1) Are healthcare services a human right?

I think that healthcare is a human right in the sense that individuals ought to be able to live healthy if they want to. I don’t like the car analogy though because you choose to buy a car, but not to be born. But I agree that self-management presumes a certain amount of intentionality: if they want to be healthy, they should plan for and manage their health. I think there is total agreement up until this point. The question becomes, what is the government’s role if this process (the self-management of health) breaks down. That’s where the two opinions diverge: I’d rather the government helps people to do this than turns a blind eye. I understand the other side of the argument, but quite frankly our differing views are moot because it will never, ever wind up that way: The government’s just not going to pull the plug entirely on helping poor people in America.

So my honest, non-idealistic thinking is pretty simple: Since we’re doing it anyway, we ought to make it cost effective. If it ‘isn’t worth it’ to pay for everyone’s health care, let’s figure out how much of it, in economic terms, ‘isn’t worth it.’ Start collecting data on what works and what doesn’t, for how long, and how well, by age, condition, demographic, comorbidity. This is how the NHS ‘rations’ care, and how private US insurers manage actuarial risk. Kaiser has even started to do it for joint replacements: google ‘TJRR’. Back to the question of ‘human right’ – in our system today, how many of our Medicare dollars go to end-of-life care for people who will die in 3 months? Would that be better served treating a kid in need who could have a long, productive life? Do either of these parties have more of a “right” to that money? These are rhetorical questions – they’re meant to illustrate how healthcare is complicated – beyond being a human right or not, it is human nature to get sick, to get old, to fall short, to need help. Our system should be designed, in my opinion, to help everyone who needs it, in a much more equitable and affordable way. If other countries can do it, so can America dammit.

Assumption Number One: Public spending on healthcare is not going to stop. So, we should be spending it more efficiently.

2) Is lifestyle a responsibility?

I agree with this wholeheartedly – it should be a collective responsibility. But one thing to consider: it’s cheaper to spend money on preventative measures than it is on treatment (remedial). This explains the existence of the multimillion dollar employer wellness industry. Employers are betting that paying for gym memberships and a salad bar will help their cost curve down the line. With the government’s current and projected health care cost crisis, doesn’t paying more for prevention for folks who we know we’re going to be paying for down the line make some sense?

Assumption Number Two: Eventually, people will fall short of their personal health responsibilities. So, we should consider if it’s worth it to spend a little to save a lot.

3) Free-Market or Gov’t?

I typed up a long paragraph detailing the government’s involvement in the marketplace before I realized that’s not the point. We agree here Jae. I hate the idea of paying for health insurance I’m not using. Fun story: Did you know I’ve been uninsured since June, and after traveling for 3 months I applied and got rejected in (this is the good part) the state of Massachusetts? I “missed the deadline” (I was in Istanbul, which is apparently too far to send me a damn e-mail SMH) so I was told to wait 9 months until the enrollment period opened, as well as pay a penalty in my state taxes for ‘ignoring the mandate’ despite having only lived in the actual state for about 3 weeks at the time of my application. So if you ask me what the state of Massachusetts proves, it’s that bureaucratic public sector coverage is awful. I don’t even think I can say I support a mandate because in our clusterf*ck system, I firmly believe it just won’t work. On paper it should, but in our marketplace it will self-segregate into shiesty government products like the one I encountered competing against the free market – the only way government keeps up is with price advantages – which means it will cost more, which means it won’t save money so what’s the point.

Single payer and universal coverage are fundamentally different in my view. The point of a mandate is that the price for individuals without a job to buy insurance is astronomical – forcing all uninsured people to buy in would make it cheaper for everyone over time. But in America, this is an intrusive concept. So there are only two alternative solutions that I can come up with. First is another form of government intervention: Setting caps on the free-market rates for individual coverage that plans set. There are currently review boards at the state insurance commissioners offices that can deny drastic price increases. There are some other even more feckless tools too. Similar to how the FDA doesn’t allow shoddy products onto the shelves at Walgreens, I think the government ought to be able to say “Listen, it is ridiculous to charge this much money to someone who doesn’t have a job.” But, the second is better: Let private companies pool together individuals to form a fake group market and negotiate better rates. Heck, even have some government incentives to encourage these companies since it will save on uninsured ER admissions and the like. Firms do this with small businesses already. It’s like a sort of union for uninsured people. Long story short, the mandate is a messy government attempt to fix a problem that hasn’t been addressed: the uninsured. Ideally, they’d extend the mandate by a few years and offer an alternative to states: Show us a plan to cover 90%(just pulled that out of thin air, but some majority percentage) of your state’s uninsured and we’ll waive the mandate. But again like I said at the top, these are stabs at discussing the issues rather than just understanding the principles we’re embracing.

