August 27, 2008

Obama, McCain, and Health Care Justice

Barack Obama is conservative. John McCain is radical.

It's true, at least with respect to one issue: health care.

The dysfunctional state of health care delivery combined with rapidly escalating costs have framed the issue to be one of the most visible in the 2008 election season. Which party has the edge? Democrats have historically enjoyed large advantages in polls declaring that people "trust" them more than Republicans by wide margins. But there are unusual dynamics at play this time around.

A 2007 poll found a majority of respondents in favor of a single-payer government health system, while 77% simultaneously supported "reducing government regulation of insurance." This seemingly contradictory finding points to the fact that disgust with the current system overrides affinity for any particular reform agenda. As the Cato Institute's Michael Tanner puts it, "Voters are saying that almost anything is better than the status quo."

In this climate, the conventional Democratic edge may not hold up. The field is wide open for whoever touts the more attractive reform package.

For all the talk of universal health care, Barack Obama's proposals actually move us only slowly and not very far in that direction. He would enact government mandates requiring employers to insure their workers and parents to insure their children, while introducing extensive new regulations of the insurance sector, such as requiring health plans to cover all applicants. Even with these changes, however, Obama's plan essentially preserves the employer-based system that has proved so troublesome.

By comparison, McCain's reforms look radical. He calls for moving away from the employer-based system by shifting insurance tax credits from employers to individuals, giving people more control--and thereby more responsibility for--their own health care. Additionally, he proposes deregulating the insurance market, so that interstate competition increases.

Both schemes must deal with the question of financing, but there is another important question to pose. Most Americans are concerned that health care provision be characterized not only by economic efficiency but also by justice and equity. When vulnerable populations don't have access to adequate health care, our obligations to the common good stand unfulfilled. Which plan aligns better with the demands of justice?

It is difficult to predict what the results of either approach would be. As incentives change, behavior changes, making calculations hazardous. Both McCain and Obama recognize that a problem as enormous as health care delivery is not easily soluble by a single reform program. But if we're at a crossroads considering whether to move toward more government involvement or more market freedom, the latter direction is likely to lead toward a more efficient and equitable system.

History proves that large government programs covering high numbers of beneficiaries with diverse needs do not fare well. At the personal level, bureaucratic rules replace individual care and attention. At the economic level, price control would almost certainly be part of the package. Price ceilings, as long lines for gasoline in the 1970s should have convinced us, lead to shortages of supply. The generation of fewer doctors and nurses is not a prescription for improved health care.

The drawback of the market is its potential for unequal outcomes. It is important to remember, however, that inequality is not synonymous with injustice. Justice does not require that all people receive precisely equivalent levels of medical treatment; instead, it dictates that basic physical needs, including health care, are met. Perfect equality, moreover, is simply unrealistic. Even in those nations held up as models of universal access--Canada, for example--the wealthy and well-connected manage to secure better or faster medical treatment.

The more critical concern is that the people who are most vulnerable--children, the unemployed, the uninsured, the chronically ill--may fall through the cracks of a health care market built on a foundation of personal responsibility. This is where other institutions play indispensable roles. Many of America's hospitals bear testimony to their religious roots: Mercy, Methodist, Good Samaritan. Provision of care for the ill has ever been intrinsic to the practice of Christianity, reflected in the traditional work of mercy, "visit the sick."

Neither presidential candidate's reform plan highlights the extensive work performed by charitable organizations, but neither the market nor the government is going to care adequately for those on the margins. Whichever reforms (if any) are eventually implemented, the imperative to visit the sick will remain as a call to each of us to lend support in our families, churches, and communities.

Comments

John:

Chris... not to get into a chapter and verse contest, but if we go back to the very basics and you violate "shalt not covet" and "shalt not steal" through the force of government what have you gained?

We are called as individuals to "love thy nieghbor", we are not called to take ... by force...the goods of nieghbor Peter to provide health care for nieghbor Paul.

James Kim: JamesKim1126@hotmail.com

I really believe Obama's health care plan hasa more long-term effect than, John McCain's.

may: magelfia_delmundo@yahoo.com

i want obama because he is concerned to the peoples living he knows the right and wrong and he also knows the good for the people he knows what are the needs of the people in their country, and i think that he can do well if he will be in the position of president................................i vote for obama

Don Phillips: donpmarilyn@earthlink.net

Ryan, Debbie, you do not get anything for nothing. Insurance companies have to charge enough to cover their payouts and hospitals have to charge enough to cover their costs. If you limit what insurance companies can charge and demand that they cover everyone, you will see the insurance companies leaving the arena. In Washington state they put so many demands on the insurance companies that many of them left the state. We need free choice, not government mandates.
Likewise with the hospitals, if you force them to treat all the uninsured and limit what they can charge for certain procedures, they will have to make up their costs by charging more elsewhere. Again, government interference causes more problems than it solves.
Note the news from Britain where people are pulling their own teeth and pregnant mothers are told to go find a midwife. Or try Canada where you can wait months for an appointment. I doubt that anyone here woould want to put up with that.

