Rebellion Against the Individual Insurance Mandate

This morning's New York Times reports that legislators in a dozen states are launching a rebellion against the possibility of a mandate that individuals must buy health insurance or pay a penalty. The legislators hope to amend their state constitutions to prohibit any federal requirement that individuals (or employers) must "play or pay."

In 2008 Arizona, a hotbed of radical anti-government sentiment, the electorate almost passed Proposition 101, "The Freedom of Choice in Health Care Act," that would have put the following into the Arizona constitution:

Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan.

The vote could hardly have been closer - 920,341 (49.8%) for and 928,452 (50.2%) against. A tweaked version of Proposition 101 will be on the 2010 ballot and may well win this time.

The brain trust behind the rebellion is the American Legislative Exchange Council (ALEC), a 30+ year old organization of conservative state legislators and policy analysts. ALEC's model legislative proposal is only available to members, but the gist of the proposal is can be seen here:

When consumers control the dollars, they make the decisions. On the other hand, a single-payer health system—which forces patients to enroll in a one-size-fits-all plan with rich benefits and weak cost-sharing—will cause spending to skyrocket and policymakers to ration care as a cost-containment measure...Under a socialized medicine scheme, many patients will suffer, and some will die on a waiting list...ALEC's Freedom of Choice in Health Care Act ensures a person's right to pay directly for medical care.

ALEC pushes all of the conservative buttons - "one-size-fits-all," "ration care" and "socialized medicine."

ALEC and the legislators in the twelve mandate-fighting states appear to favor the "consumer-driven" approach to health insurance, in which individuals are asked to do their own rationing by having to spend their own money on health services. I don't know how ALEC proposes to achieve universal coverage without a mandate. The alternative funding mechanism is to tax the better off to pay for the worse off, not a popular conservative approach.

When I first joined the practice at Harvard Community Health Plan, a non profit HMO, in 1975, "community rating" applied, and all employers were charged the same per-worker premium. Over time the payment system shifted to "experience rating," in which employers were charged in accord with the actual cost of providing care for their employees. This meant that employers were penalized for having older workers who were likely to cost more, and for making it possible for workers with chronic illnesses to hold jobs. Now conservative groups like ALEC want to disaggregate the community down to the level of individuals having the "right" to pay for their own care.

Even if a robust federal health law is passed states will continue to be crucial laboratories for reform initiatives. I'm at the opposite end of the political spectrum from ALEC and favor communitarian approaches to managing the health system. But I'd be happy to see an ethically guided state experiment that (a) achieved universal coverage, (b) tracked its results and allowed independent researchers to assess the state's performance, while (c) putting conservative principles into practice. My guess is that the rebellious legislators are better at shouting "fire" (or rather, "socialized medicine") than solving problems on the ground, but rather than trade sound bites it would be better to see if they can make their ideas work in a clinically sound and socially responsible manner.

Conservative critics of health reform emanate sound bites brilliantly. It's time to see if they can walk their talk!

(An op-ed supporting Arizona Proposition 101 by George Will is here. The Resolution that will be on the Arizona ballot in 2010 is here.)

Should Therapists Snoop in Their Patient's Facebook Site?

A colleague recently asked me this question:

What do you think about therapists going to a patient's Facebook site if that site is open to the public, not just to people who the patient has friended? My younger colleagues think it's OK - like reading about your patient in the newspaper. It doesn't feel right to me but I'm not sure why?

What a terrific question!

From the perspective of privacy ethics there's nothing wrong with going to the Facebook site. After all - the patient has structured it so that anybody can come to the site to see what's there. In that limited way the younger colleagues are right - it isn't a violation of privacy.

But it matters what kind of a clinician we're talking about here. If a primary care physician was working with a patient on a self-management problem like difficulty sleeping or weight loss and was getting nowhere, I wouldn't fault her for going to the Facebook site as long as she was prepared to tell the patient about it, as in:

I've been troubled about why we're not making any progress in what we're working on - I just don't get it. So instead of running more tests I went onto your Facebook site. I think I can see what our problem is...

