Dr. Brian’s Rx for health care

By Dr. Brian Russell

I don’t opine about many political issues here, but as I am a licensed health care provider, and as health care is such an important issue in this current election cycle and aftermath, I’d like to weigh in on it.

First, I’d like to frame the issue properly.  To listen to some politicians talk about health care, you’d think we have the world’s worst system, that it’s getting worse by the day, that nobody has access to it, and that those who do have access to it can’t afford either services or medications.  None of that is true.  Former U.K. Prime Minister Tony Blair said that you should judge countries based on how many people living in them want to get out and how many people living elsewhere want to get in, and I think that’s also a good method for judging health care systems.  The fact is, people of means from virtually everywhere else in the world, including the many countries with government-run health care systems, flock to the U.S.A. for their health care, and those who don’t have the means wish they did.  Not only is it the best system in the world, but it’s the best it’s ever been, and it’s getting better by the day thanks to the dedicated study, training, and innovation of the best medical minds in the world.  The vast majority of Americans have access to it and are able to afford both services and medications.  Of course everyone wishes that those things were less expensive, but people need to put those costs in perspective.  Health care is among the most important things that we purchase in life – it’s never going to be, nor should it be, among the cheapest.  After all, it requires the lengthy and rigorous training of its providers, as well as some of the most high-tech chemical and electronic equipment ever developed by mankind, it’s extremely labor-intensive, and the liability associated with it is extremely high.  We keep hearing that over 40 million Americans don’t have health care.  That’s not true either.  Those people have health care.  What they don’t have is insurance.  And it’s not over 40 million at a time.  It’s only over 40 million when you add up all of the people in the country who went without insurance for some portion, however short, of the year.  Not all of those people are citizens either, so there’s a worthwhile debate to be had about whether insurance should even be made available to them as it would be an additional incentive to be here illegally.  Even if we accepted that 40 million people in this country have no health insurance at this moment, it would mean that close to 90% of America is covered, yet some politicians want to “change” the entire U.S. health care system to get that figure closer to 100%.  To me, that makes no sense at all.  You don’t “change” an entire country or that country’s entire economy, or its health care system, to solve a problem that affects a relatively small minority of its population.  (By the way, that’s exactly what happened with the Medicare “Part D” boondoggle – four percent of senior citizens were unable to afford their prescriptions, so the government, very unwisely, instituted a massive new program that covers every senior citizen, including the 96% who were able to afford their prescriptions as it was.)  What you do instead is try to come up with solutions that address the needs of the people who have the problem – i.e. let the people who currently are providing their own coverage continue to do so, and try to come up with a way for those who can’t provide their own coverage to get it.  That’s of course if you want the vast majority of people to remain independent of the government – i.e. if you judge your success not on the number of people dependent on the government but on the number of people who aren’t dependent on the government.

So, why do millions of people in this country (but way fewer than 40 million) not have health insurance at any given moment in time?  Well, some people, like indigent kids and people who’ve had serious health conditions since birth, lack insurance through no fault of their own – the kids are too young to get it for themselves, and those with lifelong conditions often can’t qualify for coverage – but together, they comprise a relatively small minority of Americans.  Some others qualify for coverage, but for various reasons, like physical or mental limitations or single-parenthood of multiple pre-school-age children, can barely afford food, clothing, and shelter and have no money left to purchase insurance.  Fortunately, they too comprise a relatively small minority of Americans.  Don’t get me wrong, I’m concerned about those people, and I’m going to address their needs shortly.  But I think we have to make a distinction between them and the millions of others who are able-bodied, able-minded adults and have no health insurance, not because they can’t qualify and not because they can’t afford it, but because they choose to gamble with their health and spend their paychecks on other things.  Remember, when those people need health care, even they can still get it – hospitals in this country are required to treat anyone who shows up in need of urgent care – but afterward, they might have to sell non-essential belongings and make payments for years to pay off all, or more often just a portion, of their health care bills.  I confess that I’m not so concerned about that group.  What do you want to bet that the majority of uninsured adult Americans have cable or satellite television in their homes?  Why shouldn’t there be serious consequences for serious irresponsibility?  If we eliminated those consequences, we’d be removing a powerful incentive for the vast majority of Americans to continue to behave responsibly and secure their own insurance.  You don’t encourage responsible behavior by making it easier for people to behave irresponsibly.  I’m always amazed at how easily some politicians talk about our “moral obligation” to hand more out while ignoring completely a recipient’s “moral obligation” not to have his/her hand out when he/she is capable of meeting his/her own needs, as are the vast majority of Americans.  I acknowledge both moral obligations and weigh them equally.