Eagle Eye:

As a personal acquaintance of Dr. Schmiesing, and one very familiar with his views, I believe I can state--with a good degree of certainty--that some of the comments here indicate a misunderstanding of Schmiesing's article. The implication of the article is that Obama--radical in many cases--is being "conservative" in a case where he should not, and McCain is being "radical" about a healthcare system desperately in need of such significant change.

Schmiesing is correct that we cannot completely predict the outcome of any proposed plan prior to its implementation. That does not contradict the fact that we do have some past indicators that give us good reason to trust in some plans over others.

Willman: singlemalt8@hotmail.com

The one thing every one tends to overlook is that no health care plan will control costs until we, as a country, can come to grips with the difficult issue to realizing that we can not afford to provide aggressive care for every very early preemie, end stage cancer patient, open heart surgery for 80 year old's, hip and knee replacement for very elderly, etc. The question behind the question is what form of rationing will we use economic, prognosis, Que? Health care will always be rationed and controversial.

lynn: lynnsyvertson@yahoo.com

Why would universal health care for everyone be any different than Medicaire. Those who say they don't want "socialized" medicine probably won't wish they could opt out of medicaire when they qualify. The government also provides public schooling for everyone as well as police protection. Would we want those services strictly left up to the private market sector?

Howard Long MD MPH: howard.long@comcast.net

HSAs, Health Savings Accounts, now provide better and less costly primary care (plus tax savings better than 401K).

Over 6,000,000 Americans have now this true insurance, covering costs over ~$2,000 better and for ~ 1/3 the premium
(BC CA and Kaiser HSA plans). It is growing 35%/ear despite opposition from
the insurance companies, government bureaucracies and union-employer collaborators who have been taking money,
with HSAs kept in the pockets of the patients. That's why you don't hear more about it, as in this article.

What I like best about HSAs (I'm a family doctor) is elimination of "the payer of the piper calls the tune".
I and many other doctors now accept only cash payment, so our only allegiance is to our patient.
Every day, I see not only HSA owners but also people unhappy with government or corporate care,
who are happy to pay a small fee for the different attention of a doctor who cares only about them.
Since each person is different, dictated "quality", standard care, usually does not fit well.

In 1994, Milton Friedman forwarded to me Pat Rooney's amazing experience with 1200 Golden Rule Ins Co employees.
Refuting concern that people would neglect preventive care if paid out of pocket (usually prefunded with 1/3 the previous premium)
was that the catadtrophic costs (what the true insurance paid) were also 30% less! Fewer "catastrophies" meant better prevention!
This also means less cost for future premiums or taxes, as has always been true where competetive individual contracting
(paying your doctor like your barber or grocer) reduce socialism or interventionism, our regulation that inflates costs.

Howard Long

Miss Debbie:

Something no one is bringing to everyones attention is the charges from your hospital and doctor's office. I worked for a company that did the billing for 3 downriver hospitals in my area. During htis time the printing of the bills for patients from the hospital or doctor looked like this:
Addmission to hospital: cost = 100.00
exam: cost = 35.00
bandaid: (for whatever purpose) cost = 21.00 (yes $21 dollars for a bandaid to cover the spot where they took blood)
box of kleenex: 11.00
tylenol (2): cost = 35.00
and the list goes on....(the paper on the examing table, that lolipop for your kid being good) do you see the problem here???? things you can get a whole box of or bottle of at the dollar store or drug store for less than 3.00 you are being charged more than 10x what it's real cost is!!! THAT is what is outragious with the healtcare system. Allowing the hospitals and doctors to charge more for anything than what it is worth...Not just more, WAY more than it is worth...This is what needs ot be corrected first b/4 you can comeup with an affordable health plan anywhere for anyone.

Ann:

Another aspect to health care is preventative measures. People really need to inform themselves on how to prevent expensive conditions like HIV or live healthy lifestyles to minimize the risk of say, heart disease or obesity. Within the last 25 years or so, people have seemed to be living it up and ignoring the physical risks and consequences of what they do. This leads to prohibitively expensive and over-burdened health care for everyone except the extremely wealthy.

