One of the overwhelming conclusions we’ve had to draw on health care, as we studied hard to prepare for the September 15 Dinner at the Square “Take 2 Aspirin, Fix Health Care & Call Me in the Morning,” is that the incentives in our health care system are fantastically broken. Here’s what we mean:
The incentive for doctors, especially in the litigious climate of bazillion dollar malpractice awards, is firmly for more treatment to protect themselves.
There is no supply and demand curve where customers (patients) interact directly with suppliers (doctors, hospitals) to drive prices down and quality up as our economy has otherwise functioned. Insurance companies stand between them (they’re like a parent with an unlimited credit card to both patients and doctors.)
Toss in physician ownership of some testing facilities, so that more testing doesn’t only mean covering liability, but it means increased income and….
Voila, you’ve got skyrocketing costs with no end in sight.
Here are two great articles on incentives. They’re long, but well worth a read if you want to understand what’s wrong. The first offers a patient-centered market-based solution, the second leans toward a Mayo clinic managed care patient-centered approach.
“You must understand this, my beloved: let everyone be quick to listen, slow to speak, slow to anger; for your anger does not produce God’s righteousness. Therefore rid yourselves of all sordidness and rank growth of wickedness, and welcome with meekness the implanted word that has the power to save your souls. But be doers of the word, and not merely hearers who deceive themselves. For if any are hearers of the word and not doers, they are like those who look at themselves in a mirror; for they look at themselves and, on going away, immediately forget what they were like. But those who look into the perfect law, the law of liberty, and persevere, being not hearers who forget but doers who act – they will be blessed in their doing. If any think they are religious, and do not bridle their tongues but deceive their hearts, their religion is worthless. Religion that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress, and to keep oneself unstained by the world.”
Three factors exacerbate this paralysis by lack of analysis: labels, lifestyles and listening.
First, the labels ascribed to many potential policy tools render sensible options taboo, loading what could be rational, economic or social measures with moral baggage. This narrows our choices, hemming in policy makers.
Any proposal including the words “government-run” elicits cries of “socialism” and “communism.” Any argument invoking the words “God” or “moral” sparks accusations of “right-wing extremism,” “facism,” or “Bible-thumping.” Instead of listening to each other’s ideas, we spot the warning label and run the other way.
Second, our lifestyles favor knee-jerk reactions. The way we think, work and live in the Digital Age demands we quickly categorize information without investing time into rich interaction, research and understanding.
We’re hesitant to ask questions because we don’t have time to listen to the long, complicated answers that might follow. And we lack the time to fact-check competing claims. In our haste, it’s easier to echo our party’s position than drill down, questioning whether party leaders are motivated by our best interests or the best interests of their biggest contributors.
Third, we tend to listen only to like-minded opinions as media fragmentation encourages us to filter out varying perspectives. If you’re a liberal, you avoid FOX News. If you’re a conservative you revile MSNBC. The dynamic is even more pronounced online, where a niche media source can be found for any outlook.
This silences the opportunity for meaningful dialogue and deliberation that might lead to reformulating positions, forging sustainable compromises, and developing consensus crucial to moving our nation forward on complex issues.
In our research preparing for September 15th dinner Take 2 Aspirin, Fix Health Care & Call Me in the Morning we have learned one thing if we’ve learned nothing else: We are trying to solve a complex problem and therefore need to have a high quality “A”game conversation. The corollary to what we’ve learned… We are NOT having a high quality conversation.
I finally got around to fact-checking the allegation that the VA manual “Your Life, Your Choices” was encouraging vets to off themselves. (You can click on a link to the PDF of this 55 page document HERE.) Turns out it’s all about helping vets determine what they want, so that their wishes would be observed if they weren’t able to direct their health care decisions. That means if you want every treatment on planet earth to save you for 15 more minutes, this pamphlet will help you articulate your directive. It’s a rugged individualist’s dream come true. Here is a representative sample:
Thereâ€™s only one person who is truly qualified to tell health care providers how you feel about different kinds of health care issuesâ€”and thatâ€™s you. But, what if you get sick, or injured so severely that you canâ€™t communicate with your doctors or family members? Have you thought about what kinds of medical care you would want? Do your loved ones and health care providers know your wishes? Many people assume that close family members automatically know what they want. But studies have shown that spouses guess wrong over half the time about what kinds of treatment their husbands or wives would want.
