WHY HEALTH CARE REFORM IS NOT A MORAL CRISIS

The last Kennedy brother has passed from the scene & we now face the ‘legacy’ argument. When LBJ pressed for landmark civil rights legislation in the wake of John Kennedy’s premature death, a moral wind was at his back – and the country was not yet broke.

WHY HEALTH CARE REFORM IS NOT A MORAL CRISIS

New to the POLICY THINK SITE ( www.jaygaskill.com ), Copyright 2009 by Jay B. Gaskill. Permissions & comments: law@jaygaskill.com .

The moral case for health care reform is NOT clear-cut.

The passage of ONE specific bill (HR3200) has been presented as an overriding moral issue. That simply is not the case. [For the curious, patient and legally astute, you can locate the full text of the pending House Bill in pdf format at this LINK: http://energycommerce.house.gov/Press_111/20090714/aahca.pdf.]

THE FOUR CAUTIONS

All ‘reform’ initiatives affecting large numbers of people over long periods of time need to be tempered by the time-honored world prudential concerns, among them these cardinal four:

The ‘first, Do no harm’ caution;

The Utopian trap caution, ‘Don’t let the pursuit of the unobtainable perfect block the attainable imperfect improvement’;

The ‘Murphy’s Law’ caution, ‘Large scale changes should proceed with great care’, preferably incrementally, preserving the option to repair and reverse course;

The anti-bureaucratic caution, ‘Always allow for creative organizational and technological innovation by rejecting one-size-fits-all prescriptions’.

Politicians, especially the ideology-driven subset, tend to conflate everything to the category of a burning moral issue, even the need to drive down the cost of US medical care. But finding practical ways to contain health care costs, for example, is a primarily prudential issue…while doing so without compromising the quality of care to those now receiving it may well be a moral issue.

THE TWO GOALS

Cutting through the fog of debate, we can identify two laudable policy goals that are well supported by a societal moral consensus.

  1. Making health care insurance available to the non-indigent who are currently priced out or completely blocked by preexisting conditions exclusions.

  2. Providing reasonable, life-saving access to medical care for the indigent and near-indigent subpopulation.

WHY IT’S NOT AS BAD AS THEY SAY….

Children are now provided for, regardless of their financial circumstances, by the SCHIP program (LINK: http://www.cms.hhs.gov/home/chip.asp http://www.cms.hhs.gov/home/chip.asp ).

Senior Americans are provided for by the Medicare program as are most disabled under 65 (LINK: http://www.medicare.gov/medigap/under65.asp ).

The adjusted number of uninsured Americans (from the 47.5m number published for 1997) is about 27m (subtracting non-citizens and SCHIP eligible minors not yet enrolled) represents less than 16% of the total population. Put another way, at any given time about 84% of Americans are covered by heath insurance.

Hospital emergency rooms are required to – and do – provide care to indigent persons on application. Though cumbersome and inefficient, the ER has become the indigent care provider of last resort. I note this New York Times report from 2003 - ‘The Bush administration is relaxing rules that say hospitals have to examine and treat people who require emergency medical care, regardless of their ability to pay. Under the new rule, which takes effect on Nov. 10, patients might find it more difficult to obtain certain types of emergency care at some hospitals or clinics that hospitals own and operate. The new rule makes clear that hospitals need not have specialists ''on call'' around the clock.’

Obviously, the current system ‘NEEDS IMPROVEMENT’ both from a prudential and a moral perspective. But is it morally bankrupt? HARDLY.

Among the morally founded concerns being debated, these six animate most of the discussion:

Our common humane concern for the plight of the less fortunate.

Our natural wish to mitigate the inequities of life, especially where they affect access to medical treatment;

The physician’s ethical duty to make his or her individual patient better – this is the core of the Hippocratic Oath;

Our common AFFIRMATIONS of health over illness and life over death;

Our desire to continue the beneficial fruits of creative medical innovations, especially in America;

The inherent justice that promises relied on are to be kept and earned benefits are not to be taken away.

Here’s the dirty little secret of the current debate:

THESE MORALLY FOUNDED POSITIONS ARE IN TENSION WITH EACH OTHER. THIS HAPPENS NATURALLY BECAUSE, IN THE REAL WORLD, THERE ARE NOT ENOUGH RESOURCES TO ACHIEVE EQUALITY WITHOUT DEGRADING THE CARE NOW PROVIDED ABOUT 80% OF AMERICANS.

This ‘quality downgrade’ effect will be revealed over time in ‘new’ medical doctrines that impede the Hippocratic oath (sacrificing individual patients for the ‘common good’), in new bureaucratic rules that promote or reward the pursuit of life saving cures for more ‘cost-effective’ approaches (one prominent administration ‘reformer’ proposes using pain killers in lieu of chemotherapy as general policy), in an actual reduction in the rate of creative medical innovations, and in the denial of levels of care that had been contractually or morally promised.

To be clear: The real discussion is not between some morally enlightened government solution and the retrograde forces of darkness: it is between sets of solutions that are likely to make things better for a large number of people without making things worse for an even larger number, versus a set of politically managed and poorly constructed ‘paper’ solutions designed to mask a general reduction of care quality in the name of ‘equality’.

There is no actual societal consensus about ‘justice’ when it comes to health care. Just consider these competing ideas:

  1. Social justice, the perspective that differences in one’s social circumstances and well being should be ‘evened out’ in the name of equity.

  2. Individual justice, the perspective that one’s own actions should produce appropriate consequences to be enjoyed or suffered as the case may be.

  3. Ameliorative justice, the perspective that the adverse circumstances imposed without fault by the actions of others or the cruel turns of fate should be ameliorated.

  4. Creative justice, the perspective that the conditions that ‘grow the pie’ through creative innovation and development should be allowed to trump temporary inequities.

PRACTICAL MORALITY

Let me propose a practical approach, one framed around two, time honored principles:

[1] Do no harm. Let’s commit to limit changes in the American health care system to ones that will not degrade the care now provided the great majority of us who are sufficiently satisfied with our present arrangements that we don’t want them to be ‘messed with’ in the name of ‘comprehensive reform’. We are to be forgiven for our world-weary skepticism about the Utopian promises of government officials. We have been burned before.

[2] Slow down and proceed with great care. Reforms should be targeted at the carefully defined problem areas, employing a metric by which their efficacy can be measured, allowing a clear opportunity for review, amendment or even reversal of course. The current plan is designed to become so embedded that reversal will quickl become a practical impossibility.

So – What would I support?

A supply-side American physician program, cutting tuition costs of medical education, including specialists. [You want to drive down prices, try increasing suipply.]

Universal access to shared risk-pools for catastrophic health insurance, scaled to achieve a reasonable wholesale premium level without denying coverage for preexisting conditions. [Private insurers, individuals, businesses and government agencies would then contract with these risk pools to supplement other arrangements and these pools would become the default coverage for all employers (including part time jobs) as well as the default COBRA coverage with no time limit.]

More tax-free health insurance savings accounts for all adults and children up with no-penalty charitable sharing with others in need.

A fast track, special bankruptcy proceedings for medical costs only – repeatable in 3 years as necessary.

Reversal of the ever more intrusive and inefficient bureaucratization of medical care, allowing America’s health care sector to remain open to creative, flexible, non-bureaucratic innovations lest it mutate into death care.

THE POWER OF ‘NO’.

From a real world perspective, the needed constructive discussions first require congress to just say NO to the current bills, and NO to the strong-arm tactics of the current congressional leadership.

JBG

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