What really needs to happen is a better understanding of how to maintain a basically healthy body (including such measures as posting nutrition facts in fast food restaurants) and informing the public in schools and through church programs. Taxpayers and insurance companies are shelling out millions of dollars to fix preventable conditions. We need to mobilize to inform people how to avoid them so that our health care system only needs to deal with those who did not cause their own problems.

I don't believe that we'll ever truly stop people from damaging their own bodies through their lifestyle, but I do think that the more informed people are concerning how to be healthy (which might be more difficult for the poor, I admit), the fewer preventable conditions we'll see in hospitals.

No one can afford to keep a nation of millions healthy through pills and procedures if most are going to eat McD's 10 times a week or have insufficient exercise.

Kathryn: tednkate@tm.net

Cash across the barrel. Works for me!! What Candace says is true. When my son was in physical therapy, the provider we went with bent over backwards to give me every discount possible as long as our insurance didn't pay for it. But once our insurance started to pay for it, our cash out of pocket went up, at least until we hit our deductible.

Also, no one is talking about an interesting approach to health care cost containment: there are at least two christian medical co-ops I am somewhat familiar with. The groups "share" medical costs (I am not sure how this works, but it isn't quite the same as insurance) and pray for each other. They have specific things they will not pay for: abortions, or certain health conditions related to "unBiblical living."

Get the governement out of it. Get employers out of it. Let insurance be real insurance, like car insurance. I think you will eventually see good things happen if the market is allowed some freedom.

Richard Briggs: rgbarnabas@gmail.com

Every person should have his or her own insurancce policy starting at a young age with premiums which will cover his/her expected lifetime medical costs (discounted for anticipated insurance company proifits), a task the insurance industry is well equipped to do fairly and equitably. Such a policy should be assigned to a person on a "random" basis and cover major and catastrophic medical problems. The policy would be both portable and affordable because the individual would be paying low premiums for a very long period before reaching the end of life and encountering high medical costs. Each person should be responsible for his or her own routine medical care just as they are responsible for their own food and rent and transportation and make-up and entertainment. Mr. McCain's proposal to shift the tax advantages to individuals away is a step in the right direction. The underlying problem is that third party payers or the government set the paying rules (and sometimes the prices) insted of the consumer deciding whether or not a certain medical expediture is worth it. The immediate political problem is that there is a lot of political inertia in that many people (including consumers and providers and regulators) are adapted to and profiting from the current, highly politicized, system.

Ken Howe: kenhowe2004@yahoo.com

I don't think there is any need for any kind of governmental (health insurance )plan. It is not the governments place to be providing health care to anyone. There is a market that will work for every person who wants to have health care. It is simply a matter of what a person wishes to do with the funds they have available. In every city and town in America there are private charities who provide the basic necessities of life for those truly in need, giving to these charities should be a joy, but not being forced at the point of a gun to give to a wasteful government bureaucracy to administer to their chosen clientele.

Chris Manes: lokicsm@aol.com

Charity is discontinuous and undemocratic.

The issue is stark: should we allocate health care based on the luck of having more or less wealth, which essentially means that poor people get inferior health care and thus have higher mortality rates and a lower quality of life.

In short allocating health care by markets is inherently immoral, and accepts that the poor (i.e., those unlucky enough not to have assets) must be allowed to suffer more than the rich.

Of course, to avoid this immoral result, market evangelists (like Acton) redefine the issue and moralize poverty by claiming the poor deserve to be poor (they are feckless or lazy or not as smart).

What an ugly vision market evangelists have of America. Thank God, Obama will win in a landslide and put us back on the path of morality and caring for the least of us -- the only path that God honors in judging nations.

Isaiah 1:14, 17 - O sinful nation . . . learn to do good; seek justice, correct oppression; defend the fatherless, plead for the widow

Ezekiel: 16:49-50
As I live, says the Lord GOD, your sister Sodom and her daughters have not done as you and your daughters have done. 49 Behold, this was the guilt of your sister Sodom: she and her daughters had pride, surfeit of food, and prosperous ease, but did not aid the poor and needy. 50