Assumption Number 3) Public insurance will be a non-preferred (read: second tier) product in a mixed-market of public and private health plans.

Thanks for holding me to task man. Fixing the system vs. designing a system is like playing jenga vs. playing with legos. I don’t disagree with philosophically with much of what you’ve got to say at all. Pardon the cursing – even just dealing with the issues gets me all riled up..so you can see why I try to avoid the principles/values debate altogether, haha. I’m just more of a pragmatic optimist than an idealistic realist. And, to end on a peachier note, I will have health insurance coverage as of June 1st

Naveen

I think there should be access to some level of healthcare to all citizens. I think healthcare is a right… but the question is more “Just how much of healthcare should be a right?”

I think there should be an even greater emphasis on primary and preventive care than there is now.

I think your idea is interesting… But (just to play devils advocate) here are my problems with it. One is that that system seems inherently inefficient. With however many millions of people living in the USA, how are providers supposed to negotiate and contract with that many people? Additionally, in negotiation, I feel like the providers will have considerable more power than the people (“you want healthcare? you gotta listen to what we say to do…if you don’t like it, then no healthcare for you!”) and that one’s negotiated healthcare plan will depend upon one’s knowledge of medical issues (I’d say the majority of people have little knowledge of everything or have very misguided and unscientific viewpoints) and upon one’s ability to communicate effectively (problem for immigrants). Additionally, I can see this negotiation process giving birth to another industry of lawyers who try to win better deals for their clients, thus still maintaining the healthcare disparities gap.

But to be honest… I think health care is a sinking boat. There’s no perfect system and reform (at least in the US) seems to be like patching the holes up in the boat while creating more holes at the same time.

In short… i have no idea. The system is broke but I’m not sure there’s a good way to fix it. I did like the Taiwan healthcare system… but my understanding is that it is bankrupt… so what do I know?

1) Are healthcare services a human right? I believe that you are siding with the idea that healthcare services are a human right. He believes that healthcare services are no different than any other services available in a modern society(i.e. auto service and repair), and that an individual should have access to these services via a free market. You could akin this to a popular argument whether people believe that not starving is a human right, thus allowing an individual to walk into a grocery store and steal a loaf of bread to combat his hunger and keep from starving.

2) Is maintaining a healthy lifestyle a personal responsibility? Is it safe to assume that you’re siding with the argument that if you believe humans are inherently undisciplined, lazy, weak, or all of the above, that they cannot be expected to assume responsibility for their lifestyle decisions (eating habits, exercise, use of drugs, etc.) that produce ill health, thus the federal government should step in? Again, this would also follow if you do indeed believe that remedial healthcare services are a human right. On the other hand, I think that my father is focusing on the belief in individual liberty and the attendant responsibilities. He basically believes that an individual, not the government, is responsible for maintaining an individual’s health, whether on a prophylactic or remedial basis.

3) Efficient healthcare services delivery from free-market business or government intervention? I think you’re saying that you believe that since these services are a right and individuals cannot be expected to assume responsibility for themselves, the government must end up holding the bag and that since society will pay this bill, the government should assume greater control over this marketplace. I would probably side with my father in that i believe the government has a legitimate role in regulating a market to ensure that participants do not actively injure others(i.e. FDA approval of drugs, etc) but since healthcare services are not a right and since maintaining one’s health is an individual responsibility, I don’t think that the government really has any legitimate role in “creating a market” or “entering the market” as a participant, especially given the state of the government.

With these differences addressed, I do think he would indeed agree that the payers (i.e. insurance provider and the premium and/or co-pay payer) and the providers (i.e. hospitals, doctors, clinics, etc.) DO need to be reorganized. That being said, there is a need to explicitly state your belief system on the three points above prior to embarking on a restructuring of the payer-provider marketplace, as this will fundamentally alter the approach you would take. I’ll actually do a quick update post later today addressing this!

Naveen, thanks again for your thoughts. It’s not often that individuals take the time to break from the “CNN mindset” of “black or white(yes or no)” answers and instead think things out.