You can help assure that your wishes will direct future health care decisions through the process of advance care planning…
What else can I do to make my wishes known? It is a good idea to write down your wishes for future health care because it gives others the most complete picture of how you feel and what you would want. You can do this by signing an advance directive, which can be either a formal, legal document or an informal statement of your wishes. There are two types of formal directives: proxy and instructional. A proxy directive uses a legal document called a â€œdurable power of attorney for health careâ€ to appoint a spokesperson who can make health care decisions on your behalf. It goes into effect when health care decisions need to be made for you and you canâ€™t communicate or make health care decisions for yourself.
If you are conservative, I think a valid question to ask about health care reforms is “if government is financially invested in my health care, given the massive potential power of government, how do we know they will use this power judiciously?” But you might want to know that the argument by many health reform advocates is that private insurers currently have a financial investment in your health and that it isn’t hypothetical or speculative at all that they are looking to rescind your policy if you get expensively sick. Some of their agents actually earn more money directly if they can find cause to retroactively cancel your policy.
The VA “death pamphlet” just isn’t a valid argument. It takes our eye off the ball as we try to play our “A” game.
Florida State Senator Dan Gelber wrote this morning about his father Judge Seymour Gelber’s 90th birthday. (Judge Gelber was also formerly the Mayor of Miami Beach). Anyone who follows us knows we find a lot of wisdom in the way things used to be and we just love knowing each other as neighbors, so I was a sucker for this story. I’ll let Senator Gelber take it from here:
My Dad has always believed that the mark of a great public servant was accepting that anything truly good you do will come to fruition when you are long gone from public life. In the age of constant media cycles and focus groups, his views might be considered outdated or quaint. But today as Florida faces so many challenges borne out of short-term thinking and shallow policies, I think my Dad and his bowties are still pretty fashionable.
Please take a moment to read a son’s 90th birthday tribute in its entirety. As we trade fire in the partisan wars, we might do well to remember dads like this one.
And Happy Birthday, Judge Gelber.
POSTSCRIPT: I googled Senator Gelber’s dad and found this wonderful YouTube video that speaks volumes both to his character and his ability to wear a bowtie.
Well, it’s not about bipartisanship. I think that has its moments and its peaks and its valleys. It’s civility in the process, I think more than anything else. …when we get back into session, if you want to, if you want to honor Teddy’s memory, it’s to come back and sort of, as I said the other night, to put behind us the blistering days of August and, and to enter the cool days of September and start acting like Senators again where you respect each other. There are differences. You bring that partisanship to the table, but you work out your differences. That’s what’s we were elected to do, that’s what Teddy understood adamantly about the place… When you abandon civility, then you’re going to be in trouble.
…I believe such a grand bipartisan compromise is still possible with health care.
Since the days of Harry Truman, Democrats have wanted universal health coverage, believing that if other industrialized countries can achieve it, surely the United States can. For Democrats, universal coverage speaks to Americaâ€™s sense of decency and compassion. Democrats also believe that it will lead to a healthier and more productive country.
Since the days of Ronald Reagan, Republicans have wanted legal reform, believing that our economic competitiveness is being shackled by the billions we spend annually on tort costs; an estimated 10 cents of every health care dollar paid by individuals and companies goes for litigation and defensive medicine. For Republicans, tort reform and its health care analogue, malpractice reform, speak to the goal of stronger economic growth and lower costs.
The bipartisan trade-off in a viable health care bill is obvious: Combine universal coverage with malpractice tort reform in health care.
If you have not seen Republican Orrin Hatch’s eulogy of Ted Kennedy, please watch before we forget what a Republic looks like (3 parts). This conservative Mormon and liberal Catholic did it just as our Founders intended. This is a rivalry befitting this great country. This is the real conversation of democracy. If this isn’t the standard your Senator or Congressman strives for, I hope you’ll expect better beginning tomorrow morning. If you don’t, who will?
This video is making the rounds at the speed of light on the left side of the aisle as a convincing and common sense argument for single payer. It is important to recognize that single payer does not mean doctors would be directly employed by the government or hospitals owned by the government. It would mean that everyone would be paid by the government, which does suggest that government will control how much everyone is paid. It is often described as “Medicare for everyone.” Fly in the ointment: Doctors and hospitals lose money given what Medicare is willing to pay (and they don’t negotiate group rates like other insurers, they just tell doctors and hospitals what they’ll pay). A single payer plan (currently an option only in HR 676 which no one thinks has a chance) would have to, unlike Medicare, pay a reasonable market rate to allow doctors and hospitals to stay in business. (No doctors is distinctly horrible for health care.)
Last Tuesday, I attended the Tallahassee health care town hall. I have lived to tell.
