Freeing the Health Reform Debate from Politics?

I’ve been wondering recently how well the health reform debate can be freed from the bickering of partisan politics. I’m getting more and more cynical about it, and here’s why: The most apolitical objective research one can conduct is certain to become fuel for the political fire for one side or the other. Granted, the researcher can–and should–remain objective in his or her analysis, unless we count the selection of which questions to investigate as inherently biased–which it may well be. The problem is that the results of research do not make decisions. Rather, decision-makers do and these individuals are typically awash in a sea of politics. Consequently, the decision-maker usually has some idea of what they want to do, and they are looking to the research to confirm their inherent wisdom. When it fails to do so, the problem lies with the research, not the decision-maker, and the results are cast aside. I don’t like this, but I can understand why it happens.

But what about the public? Why are they so quick to discount evidence in favor of things like feelings? Why do people who loudly proclaim their distrust of government look more to politicians for guidance than they do independent research? Is it merely that they distrust those in the government who espouse a different view from their own, while in all matters blindly trusting those who agree with them on some issue? Why, for instance, do people continue to think that President Obama is not a natural-born citizen even after the White House has made two versions of his birth certificate publicly available? That should serve as ample evidence of the man’s origins regardless of whether or not you agree with his policies.

Similarly, how many people do you need to hear say that we already ration health care in this country before you acknowledge that fact? How many well-argued pieces do you need to read to understand that health care doesn’t work like most other goods and services? That health insurance has very real limitations? That the system isn’t fair? Well, according to the results of a recent poll, we might finally be getting somewhere. And yet, there are politicians on both sides of this issue, and the people only seem to be responding to their own economic crises. Perhaps we’re no closer after all, and health reform and politics can never be disentangled.

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Two Takes on the Budget Crisis

Not quite two weeks ago, Rep. Paul Ryan debuted the GOP’s budget plan. Not quite two days ago, President Barack Obama laid out his own ideas for a budget plan. Both plans were brought forth under the mantle of reducing the deficit. I thought it would be interesting to take a look at both men’s public remarks using word clouds showing the 100 most used words (with common English words like “and” and “of” omitted). Here’s what you get. First up, Paul Ryan’s comments (click on the image to view full size):

Next, we have Obama’s comments (click on the image to view full size):

In looking at these two word clouds, the results one can draw are fairly subjective, but some big differences do jump out. You’ll see, for instance, that Rep. Ryan used the words “budget” and “government” far more often than President Obama did. You’ll also see that Ryan uses the word “reform” far more often than Obama, but Obama mentions “spending” and the “deficit” much more than Ryan does. Reducing the debt also figures more prominently among Obama’s words than Ryan’s, and Obama seems to be a bit more concrete with regards to programs like Medicaid, Medicare, and Social Security than is Ryan. Both Obama and Ryan reference taxes quite frequently, but while Obama also mentions the people–“children” and “seniors” for example–Ryan doesn’t bring these groups up, though he does speak frequently of the “future.”

I have my thoughts about the “why” behind all of these differences, and from what I’ve written before, you can probably figure some of them out, but I wanted to leave the analysis of this up to my readers. What do you see? How are the remarks similar? How are they different? What do you think these similarities and differences mean? Think about it and leave a comment. Chances are not everyone will see things the same way.

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A New Review for Health Wonks

A lot has happened in the past couple of weeks. The proposed regulations for accountable care organizations came out, Rep. Paul Ryan released a GOP budget plan, and just yesterday President Obama laid out his own plan to reduce the deficit. A variety of views on these and other issues are included in the latest Health Wonk Review hosted by David Williams of the Health Business Blog. Check it out here.

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Adverse Events in Hospitals Higher than Expected

The hospital isn’t really ever a place you want to be. Granted, that’s changed a lot over the last several decades, back when hospitals were just places people went to die. Now, at least, hospitals are places many people go to get better, but they’re still dangerous. All sorts of bad things, known as “adverse events,” can happen within the walls of the hospital. You can catch a nosocomial (hospital-acquired) infection. You can take the wrong medication or too much or too little of the right medication. You can have the wrong leg amputated in surgery. You can be the wrong patient in surgery to begin with. You can develop pressure sores if you are stuck in bed for too long. You can slip and fall if you get out of bed too soon. The list goes on and on.

Identifying these adverse events, so that they may be prevented in the future, is a key aspect of improving health care quality. A recent Health Affairs article by Classen et al. compares several different methods for identifying adverse events. For the layperson, the take home message is: Adverse events are much more common than previously thought. It all depends on how attempts are made to measure them. As it turns out, the Global Trigger Tool developed by the Institute for Healthcare Improvement finds a lot more adverse events than any of the other widely used methods, including one developed by the Agency for Healthcare Research and Quality (AHRQ). What kind of difference are we talking about? Well, in a review of 795 patient records, AHRQ’s method identified 35 adverse events. The Global Trigger Tool identified 354 adverse events. That is what we in the business call “an order of magnitude.” And, compared to local hospital reporting systems that identified only 4 adverse events, we’re talking about two orders of magnitude (i.e., about a 100-fold difference). Just when you thought it was safe to go back in the water…..