You seem to be saying that the reform bill is unnecessary, but also that it falls short. Therein lies the dilemma: without being reductionist and ascribing this to any one simple fix, there’s simply no way of getting it all right – our nation has created too big of a problem to fix in one reform bill. All of the parts of the ACA make sense in their individual vacuums, but when you pop the bubble and expose them to the air of the real world, then apply them all together, and then add up the costs, it’s clear that we’ve got an absolute boondoggle of a policy.

I agree broadly with your frustration: The ACA reforms are akin to rearranging the deck chairs on the titanic. But we agree wholeheartedly that our system is in DIRE need of repairs at every level. The government has done things it’s way; I think we agree that health reform is not any one entity’s responsibility – it’s a team effort if it’s going to work.

I think your thoughts suggest a sense of idealism, which I share: We both magically hope people will change their behavior and government should encourage that but not drain it’s (our) pocketbooks to drive it. I would take a slightly different view – I agree with the need for change on individuals’ parts, but my public health training tells me it’s not going to happen without money and time –and even then it will be underwhelming. We can pay for it now via more taxes, or pay for it down the road via higher Medicare and social security costs (and fewer received benefits when we’re of age). Without getting into the government’s role in all of this however, I think health care reform should be fundamentally fixing the incentives in the system at all levels:

1. Systems who charge a la carte (should be capitated/bundled episodic payments)
2. Individual clinicians who profit apart from patient outcomes (we should ideally have team-driven care like in medical home pilots at places like Geisinger, Group Health, Healthpartners) – see Gawande’s latest TED speech, brilliant as usual: http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine.html

3. Payers: should not be for-profit or national networks. The most successful systems in America (see above, plus Kaiser, respected around the world) are integrated delivery systems – the incentives are aligned and more importantly, it’s more easy, convenient, accessible for patients to navigate. This makes it less likely they’ll pay redundant fees, undergo redundant tests, see unnecessary providers, etc. Like diet, one broad tenet of healthcare should be to do what’s necessary and not much more.
4. People – you hit the nail on the head. While I’m more sympathetic to their plight (or pessimistic on their ability to change), without comprehensive and widespread behavior change we will be, pardon my French, fucked as a nation.

As far as the mandate, I don’t think we’ll see eye to eye. I understand the reasons you oppose it, but those same reasons apply to too many other things currently funded by taxes. Do I like those things? Of course not, but I’ve given up trying to oppose the need for taxes. I support the mandate in purely economic terms: that’s how actuary science works. But trust me, I understand and share the frustration of yet MORE money being taken from our pockets – we who put in the time and money to get a solid education, develop skills, find jobs and work hard. In countries where insurance is tax-funded, it’s been that way forever so people are blissfully ignorant – the same way Americans are about social security, medicare/caid, and military spending – each of which take up about 20% of our tax burden. Nobody makes too much of a fuss about those, and I’d argue their benefit is not proportionate to their costs (e.g. I obviously support having a military, but my sister worked for Raytheon’s finance department and those contracts are….generous. Very, very generous).

So what’s the solution? On the ground, everyone should strive to make their friends, families and communities healthier – less fast food, less alcohol, less cigarettes, more exercise, more learning, more loving (not that kind of loving). We should promote technology that makes care easier and cheaper for individuals, like telemedicine and mHealth tools, and easier and cheaper for systems, like health information exchange and medical records. Ideally our delivery system will be reorganized to promote value over volume of procedures, and clinicians’ biggest paychecks will be reserved for treating patients safely, efficiently and effectively.

These things are all happening in small pockets. That’s the reform I try to see and be a part of in my work and day-to-day. It’s too easy to get jaded with the government’s clumsy, expensive heavyhandedness. But their money is doing something – horribly inefficiently and pretty ineffectively. But if you look closely, reform is happening. I’m just going to keep on paying my taxes and try to push this boulder back up the hill until I retire (probably without any benefits).

Naveen

PS – Thanks for inviting me to the discussion! Excuse my typos and hurriedness – this is a big post, and time is one thing I never seem to have enough of (even as a freelancer). Looking forward to more.

Never give up hope. Keep striving for your dreams. And pursue the desires of your heart. Also, don’t ignore intuition (i.e. just because a job pays doesn’t mean you should necessarily take it: evaluate it for what it is and if it’s a good fit for you). Peace.

I’ve been reading a book about by John Wooden, which has helped me develop a healthier perspective. I recommend it to anyone looking for some guidance – http://www.amazon.com/gp/product/0809230410/ref=oh_o00_s00_i00_details.