Don Broesamle: broesamle@earthlink.net

Someone send a therapist to "ryan" before he hurts himself. In a careful response to Dr. Schmiesing's article, let me point out:
1) what people "trust" Democrats for more than Republicans is socialist largésse ... just replay the Kucinich convention speech and watch the crowd shots for confirmation - it's a heady tonic;
2) public confusion over the health "plans" out there makes this prime time not for an "attractive" reform package, but one that WORKS! This will require leadership;
3) Dr. Schmiesing rightly points out the Obama "plan's" flaw of "preserving the employer-based system that has proved so troublesome," but devalues the obvious antidote, an "individual-based" system, such as is offered by McCain;
4) McCain's plan gets government out of health care, which in itself would drastically reduce costs across the board. It introduces portability and interstate competition, which will deliver further dramatic savings;
5) Dr. Schmiesing's compassion for justice is commendable, but sidesteps the "just" affect of a much lower cost thereby OPENING quality affordable health care for the "common good" of those now shut out of a seriously flawed system - it's not a socialistic question of "justice," but rather a moral question of "opportunity;"
6) Wow! Look what Dr. Schmiesing now says: "whether to move toward more government involvement or more market freedom, the latter direction is likely to lead toward a more efficient and equitable system." Congratulations! So much for his previous statement that it's "difficult to predict the results of either approach..." As Dr. Schmiesing goes on to say, "History proves that large government programs ... do not fare well." ... which also is QUITE predictable!
7) Dr. Schmiesing, "market" health care is not a "zero sum game." The same Judeo-Christian ethic that brought us "religious" health institutions continues on, and with that the competition to be enjoyed in a market system that will also seek to care for the quite large segment of 'customers' who are not wealthy.
McCain's plan moves strongly in that direction. Obama's is same-o, same-o – the only 'change' he offers is in the dramatic drop in quality of care across the board such a "plan" would bring, and the strangling costs to the economy such a system would impose. Justice? Not by THAT course.
McCain's course seems "radical" to Dr. Schmiesing precisely because it demonstrates a leadership we have not seen since ... hmmm - Reagan? Now that's 'change we can believe in!'

Dan Hugger: DJHugger@gmail.com

"A 2007 poll found a majority of respondents in favor of a single-payer government health system, while 77% simultaneously supported "reducing government regulation of insurance." This seemingly contradictory finding points to the fact that disgust with the current system overrides affinity for any particular reform agenda."

I don't believe that this demonstrates any dissatisfaction with the "health care system" as such but with the costs associated with health care in general. Most people believe, and rightly so, that their direct costs (The amount that appears in the bill) would go down under either reform measure.

The problem with the first are the tremendous costs hidden from the consumer that are paid for by employers resulting in fewer jobs and lower wages, hospitals resulting in inflated billing for procedures not regulated by price controls and a decrease in quality of care resulting in well you know...

The problem with the second is that it would result in uninformed first time buyers of insurance buying into plans which they believe cover substantially more than they promise resulting in sob stories on the evening news and a political backlash against the reforms and companies offering minimum cost insurance.

In order to reduce the cost of health care one must either reduce the demand for health care or increase the supply of health care providers and facilities. The first is best realized through healthy individual choices and a shift in cultural attitudes regarding suffering, death, and dying. The second could be accomplished by either liberalizing the licensing policies for health care professionals or by forcing health care providers to pay for their state granted health care monopoly through either national service at state hospitals and by increasing licensing fees and using the money to fund public health and health education projects.

People want lower costs but the only way we can truly lower them is by changing fundamental attitudes towards health care and the place of health care providers in society.

James Pakala: jim.pakala@covenantseminary.edu

Hearing McCain's plan presented on a radio program, I definitely would not want to see it implemented.

candace: candace@care-usa.org

How about a really novel approach? Why don't we get the government and the insurance companies out of the way and let each American work with individual doctors to negotiate their healthcare? I currently pay between $30 and $55 to see doctors of my choice provided we skip filing insurance claims since my current healthcare insurance is in the form of a health savings account that has a $5,000 deductible before anything is covered. Lest you think this is because I am young and healthy, I am 61, diabetic, hypertensive and plagued with arthritis. I'm still paying off more than $6,000 in insurance co-pays from last years healthcare. I've already experienced government healthcare as a military dependent for over twenty years. It is time consuming, rationed and cost driven not care driven. It was supposed to remain a benefit that be cost free for life if the recipient remained in the service until retirement. It hasn't. So much for trusting the government to keep its promises.

ryan:

Obama plan is a real plan. McCain has no plan other than letting the insurance loose on american people. McCain plan or lack of it let insurance companies charge whatever they want and deny coverage to anyone they choose. The tax credits mean nothing if you can't even get coverage or afford it. It's not a plan period.

Obama's plan is, even though not universal, it at least provide certain restrictions on what insurance companies can charge and prevent them denying people with pre-existing conditions. With the formation of an insurance exchange to help americans to buy insurance at group rate and not having to loose coverage when they lost their jobs alone is a big help to those who really are in need.

McCain has no clue about what average americans are going through. He surrounded himself with lobbyists and idiotic neo-conservatives who care about nothing but their profits and personal agendas.

Acton Commentary

Obama, McCain, and Health Care Justice

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Obama, McCain, and Health Care Justice

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