In June the Supreme Court will rule on the constitutionality of the “individual mandate” in the ‘Patient Protection and Affordable Care Act’, (aka “Obamacare”). If it is ruled unconstitutional the entire Act will be gutted and the President’s signature achievement will be so much rubble.
The media and experienced court watchers are predicting, from the tenor of the questions the Justices asked, that the result will be a 5-4 decision against it. (This pundit predicts that in a surprise, Chief Justice Roberts, in an attempt to model his legacy more after Earl Warren than Warren Burger, and Justice Kennedy, atoning for his sloppy reasoning in Citizens United vs. The FEC, will join the four liberals in upholding the mandate in a 6-3 decision.) - Update: Now that the President has come out and warned the court not to be ‘activist’ he may lose Roberts.
But which ever way the court decides it will not address the fundamental flaw in our medical system, which is that “the costs are too damn high”. We are #1 in money spent per capita on healthcare at almost $8,000, more than $2,500 ahead of #2 Norway. We are also #1 in healthcare cost as a percent of GDP, which at 18% is half as much again as #2 France.
These costs might be justified if our healthcare outcomes were world beating. But in life expectancy, infant morality and insurance coverage we lag behind countries that spend far less than we do. Rational people would insist that we do something to generate better results. But instead of demanding value for money, conservatives ignore these statistics and claim that we have the best healthcare system in the world; using as proof stories of foreigners who prefer treatment in US hospitals to their own. That is to miss the point. No one denies that we have some of the best hospitals in the world but that tells us no more about our healthcare system than Harvard or Yale informs us about the quality of our high schools.
Why are the costs so high? One reason is our love affair with hi-tech – and expensive – diagnostic tests. To control these costs Republicans suggest tort reform, on the theory that fewer medical malpractice suits will lead to fewer of these costly and often useless ‘CYA’ tests. It is an idea worth exploring. As is whether doctors who also own diagnostic clinics ‘over-prescribe’ diagnostic tests.
The makers of these hugely expensive machines have to sell them. GE Healthcare, for example, showers money, trips, meals and other bennies on doctors and hospital administrators to keep the machines in demand. It is not in GE’s interest to discuss whether these tests are worth the money.
The pharmaceutical industry (aka ‘Big Pharma) is equally aggressive in pursuing the healthcare dollar. In 1997 the FDA opened the floodgates by changing the rules to allow the US to join New Zealand as the only countries that allowed prescription drugs to be advertised directly to the consumer. Doctors, who have no incentive to control drug cost, now treat people who have been taught to demand expensive drugs.
The insurance system itself is a cost generator. In a rational system insurance premiums would be dedicated to medical care alone, but in our system some of the money pays for a bureaucracy that looks for reasons to deny you treatment or even to get you thrown off the insurance rolls if you are too expensive. Politicians use the ‘R’-word – rationing – as a weapon against Obamacare. But if losing your insurance isn’t the worst form of health care rationing, I don’t know what is.
And that brings us to the root of the problem or “Cherchez le politician”. Politicians are elected by the people but are financed by corporate money; which requires them to convince people that their interests are being served when it is business’s needs that are being met. In healthcare, politicians can promote corporate interest by promise the voters that they will fight any attempt to ration their healthcare today.
Talk of rationing is so toxic that in the Republican budget plan huge cuts in Medicare are achieved by the magic of ‘block grants’ and not by rationing. The shame is that if politicians would actually face the hard issues we could cut Medicare, not with rationing but by excising wasteful tests and procedures and by a better understanding of which drugs are truly effective.
And talking of Medicare, one vilified and completely misrepresented part of the ACA is the provision for seniors to have their end of life choices explained to them. Meetings with doctors would give information on healthcare proxies, DNI, DNR, palliative care, quality of life etc. (if some of these terms are unfamiliar you might like to have the session). Living wills and other options would be examined. These meetings would be voluntary and decisions made if any would be by the patient alone. But despite this, opponents of ACA characterized them as “death panels”. What does that achieve beyond political posturing? The very real possibility that many Americans are being kept alive, with no quality of life, against their unexpressed wishes at great expense.
The fantasy of healthcare is that medical decisions are solely the province of a patient and her doctor. The reality is that medical decisions are being made by politicians, medical machine makers, insurance companies, lawyers and big pharma – mostly with profit, rather than efficient, effective and affordable healthcare as the goal.