But what about a psychotherapist doing the same thing? Here I think the younger colleagues are missing the boat. Psychotherapy isn't just a matter of gathering information as part of the effort to solve a problem. The relationship itself is at the heart of the effort. The commitment on both sides is to use the experience of the relationship on behalf of the treatment goals. It wouldn't be surprising for the patient to see if the therapist has a Facebook site, but it would be important for the patient to bring the fact of the search into the therapy. What did the patient's curiosity focus on? What did what he found mean to him? What feelings were associated with the process?

If the therapist and patient were talking about the patient's self-presentation on Facebook it would be fine for the therapist to say - "would it be OK for us to look at it together right now?" That would lead to collaborative inquiry. But it wouldn't be OK for the therapist to go to the site covertly. What was the therapist looking for? Why didn't he bring up whatever the question was with the patient? If the therapist has a question he should ask it. If he goes to Facebook instead it suggests that he feels an impediment to direct work with his patient. That's what's key - not the information on the Facebook site.

Health Care Organizational Ethics Blog Cited

Medicine 3.0 recently cited this blog as one of the top 50 health policy blogs. I appreciated the honor, and also appreciated learning about a number of interesting blogs I had not been aware of. I encourage readers to check out the site (see here).

Last November, the blog Online Universities cited Health Care Organizational Ethics as one of the "100 blogs that will make you smarter." The list is worth perusing.

The Art of Dying

In the July/August issue of the Hastings Center Report, John Hardwig, professor of philosophy at the University of Tennessee, offers guidance on "the art of dying." Hardwig encourages us to think deeply about what we want for the end game of our lives and to create the groundwork for life to end the way we want it to.

Here's how Hardwig sets the context:

When the sensible fear is that death will come too soon, the reasonable course is to flee it - try to postpone it or put it off...

However, many of us now worry that death will come too late - long after life has lost its usefulness and its savor, long after we have ceased to have a 'life,' perhaps long after we even are ourselves. When the more sensible fear is that death will come too late, the reasonable course is to make death come sooner - to seek it out. Learning how to go to meet death is, I believe, one of the basic tasks of our time.

In Hardwig's view, and I agree, "our institutions - our law, our medicine, our customs and traditions, our ethics, our religions - are all designed to respond to the older kinds of death [deaths that came too soon]." He tells us that he is 69, and he envisions a generation that will have to grapple with the question of life's end game without much help from others. Insofar as he's right, what a sad situation!

I'm part of Hardwig's generation, but I wouldn't have had the guts to speak as directly as he does prior to reading his essay. Consider this:

At my age I should be ready to die...I should realize that I have already had a full life...If I am not yet ready to die, something is deeply amiss in my outlook on life. My basic beliefs and values need revision.

Hardwig warns about the danger of waiting for an exact point at which one wants death to come. We can't count on having that kind of control. Probably most of us mid-life or older know people who found themselves imprisoned in a prolonged end of life that they dearly wanted to avoid. He discusses refusing life-sustaining treatment, cessation of eating, and active suicide. It's my impression that many, perhaps most, people in their 60s and beyond mull over these questions, but that relatively few discuss the issues in depth with those they are close to.

Before I decided to go into medicine and psychiatry my alternative career plan was to become a philosopher. Had I done that (I decided I wasn't scholarly enough to take to a full time academic career) I would have hoped to do Hardwig's kind of writing - disciplined, well argued, and fully engaged with questions of personal meaning.

