to material aid that meets the needs of a city where 30 percent residents live at or below the federal poverty rate—twice the national average.” Hundreds (I suspect thousands) of similar crisis pregnancy centers already exist throughout the country. These centers have the infrastructure and experience and the relationships that government bureaucrats cannot forge that are necessary to assure that health coverage translates into medical care and healthier outcomes.

Just as the Women’s Care Center and Turning Point model how crisis pregnancy centers can reach at-risk populations, the San Antonio police department’s mental health squad showcases a new and ideal prototype for reaching the mentally ill. NPR featured this unique program in its piece “Mental Health Cops Help Reweave Social Safety Net in San Antonio.” As NPR explained, select officers receive Crisis Intervention Training; when a 911 call comes in involving a mental health emergency, those officers are dispatched.

Furthermore, San Antonio built a Restoration Center as a separate facility that offers “a full array of mental and physical health services.” According to NPR, “[m]ore than 18,000 people pass through the Restoration Center reach year, and officials say the coordinated approach has saved the city more than $10 million annually.”

This approach should be mirrored throughout the country to address not just severe mental illness, but also the escalating problem of drug addiction. Addicts and those suffering severe mental illness, even if they are competent enough to obtain health coverage, do not have it within their means to access medical care. And as Dallas Police Chief David Brown said after the murder of five of his officers: “We’re asking cops to do too much in this country. We are. Every societal failure, we put it off on the cops to solve. Not enough mental health funding, let the cops handle it.”

While the police will always be our front line of defense, with proper training and the funding to address the health care needs of addicts and the severely mentally ill, over time, the demands will be less. And more people in need of health care will receive it in an appropriate setting, rather than in prison.

As the debate continues over Obamacare’s appropriate replacement, politicians and policy experts should not pretend that a perfect plan can reach all segments of our society. Congress should instead recognize that health “coverage” is an imperfect proxy for health “care” and “outcomes,” and refocus a portion of its attention and funding on policies and programs that provide health care to the severely mentally ill, the addicts, and dysfunctional members of society.

This approach will also go a long way toward providing employment opportunities, combatting fraud, reforming the criminal justice system, and assuring our first responders have access to the resources they need when confronted with impossible situations.

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6 responses to “Mere Medical Insurance Won’t Fix Our Problems

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  1. How popular are these opinions of yours, Rick – asking as a non-American, watching from outside. Just interested in knowing how many people follow your suggestions. And why they would be difficult to implement. Daria.

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    • The opinions themselves are commonly held by American doctors … in private. If you’re in private practice, you can get away with saying these things. I can’t stand up publicly and make such suggestions under my own name because that would be the end of my career and I love advancing discoveries in my field of study. Lela tells me that it’s also a commonly held view in community mental health … the idea that poor-decision makers will continue to be poor-decision makers even if you provide them with completely “free” medical care.

      Anyone who has ever worked with Medicaid recipients can attest to the complications involved in that system. The care is “free”, but very few doctors will accept Medicaid patients, so it is difficult to access care. Same with Bureau of Indian Affairs care. As tribal members, Lela and I both qualify for benefits, but we choose not to use them because the medical provided is substandard..

      A large part of the problem in the United States is that we refuse to acknowledge that we have a sizeable chunk of the population who are poor decision makers for whom even completely free medical insurance will not work. A part of that is based on political correctness and “blame the other”. If I smoked two packs at day for 30 years, the cancer I develop isn’t my fault. It’s the cigarette companies’ fault. If I’m 50 pounds overweight, it’s McDonald’s fault for not having enough healthy choices on their menu … or for offering the Big Mac at all. It would be easier for me to eat healthy if salad was my only choice. If I am an unwed mother who cranked out four kids before I turned 18, that’s not within my control … it’s a failure of the schools, the contraception companies, men in general and churches for teaching abstinence. None of these problems could simply be because I am a poor-decision maker who makes phenomenally bad lifestyle choices. I couldn’t possibly be responsible.

      As for the difficulty of implementing my proposals … well, things like grocery stores in inner cities are blocked by the politicians who control most large cities. They have an inbuilt hatred of big business. They champion the corner store and keep Walmart and Safeway out. Constitutionally, the federal government can’t force local governments to change their zoning, so implementation won’t happen through government, but it might happen through the market. It’s not something that can be forced by government, although government could institute policies that encourage it.

      Right now here in the US we’re debating whether to defund Planned Parenthood, which is the largest abortion mill in the country. Although the federal government insists it doesn’t provide funding for abortions, PP takes grants for women’s health care and uses those grants to keep the lights on in the same facility where the abortions are being performed. It’s called cost-shifting. Supporters of PP are screaming that this will devastate women’s health care, but in reality those services are already offered by crisis pregnancy centers, which do not perform abortions. If the funding were shifted away from PP to these other centers, the quality of medical care for women would increase incredibly. There’s a lot of political blow back for that suggestion, but it is within the ability of Congress to implement it.

      Primary care could be handled by medical cooperatives for an affordable monthly fee. Those exist in some places now, but government regulations make them difficult to establish. Again, government needs to get out of the way and let people and doctors handle it.

      The biggest hurdle to overcome is the current mindset of some people in the country that we need a universal system that addresses everyone’s needs in a single program, dictated by the Wise of Congress. The hysteria over 24 million people “losing” insurance coverage is a prime example. About 20 million of those folks didn’t want medical insurance in the first place, so they will voluntarily opt not to have it. That’s not really a bad thing. Most of these people are young and healthy so don’t need a lot of medical care or they were well-to-do enough that they didn’t need insurance. Rand Paul’s replacement plan for Obamacare has a lot of good examples for giving people choices for how to address their medical care. I think we’ll have an article on that.