Now, let’s take a step back and look at why health care costs have risen more sharply than costs in other high-tech industries over the past several decades.  Believe it or not, in large part, it’s because so many Americans actually have had health coverage and because that coverage has continuously expanded to encompass more and more services.  Health insurance used to be like other insurance, intended to guard against catastrophes.  People purchased health coverage at relatively-modest prices to protect themselves against financial devastation in case they needed relatively rare things like surgery or were diagnosed with a major illness like cancer that required extensive and expensive services and medications.  Back then, insurance wasn’t intended to cover routine office visits for minor things like sore throats and colds.  People paid out-of-pocket for expenses associated with such common conditions.  Enter the H.M.O., the answer to American consumers’ demands for ever-expanding coverage at ever-decreasing costs and one of the most vilified institutions in America.  Over the years, Americans wanted to pay lower and lower premiums for health insurance, while, at the same time, they wanted their policies to cover more and more services and medications, including common things like routine checkups, colds, and cough medicine.  Well, insurance doesn’t work when the likelihood of covered incidents occurring among policy-holders on an annual basis is high – not unless the premiums are extremely high or the coverage is extremely limited.  HMO’s met consumer demand for low premiums and expanded coverage in two ways.  First, they contracted with doctors to pay reduced prices for services (e.g. percentages of the doctors’ customary charges).  Second, they made it difficult for patients to see doctors with whom they didn’t have contracts, difficult for patients to see specialists, and difficult for patients to receive costly treatments and medications.  While traditional insurance policies have remained available, many Americans have opted for the h.m.o.’s to save money during times of good health, only to complain about their limited coverage and bureaucratic procedures after health issues have arisen.

As the trend toward h.m.o.’s was developing in America, so was the trend toward health insurance premiums being paid by employers rather than patients.  That began when employers realized that they could use their volume purchasing power to accomplish two things.  First, they could secure health coverage for their employees, which they hoped would result in healthier employees and lower rates of absenteeism.  Second, they could offer the insurance to their employees as a benefit and reduce employees’ salaries by more than the bulk-rate cost of the insurance.  You see, it was out of economic self-interest that employers got involved in providing health insurance for their employees.  But over time, the practice has become so ubiquitous that many employees have lost sight of that fact and now look to their employers almost as some kind of quasi-parental figures, obligated to pick up “in loco parentis” where their parents left off with respect to providing their health care.  When you think about it, that’s kind of a bizarre notion.  Why should the person who pays you for your work be responsible for taking care of you if you get sick?  Why not your parents, or your barber, or your grocer, or your landlord?  Just because a lot of employers do it doesn’t mean it’s an employer’s moral responsibility.  If they choose to do it, great, but I don’t see a moral or legal basis for mandating that employers cover their employees, as has been proposed recently.  So, the combination of these two trends – expanded, albeit corner-cutting, health coverage administered through h.m.o.’s, and employer-provided health coverage – created a market in which the end-users of health care services and medications no longer had any incentive to care about the cost of those services and medications, effectively removing normal market forces, e.g. competition, from the health care market.  It should be no surprise to anyone then that costs have continued to rise sharply.