The Hastings Center Report article isn't addressed to physicians. I was pained by Hardwig's view that my profession is not ready to partner with patients in the kind of thinking he presents. I'd like to think that he's underestimating the capacity of the profession - that if doctors felt they had permission to help their patients think about - and talk about - "the art of dying," most would be ready to do so. When I was a medical intern at UCLA in 1964 my first outpatient undertook to teach me about Hardwig's topic. I was 25. He was 50, with a lymphoma that wasn't curable. At our first appointment he asked me to renew his sleeping pills. He told me that when the time came he would use them to end his life. Even though he didn't know I was going into psychiatry he gave an important lesson in succinct form - "I'm not depressed - I enjoy my life - but I'm realistic, and I know what I want." I renewed the pills. He was still alive when I ended the year of medicine and returned to Boston to do my residency in psychiatry. If his spirit has access to the Hastings Center Report I expect that he's saying "right on John Hardwig!"

(The July/August Hastings Center Article is not yet available online, but many of Hardwig's earlier articles, including his important essay "Is There a Duty to Die?" are available at his website.)

Shamans, Placebos and Multicultural Ethics

Over coffee I read in this morning's New York Times about how Mercy Medical Center, an acute care hospital in Merced, California, allows Shamans to participate in the treatment of Hmong patients from Laos.

The Merced area has a large Hmong population (from Northern Laos), beautifully described in Anne Fadiman's superb book "The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and The Collision of Two Cultures." What's especially interesting is that Mercy Medical Center is part of Catholic Healthcare West, a faith-based system "committed to furthering the healing ministry of Jesus," as well as "to providing high-quality, affordable healthcare to the communities we serve."

It's easier for our scientifically-minded U.S. culture to recognize the importance of religion and magic in dealing with "foreign" cultures than with our own. In my own experience as a psychiatrist, and in my relatively limited interaction with other doctors as a patient, I've been aware of how much of what we do is anthropologically similar to what Shamans do.

When patients ask "so I have a chemical imbalance, right?" and I agree, our exchange has much in common with what is happening when a Hmong patient asks "so a spirit is causing my pain, right?" and the Shaman agrees. Whether or not a chemical imbalance or a spirit is responsible for the clinical state, applying a cognitive model the patient trusts in concert with a trusted healer can have a powerful impact.

In 1986 I made my first and thus-far only trip to China. On a train I conversed with a man who spoke English. I asked how he used "western" medicine compared to traditional Chinese medicine. His answer made excellent sense. "If I have a headache or pain in my back I go to a traditional Chinese healer. If I have pneumonia I go to a 'western' medicine doctor and get an antibiotic."

On returning to the U.S. I was referred a man who had recently arrived from Southeast Asia but who was ethnically Chinese. He had classical symptoms of major depression - depressed mood, suicidal thoughts, weight loss and sleep disturbance - for which antidepressant medication was (and is) the standard treatment in the U.S. He was dubious about trying the medication, so I wrote out my thoughts and encouraged him to discuss the treatment with his herbalist. The herbalist approved of my suggestion and in some weeks the depression was gone, presumably (but not necessarily) due to the medication.

A year later my patient returned and described what sounded like symptoms of erectile dysfunction. I began to ask the kinds of questions I would typically ask in that circumstance. My patient looked horrified at the direction the conversation was going, at which point I encouraged him to see his herbalist for the problem. A few years later I met him at the clinic carrying a baby. Presumably the herbs did the job!

Mercy Medical Center and Catholic Healthcare West are practicing admirable small 'c' Catholicism (in my dictionary "broad and comprehensive in interests, sympathies; liberal"). U.S. medicine needs to extend the same cultural sensitivity and anthropological sophistication to our own practices. We tend to use the term "placebo effect" disparagingly - "the Shaman's ritual is just a placebo effect." Each group takes its own beliefs as literally true and, ideally, acts like Mercy Medical Center with regard to the different beliefs held by others.

If we were more attuned to how much "evidence based" medical practice depends on the power of faith, magic, and the lowly placebo effect, we would be less inclined to flog patients with excessive technical interventions and readier to minister to them in a truly healing manner. When religious fundamentalists persist in using prayer as the only treatment for children with curable cancers we take them to court. But when medical fundamentalists persist in using one technical intervention after another rather than acknowledging that cure is not in the cards our insurance pays their fees.