      I used to believe that government intervention was the way to go, but then I worked in Europe and saw how really inadequate their medical care is. So inadequate that when I developed appendicitis, I dosed myself with antibiotics and painkillers, got on a plane and flew to the US for surgery. The only European country I would feel comfortable having surgery in is Switzerland, which doesn’t have a government-run medical care system. I count that as my turning point in changing my views on this subject. I gradually grew to oppose government-directed medical care. Government does have a role to play, but I’m more and more thinking Lela is right and that role ought to be to get out of the way. Sue and jail doctors who violate the Hippocratic Oath, but pretty much rescind all medical regulations. Let the market sort it out. End the crony entanglement of the American Medical Association and the insurance companies with the government. The only way to do that is by getting rid of all the regulations. Within a decade (I actually think it would take a year), the medical community would organize itself to assure standards. We would and could police ourselves.

      But we’d still have that 30% to contend with because some people are just going to be dysfunctional. The best we can do is make options available to them and try to educate them to use them. Encouraging their behavior by providing them with completely”free” medical care is not the answer. Just look at the NHS. I know you’re in Australia, but the NHS is sort of the standard everyone holds up in government-directed universal medical care. But it has a 45% higher mortality rate than we do in the US. That says something about what you get when you encourage poor decision making with “free” medical care. You end up with much worse health outcomes. It SOUNDS good, but it doesn’t turn out well.

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  2. You made some excellent points. Medication compliance is an issue with the elderly as well as lowering functioning individuals. Even with all the efforts made to educate people about diabetes, most think it is only about how much sugar they eat.I think it is important for people to have a relationship with their doctors where they feel that they matter. I would love to see more medical co-ops.

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  3. Medical co-ops are a great idea, Onisha, and one reason I like Rand Paul’s plan and dislike the AHCA so much. Paul’s plan would encourage medical cooperatives, while the AHCA continues to discourage them. For the unfamiliar, a medical cooperative is a non-profit agency that connects you directly to a doctor at an affordable monthly price. These doctors provide basic medical services (primary care visits, preventive care and management of chronic medical conditions). Specialists are available often by referral, but sometimes as part of the cooperative. There’s a simple payment plan and pre-existing conditions are not denied.

    What I like best about cooperatives is that they are not a new idea. They actually existed back in the 1880s through the Depression. Fraternal organizations administered them back in the day. They were highly successful until the American Medical Association got involved and complained that they were undercutting doctors who weren’t part of the networks and the government made a law that essentially ended the system. Now we’re revisiting the idea.

    I’m skeptical of it being administered as a government grant. I’ve gradually come to the realization that Lela is right and that government needs to get out of medical care entirely. They’ve screwed it up enough and just need to let doctors and patients decide among themselves how best to cooperate … which is the purpose of cooperatives. Rick

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  4. Well we do have free medical care, but our population is no where near that of the States. I think our overall socioeconomic situation is different as well. We do have those “dysfunctional people” but I would never recommend taking medical benefits away. To do so would only encourage poverty or suffering – as those who also pump out kids here, would suffer the consequences (the kids I mean). We have the same issues: obesity, diabetes, drug use, & education in better lifestyle choices is encouraged. Luckily, our government implemented Medicare here back in the ’70’s (I think). We are encouraged to take up private health insurance for added tax benefits, & we’ve never had health insurance connected to a job. Thank God for that, I say. I suspect (but don’t factually know so please correct me if I’m wrong) employer health insurers would also have restrictions on what they provide for. You certainly have a difficult system to manage. Thanks for your reply.

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    • Rick isn’t recommending taking medical care away from people. He’s recommending the federal government back off, let the states and medical providers handle it. He advocates for community clinics, supported by cooperative fees, for example. He has come to the conclusion over a 40-year career that people who have free-to-them medical care overuse it while not taking care of themselves in their personal lives. We see that here in the United States. He’s seen it in England. It’s the curse of all welfare systems … it takes disincentives people to do things for themselves.

      And, you’re right. You don’t have the population the United States does, which actually supports my argument that the federal government’s one-size-fits-all mandates from on high don’t work for all 350 million people. The states have a better feel for what will work within their states and that allows people who truly hate Romneycare in Massachusettes (which had the same problems Obamacare has now), can move to another state that has opted for a free market system or something inbetween.

      Employer provided insurance used to have restrictions on what they paid for, but Obamacare forced them to provide a bunch of things “included in the premium” that are contributing to the spiraling costs of premiums, which is driving a lot of businesses to drop their employee coverage. That forced their employees into the exchanges, which if you make too much money for the subsidies (and that’s most of the middle class), you are paying on average $1,500 a month. That’s 20-40% of most people’s income.

      All the salient thing to remember is that’s for INSURANCE, not actual medical care. A medical cooperative would charge my family less than $500 a month for actual medical care, but if more people were involved the monthly costs would go down. A coworker of Rick’s crunched the numbers and said if all 350 million were in cooperatives instead of Obamacare, we’d all be paying less than $25 a month — that’s per person . That would be well within the finances of everybody but homeless people here.

      And it would free up a lot of government dollars to actual deal with homeless people.

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