Category: Society

WITHOUT KNOWING IT: A New Poll

According to the New York Times today, Americans show surprising clarity about financing health care: “Half of those questioned said they thought government would be better at providing medical coverage than private insurers, up from 30 percent in polls conducted in 2007. Nearly 60 percent said Washington would have more success in holding down costs, up from 47 percent.” (See In Poll, Wide Support for Government-Run Health)

Despite the scare tactics of the insurance companies, hospitals, and professional associations and the intense lobbying that the health care industry is engaged in, there is an underlying fact that the public seems to have grasped: in a society where health care has become a business, the best way to hold down costs is to remove the profit motive. Businesses have to make money: hospitals have to turn a profit, insurance companies and manufacturers of drugs and medical equipment must earn a return for their investors, providers are encouraged to become entrepreneurial. It adds up, of course.

In a review of a new book by Ezekiel J. Emanuel on reforming health care, Dr Arnold Relman, Professor at the Harvard Medical School and former editor of The New England Journal of Medicine, makes the essential point: “No other health care system is as focused on generating income as ours, and in no other country is medical care marketed and advertised so aggressively, as if it were just another commodity in trade.” (See The Health Reform We Need & Are Not Getting) Our enthusiasm for free markets, for privatizing essential services, our horror at “socialized medicine,” at government control, have pushed us down this path – and too many interests are at stake to make any significant change seem possible.

So this underlying fact has disappeared from our debates on the subject, our conversations, and from our conscious minds. Even the book that Dr. Relman reviews, written by the brother of Obama’s Chief of Staff, Rahm Emanuel – a good book with lots of useful ideas, according to Relman – fails to make that point.

But, in its way, the public knows it. They are not preoccupied with the political problem of what is possible to get through Congress, or how to contend with special interests and their powerful lobbies, or how to get re-elected. But they have their day-by-day encounters with buying drugs, paying bills, filling out insurance forms, sitting in emergency rooms, losing jobs and losing coverage. They may not be able to think it or speak it clearly, but they know the underlying truth of the situation. Only government is not out to make a profit.

Another Skirmish Over Health Care

“Rationing!” exclaims David Leonhardt in the business section of today’s New York Times: “Wait, are you talking about rationing medical care? Access to medical care is a fundamental right. And rationing sounds like something out of the Soviet Union. Or at least Canada.” (See Health Care Rationing Rhetoric Overlooks Reality)

Leonhardt does not specify where this particular charge originates, but I suspect it’s from the insurance companies – and maybe the drug companies as well. In Monday’s post, I suggested that each of the stakeholders in the health care industry will seek to arouse in the public specific anxieties that suit their interests. Restricted access to health care is what the insurance industry wants us to fear. After all, that is exactly what they do by allocating only so much for each medical procedure, limiting providers, authorizing some drugs and not others, etc. But when Big Brother gets in the act, then, it’s “rationing.” The consumer can feel a helpless victim. More to the point, the insurance industry will have serious competition. And they may end up being dominated by government agencies setting policy, with the final effect being that they will lose profits.

“The r- word” will get a vigorous workout in Washington this summer, Leonhardt predicts, as legislators wrestle with the issues and deal with the buzzwords that sway voters. He makes the reasonable case that all health care services require some restriction. But “rationing” stimulates thoughts of deprivation, wartime shortages, governmental control, arbitrary restrictions and impersonal bureaucracies. If the insurance companies can persuade us that this is the most important thing to fear, they can hope to retain control over the distribution of health benefits. They will be the ones who determine how benefits get “rationed,” and their share of the $2.5 trillion industry will be safe.

Will the Greatest Fear Win Out?

Different stakeholders are battling to protect their different interests, in the reform of an industry that is responsible for $2.5 trillion annually, 1/5^th of our total economy. The New York Times in its News of the Week in Review, lays it out nicely in its lead article, Following the Money in the Health Care Debate. But each interest group and each of their arguments they make preys upon a different set of fears in the public. Those fears will not be explicit, but they are likely to be what determines the outcome.

Doctors fear a government-run insurance program that looks like Medicare will pay like Medicare, said Robert Laszewski, a health policy consultant in Alexandria, Va. “Medicare pays doctors 80 percent of what an insurance company pays,” he said. “If you get a public plan, the doctors are going to get a 20 percent pay cut.” The AMA has already staked out its opposition.