Most politicians seem to share the goals of reducing the costs of health care and prescription drugs and giving every American access to health insurance.  The fundamental disagreement seems to be about how to accomplish those goals.  Some want to have the government take over the entire health care system, and in my opinion, that would be a disaster.  From a practical standpoint, think of the last time you interacted with a government agency.  Do you want your doctor’s office to operate like that?  I think it would degrade the system terribly.  It would result in all of us having equal access to a mediocre system, when today, the vast majority of us have access, albeit expensive, to the best system in the world.  What’s needed is more competition, more providers, more insurers, more choices for consumers, and more personal responsibility in the system.  Those are the elements that made the U.S. health care system, and the entire U.S. economy, the envies of the world.  Abandoning all of that and adopting a government-run “single-payer” system would be moving in the exact opposite direction and would lead to the exact opposite result.  I hate it when people propose moving our country’s economy away from the traditions that made it strong and toward the traditions that have made other economies, e.g. European economies, weak (and as their economies have dwindled, so has their geo-political relevance and influence).  Personally, I believe, philosophically and Constitutionally, that it’s neither a fundamental purpose nor a permissible undertaking of our government to make sure that every American has health care.  People often misinterpret that whole “promote the general welfare” thing in the Constitution — it means that the government should have plans for what to do and take action if we have a drought or an epidemic of Bird Flu or something, not that the government should be paying for everyone’s day-to-day nourishment or health care.  I believe that there’s a critically-important distinction to be made between responsibilities that are government’s and responsibilities that are society’s.  I believe that our responsibilities to look out for one another and to take care of those who are unable to take care of themselves are societal, not governmental, responsibilities and that they should be carried out by private, not public, institutions and individuals.  Ours is the most generous society that the world has ever known, and I believe that the less government tries to mandate and regulate our generosity, the more generous we are.  For example, there are children’s hospitals all over this country that will treat any child for any condition without regard for that child’s parents’ ability to pay.  Religious and university hospitals often do likewise for adults.  Television talk-show host Montel Williams is traveling all over the country to make Americans aware of a program through which the major pharmaceutical companies, vilified as they are by some politicians, make medications available for low cost or no cost to uninsured Americans who can’t afford them (and by the way, they’re doing the same in Africa with H.I.V. medications, which are among the most expensive in the world).  And perhaps the most vilified corporation in America after “big oil” is Wal-Mart, but that company has made many common prescriptions available to its customers for as little as four dollars (for a month’s supply), and a number of its competitors have followed suit.  I love those kinds of solutions!  But I understand that more needs to be done, and I don’t disagree that government has a role to play – I just disagree about what the appropriate role of government is.

Generally, I want the government to get further out of the business of health care rather than further into it.  When it comes to cost, government can reduce the tremendous overhead cost of malpractice liability insurance by making it more difficult to sue health care providers and recover large sums of money in the absence of clear misconduct by providers.  But I also want to hear politicians talking more about personal responsibility, about Americans needing to go back to the old days, buying relatively low-cost catastrophic coverage and paying out-of-pocket for routine health expenses, incentivizing patients to shop around, maintain healthy lifestyles, and avoid overuse of the health care system, while incentivizing health care providers to compete on price.  And when it comes to access, I want the government to make it easier for Americans to start new health insurance companies to compete with the entrenched industry players on both price and coverage, for Americans in all 50 states to purchase health insurance from companies operating anywhere in the country (currently, people’s options are limited by the states in which they live), for insurance companies to offer limited coverage to people who have one expensive condition that keeps them from obtaining coverage for any other condition (e.g. insure a smoker for everything but lung cancer), and for Americans to set aside and accumulate money tax-free in health savings accounts for out-of-pocket expenses.  (And while we’re on the subject of what the federal government can do for health care in America, I want to see a program whereby the parents of babies who die tragically in the womb can donate their babies’ embryonic stem cells if they so choose so we can sidestep the debate about whether it’s morally permissible to get them either from aborted babies or from embryos created during in vitro fertilization procedures.)  Essentially, I want to see the government removing barriers to health care and increasing health care options but not distributing services and medications to people.  Believe it or not though, there’s one instance in which I do think it’s our federal government’s responsibility to pay directly for people’s health care, and that’s when the recipients are veterans whose needs for health care arise from their service to our country.  Having worked in the V.A. health care system though, I can tell you that you need look no farther than the V.A. to see why you don’t want government-run health care.  I would skip the radical reformation of the V.A. health care system that most politicians promise, and I would disband it altogether.  In its place, I would have the government purchase private health insurance to cover any condition(s) related to a veteran’s service for that veteran’s lifetime.

So there you have it, Dr. Brian’s {post}election-year prescription for health care.  Use as directed, and call me in four years.

Originally Posted Monday September 8, 2008

Dr. Brian Russell is a licensed psychologist, attorney at law and familiar national television pundit on psychological, legal and cultural issues.

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