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Another Word on Subsidies

I’ve written before about how the federal government’s tax-exemption for employer-based insurance premiums is the equivalent of a federal subsidy for a private product. Each time I’ve written that, I’ve encountered some resistance from readers. Now, I could get into a protracted debate in the comments section of the blog, but I have other things to do. Therefore, I refer you to this piece from Princeton economics professor Uwe Reinhardt. And, for those of you who would argue with a fencepost, ask yourself one simple question: Do you really think you know as much about what is or is not a subsidy as a full professor of economics at an Ivy League university? (Hint: Unless you have a PhD in economics and a few decades of work experience, you don’t.)

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A Liberal Christian’s View on Paul Ryan’s Budget

Today I want to talk about Paul Ryan’s proposed federal budget and ask some very serious questions of my readers as the clock keeps counting down towards a government shutdown. I was originally going to write this post on Tuesday, but I wanted to give myself some time to collect my thoughts after actually looking at Ryan’s proposal. You can read the plan for yourself here. There’s a lot in there, but since this is a health care blog, that’s where I’ll be focusing.

For those of you not up for reading the document yourselves, here are the basics as they relate to health care:

• Transforms Medicaid into a block grant
• Privatizes Medicare
• Repeals the Affordable Care Act
• Cuts taxes for the wealthiest Americans
• Cuts corporate taxes

Let me begin by saying, something has to change. This is one area where I agree with Ryan. The federal deficit and the resulting federal debt must be addressed. Medicaid, Medicare, and Social Security make up a large proportion of the federal budget, so it makes sense to look at those areas when attempting to save money. And, that is basically the precise point at which we no longer see eye-to-eye.

For starters, if Rep. Ryan is so adamant about reducing the deficit, why is he cutting taxes for the wealthy and cutting programs for the poor and the elderly? Didn’t he learn back in Budget 101 that there are only three ways to reduce a deficit? You either reduce spending or you increase revenues or both. You don’t ever reduce revenues. That move alone has me convinced that Ryan is less than serious about reducing the deficit.

So, if it’s not entirely about balancing out the bottom line, what is it? I think this is about political posturing and ideology. In policy matters, the GOP is the party of the wealthy. That’s it, plain and simple. They are also the party that despises government programs for vulnerable populations, but it starts to get murky pretty quickly after that. And, it is important to note, a lot of non-wealthy middle and lower-middle class types support the GOP. Much of that has to do with things that the GOP talks a lot about, but never does anything to address. Let me explain.

Somewhere along the way, Republicans convinced a large sector of the American people that they were the party of Christians and honest, salt-of-the-earth types. At the same time, they convinced these people that the Democrats were atheistic heathens who were out of touch with reality. Their ruse worked. If you don’t believe me, read this. That might be okay if they actually did something to advance their platform, but they haven’t. Abortion is murder, and murder is sin, ergo abortion is sin, and the GOP is pro-life. Millions of people (I’m guessing) vote Republican on this issue alone. Yet the GOP hasn’t managed to move us any closer to the court overturning Roe v. Wade. Apparently that doesn’t matter.

Now ask yourself this question: Who would Jesus deny health insurance? The GOP’s answer is something like: “The 50 million or so undeserving poor and illegals.” You’ll have to forgive me for thinking they’ve missed the mark on that one. At least, that’s how it came off when the Affordable Care Act was being debated, and seniors–bless their hearts–were outraged that the government would get its hands all over their federal Medicare coverage. There was such vitriol–Obama as Hitler, the now-infamous “death panels”, and guns brought to public forums–surely the recently elected Republicans wouldn’t try similar things?

And yet they have. Ryan’s plan would privatize Medicare (at least now the seniors’ protest signs will be right) and–get this–basically create a federally-subsidized health insurance exchange for seniors. If that sounds like the Affordable Care Act to you, congratulations. The GOP plan to save money is modeled on the plan Democrats passed last year, which shouldn’t be a surprise. As I and others wrote about, that plan was originally a Republican one to begin with. But, for seniors and the disabled, this is going to mean higher out-of-pocket costs. That wasn’t true under “Obamacare.” If they were so up in arms then, they should be utterly outraged now, but I haven’t seen it.

Things are even worse for Medicaid. By turning the program into a block grant, states get a fixed amount of money from the feds. When that’s gone, there is no more coverage, shifting full responsibility for the entire cost of their care onto pregnant women, children, the low-income elderly and disabled. Well, by all means, those seem like the people who are most capable of getting a job and taking care of themselves! There’s no way to reconcile that type of attitude towards the vulnerable with notions of decency, fairness, or Christian morality.