So doctors will argue to the public that low pay will degrade the profession and lead to fewer, less qualified doctors and inadequate care. Yes, you can have government insurance, but your health will suffer.

Insurance companies may get some new customers, but their trade association fears its members would be driven out of business as the government uses its purchasing power to demand much lower prices.

The insurers will argue that government insurance is inefficient, full of gaps. The public, they suggest, will be not get the care it needs when it needs it. The fear: you will be neglected, forced to wait, maybe even overlooked.

The hospitals’ concern is that, like the doctors, they will be paid less. The fear they will arouse in the minds of the public is that hospitals will be overcrowded, inadequate, poorly staffed. Do we want that?

The nation’s drug makers are afraid of the government’s ability to demand lower prices for their products. “The more government intervention you have, the less payment you have,” said one analyst. These companies also fear that the government will play a greater role in determining the effectiveness of different drugs and medical devices and use that information to control costs. (The Times points out that insurers, not surprisingly, support the government’s intervening with drug and medical device makers so they don’t have to.)

There are real issues and real complexities at stake here, and clearly some plans will be better than others – and some worse. But we all are easy prey to anxiety, especially as we all fear sickness and disability so profoundly. And we are not likely to be conscious of having our fears manipulated.

It will be tough for legislators, besieged by lobbyists and anxious constituents, to thread their way to a logical and effective plan. But the hidden role of anxiety will make it even tougher.

THE PROBLEM WITH GITMO

In this week’s Newsweek, Dahlia Lithwick asks “Why are we so worried about Gitmo?”  “The current legal meltdown over what to do with the 240 prisoners shows that Americans actually care a lot about prisons, prisoners and prison reform, but only when the inmates threaten to tumble out into their backyards.”

She points out how overwhelming a problem our prison system presents. With 5 percent of the world’s population, we house nearly 25 percent of the world’s prisoners.  We incarcerate 756 inmates per 100,000 residents—nearly five times the world average. Approximately one in every 31 adults in the United States is in prison, in jail or on supervised release. Local, state and federal spending on corrections amounts to about $70 billion per year and has increased 40 percent over the past 20 years. What is going on here?

Senator James Webb (D. Va) concluded: “Either we’re the most evil people on earth or we’re doing something wrong.”  Webb is backing a major effort at prison reform, an extremely complex and difficult set of issues as it involves all levels of government, thousands of laws, and many different types of offense.  Because of that complexity, changing our investment in the penal system is not going to be easy.

But there is underlying issue here, a common element in our approach to a major social problem.  This is reflected in the fact that  the pressure to close Gitmo and relocate its inmates evokes a collective fear.  This forces our attention on a problem we really don’t want to face. It’s not just about Gitmo;  it’s about our relationship to prisoners and the prison system.

Why is it that on so many levels and in so many different ways we have embraced jail as an answer?  What is the underlying meaning of that?

Jail represents the underside of opportunity.  The ideology of our systems tells us that for those who work hard, the doors of success will open, but for those who do not, those who cheat or steal or rebel —  or those who hang out on street corners — the doors of jail will clang shut.  Tending to believe, as we do, that the chance of success is each person’s responsibility, jails represent not only a punishment for crime but also an exile from the American dream and a punishment for failure.

As Senator Webb knows, prison reform represents a difficult and complex set of issues.  But we also have to look what underlies an obvious social consensus.

from Ann D’Ercole

As I walk or drive around neighborhoods here and in Europe I’m still struck with how pleased I feel that everything, everywhere is clean, attractive and projects a sense of relative safety compared to the old days when many more decrepit buildings and neighborhoods blighted the world.
A couple of years ago I did start to wonder how it was all being financed. But I was willing to forget that question because I liked what I saw. So, my question to you is in our post 911 collective unconscious could it be that we were all happy to sign onto what appeared to be an equalizing egalitarian world where all neighborhoods were places where people would want to live? We accepted a sign of global prosperity because we wanted one rather than accept 911 as a sign of global disaster.

Dear Ann:

I think you are right that we were all happy to sign on to the evident signs of prosperity, the clean streets, the restored neighborhoods and new cultural buildings — and our increasing retirement portfolios as well.  Behind the facade was a good deal of social inequality less easy to see.  But your main point — and I agree very much — we were complicit.  We did not ask and we did not want to know how it was accomplished.