No question there was anger. There was also a good dose of tension. I heard random angry comments about government. But there wasnâ€™t violence and to be honest, there werenâ€™t even many raised voices. I think everyone was trying to comport themselves consistent with grown-up-hood, which never makes good news copy. The most disruptive part of the whole shindig was alternating team clapping and I say democracy can survive a little team clapping.
To get into the town hall, I stood (and stood and stood) in line next to a nice minister who didnâ€™t see health care the same way I did and admitted he watched a bit too much Fox News (but then again I probably watch too much MSNBC). We talked honestly and with respect and at least passingly entertained the notion that we might learn something from each other as we whiled away the hour(s)(s)(s).
I left with sore feet and a measure of hope but – to be honest – a larger measure of despair about the unfolding pointless American tragedy that weâ€™ve found our communities pulling apart at the connections we used to have so naturally with each other. If only we had a lot of food and the requisite amount of alcohol (with apologies to my Baptist friends) and maybe a football or two, we might have left the town hall with both a hangover and a new health care bill.
On the way home, just as I was about to drive past a double amputee on the sidewalk (really not making this up) the man tried to take a run at a ramp in his wheelchair and instead fell out of the chair completely and almost into the road.
A good number of people stopped to help him back into his chair, and check to see if he was hurt. A couple of us wheeled him back to what seemed to be his home as best as we could make out from his distorted palsied speech and his pointing. Reaching to restore a bit of the dignity I felt this man had at least temporarily lost, I stopped to introduce myself and shake his hand before I left.
His name was Tony.
Given where Iâ€™d just been, I couldnâ€™t help wondering on the way home whether Tony was one of the uninsured or maybe he was one of the people â€œsucking on the government teatâ€ of Medicaid as had been described more than a time or two by health care reform opponents that night. I think that as most of us think about government help, we easily forget the people who need help in ways so daunting and desperate that if we really appreciated the truth of the matter – that â€œthere but for the grace of God go Iâ€ – weâ€™d wake up on the hour in a cold sweat. Itâ€™s so comforting to think that what separates us from Tony is big and made of impenetrable steel instead of an unlucky second or two of life taking a horrible turn.
At the end of only two more hours that day, Senator Ted Kennedy â€“ who had spent a lifetime fighting for universal health care â€“ would be dead. A year to the day before he died, Kennedy said of health care: â€œThis is the cause of my life.â€
Some days leave you feeling a little shell-shocked.
Iâ€™m going to go out on a limb and say that the jury is out on what the heck weâ€™re going to do about health care. What government does versus what we do privately is a real and legitimate question. But last Tuesday, for me the question suddenly had a human face.
We fill the space of our public discourse talking about whatâ€™s wrong with some other guy, some other political party, some other country. And to be sure plenty is wrong with â€œthem.â€ Volumes could be written (and have) on how Ted Kennedy fell short in his life.
In keeping with the hateful way we have come to see each other, some were posting putrid partisan obits of Kennedy before I fell asleep on what weâ€™ll call health-care-has-a-face-day. As I read through the nauseating words, the diverging roads we could take from here appeared for me in sharp relief: We could continue to point our fingers, or we could take a look in the mirror and ask ourselves or â€œor sideâ€ where we fall short.
And maybe, just maybe, when we look in the mirror for a passing moment we could imagine finding ourselves without legs lying in the street.
If you didn’t see this today, skip the words… just watch the tape.
“He never was petty. He was never small and in the process of his doing, he made everyone he worked with bigger, both his adversaries as well as his allies. Don’t you find it remarkable that one of the most partisan liberal men in the last century serving in the Senate had so many of his foes embrace him? Because they know he made them bigger, he made them more graceful by the way he conducted himself.
“You know, he changed the circumstances of tens of millions of Americans in a literal sense. He changed also another aspect of it as I observed about him. He changed not only their physical circumstance, he changed how they looked at themselves and how they looked at one another. That’s remarkable… I just hope we remember how he treated other people, and how he made other people look at themselves and look at one another. That will be the truly fundamentally unifying legacy of Teddy Kennedy’s life if that happens, and it will for a while, at least in the Senate.”
Republican Senator Orrin Hatch eulogized Democratic Senator Ted Kennedy early this morning on news of his passing:
“In the current climate of today’s United States Senate it is rare to find opportunities where both sides can come together and work in the middle to craft a solution for our country’s problems. Ted Kennedy, with all of his ideological verbosity and idealism was a rare person who at times could put aside differences and look for common solutions. Not many ever got to see that side of him, but as peers and colleagues we were able to share some of those moments.”