If the budget was mine to make, here’s what I would suggest: First, don’t cut taxes for anyone. That doesn’t mean you have to raise them (although I’d look into a flat tax), but by cutting taxes you’re making your job of reducing the deficit harder than it has to be from the very beginning. Second, don’t cut programs that provide for our nation’s most vulnerable populations. There are plenty of other places to find substantial savings. Rep. Ryan’s plan is entitled “A Roadmap for America’s Future.” Balancing the budget is an important part of that, but he would do well to remember that, much like the church his party strives to appeal to, it is the people–not the building or the money–that defines us.

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Point of Clarification: The Blog Is FREE

Five days ago, I wrote this post, which outlined the implementation of a New York Times-style paywall for the blog. From the comments I received, some of you “got it” and some of you didn’t. Today is April 6th, which means that five days ago when that post went up it was…….April Fool’s Day. In fact, if you clicked the link to “subscribe” it took you to aprilfools.com. But, in case of any of you are still under the impression that I’m charging for access to the blog, let me clearly state that I am not. Okay, back to regularly scheduled programming…..

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A Question of Fairness

There are two camps in America: Those who think that health care is a right and those who think that it’s a privilege. Well, perhaps that’s a bit of an oversimplification, but bear with me. Given these two respective positions, what are we to make of the health inequalities that are well documented in the United States? First, we must acknowledge that health is the product of multiple factors such as lifestyle, genetics, and access to health care. In general, these may be lumped into two categories as well: individual-level factors and system-level factors. Both levels may also be sub-divided into modifiable and non-modifiable factors. For instance, we cannot modify the circumstances of our birth, but we can decide whether or not to smoke. Again, bear with my gross oversimplification. Similarly, we can change certain aspects of the health care system, but we cannot change the fact that we must operate under the constraint of limited resources.

Okay. Now that all of that’s on the table, we return to the question: What are we to make of health inequalities in the U.S.? To the extent that the inequalities are the result of modifiable individual-level factors, we may feel no obligation. People who choose to smoke are taking the risk of getting lung cancer. People who chose not to smoke and get lung cancer anyway may seem to some of us to be more “deserving” of treatment. Others may not make such distinctions. But generally, where personal responsibility can be identified, we feel less of an obligation to help. In fact, some of us take this to the extreme, excusing our self-interested behavior by creating things for which to blame the person in need. The homeless we pass at the intersection are “lazy” or “lack self-control”, which resulted in them becoming alcoholics who don’t bother to get a job. Once we make that leap, we feel justified in not sparing them a dollar. If we were confronted with their reality that they were abused as a child, had a genetic predisposition to mental illness, or some other circumstance beyond their control, we would likely find it much harder to squelch our pity.

At the heart of all of this is the notion of “fairness.” Everyone has some conception of the term, but it varies from person to person. The group that believes health care is a right is more likely to support an approach that maximizes the number of people who have access to health care. It’s purely utilitarian. The group that believes health care is a privilege is more likely to support an approach that maximizes the number of “deserving” people who have access to health care. And, as above, those who deserve it are typically those who either have access to care already, or who need access to care and are without it through absolutely no fault of their own. For many people, especially those who have access to care, there are very few uninsured sick people who appear blameless. It’s utilitarianism infused with judgment. Not that that judgment is wrong, mind you.

For more on this topic, you should read a recent article by Blackser, Rigby and Espey, which inspired this post. They conducted a fascinating study of the public’s values surrounding fairness concerning health inequalities.

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Wright on Health Subscription Service

For nearly two years now, I’ve enjoyed writing this blog. But writing a blog takes time, and time–as they say–is money. Of course, having been a student for approximately 26 of my 30 years, money is not something I am terribly familiar with, as many of my most beloved commenters are quick to point out. Fortunately, that’s about to change, as I complete my education and prepare to head out into the “real world.” To think that I’ve spent three decades in some sort of imaginary world is a little unsettling, but I digress.

Today’s post serves as an announcement that beginning tomorrow, all “Wright on Health” content will be made available only to members of the site with a paid subscription. While I hesitated to make this transition initially, the recent implementation of a paywall on the New York Times website convinced me that requiring people to pay for content is the only solution to maintaining the quality of this blog for the long-term. I mean, seriously, how can I continue to justify doing this for free?

So, starting tomorrow, non-members who access the site will only be able to read the title of each blog post. They will then have several subscription options. Using PayPal, which accepts credit and debit cards as well as electronic transfers from checking and savings accounts, individuals will be able to purchase access to a single blog entry for $2.99. They may also purchase a 1-day pass, allowing them to access, save, and print all content for 24 hours. The 1-day pass is $4.99. Monthly subscriptions are also available for $9.99, and for a limited time, special lifetime memberships are available for $249. To subscribe, please visit this site, and thanks again for your loyal readership.

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