Years ago a dear friend had come to the end of the available treatments for multiple myeloma and the disease was progressing. When she visited with her oncologist - a leader in technical medicine - he said "the best thing I can do for you now is to give you a hug," which he gave. I've used that as an example of ideal care with medical students.

Our health system can learn a useful lesson from my friend's oncologist and from Mercy Medical Center and Catholic Healthcare West!

How Much is Life Worth? - An Oncologist's Call to Arms.

Between 1997 and 2004, Medicare spending on cancer drugs rose by 267% compared to an overall rise in Medicare spending of 47%. With an aging population, the cost of cancer drugs will become a progressively greater problem for the U.S. health "system."

A recent issue of the Journal of the National Cancer Institute has a very important article by Tito Fojo, an oncologist at the NCI Center for Cancer Research, and Christine Grady, an ethicist with the NIH Department of Bioethics. "How Much is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question" calls for a fundamental change in research, the drug approval process, drug pricing, and clinical practice. The analysis and argument will be familiar to ethicists and policy wonks. What's especially important about the article is that Dr. Fojo speaks as a distinguished cancer researcher and addresses his recommendations to fellow oncologists.

Drs. Fojo and Grady don't flinch from using the "c" word - cost:

In some sense, every life is of infinite value, and we naturally avoid confronting the tension between not wanting to put a value on a life and having limited resources. But the spiraling cost of cancer care in particular makes this dilemma inescapable. We, the oncology community, cannot continue to ignore it.

The main example in the article is Cetuximab (Erbitux). Erbitux adds 36 days of life for patients with non-small cell lung cancer, but also adds a number of significant side effects. Conveniently, the study that demonstrated the 36 day extension of survival did not include quality of life measures. At its present cost, adding an average of 36 days of life is the equivalent of $800,000 per non-quality adjusted year of life. Fojo and Grady argue that this is far too much cost for far too little benefit.

The authors urge oncologists to act as true professionals who consider wider societal concerns like the uninsured or the U.S. economy going down the tubes. They don't use the word "narcissistic," but their analysis suggests that a profession that considers only its own perspective is just that. They make six specific recommendations for practice and policy:

1. "Research studies that are powered to detect a survival advantage of 2 months or less should only test interventions that can be marketed at a cost of less that $20,000 for a course of treatment." Here they are using the standard of one quality adjusted year of life for patients treated with dialysis ($129,090) as their standard.

2. Drugs should be priced accordingly.

3. "Drugs shown to be active in one subset of patients should be advocated, approved, and prescribed for that subset only. The marginal benefit, if any, which may be achieved in other patients should not be an excuse to administer a therapy even if it is decided that there is nothing further to be done."

4. FDA approved indications should be strictly adhered to.

5. "The all too common practice of administering a new, marginally beneficial drug to a patient with advanced cancer should be strongly discouraged. In cases where there are no further treatment options, emphasis should be first on quality of life and then cost."

6. "For therapies with marginal benefits, toxic effects should receive greater scrutiny."

Having exposed the chemotherapeutic emperor's new clothes for what they are, Drs. Fojo and Grady conclude:

We must deal with the escalating price of cancer therapy now. If we allow a survival advantage of 1.2 months to be worth $80 000, and by extrapolation survival of 1 year to be valued at $800 000, we would need $440 billion annually — an amount nearly 100 times the budget of the National Cancer Institute — to extend by 1 year the life of the 550 000 Americans who die of cancer annually. And no one would be cured.

The current situation cannot continue. We cannot ignore the cumulative costs of the tests and treatments we recommend and prescribe. As the agents of change, professional societies, including their academic and practicing oncologist members, must lead the way. The time to start is now.

Drs. Fojo and Grady have issued a courageous and compassionate challenge to their fellow medical professionals. It deserves wide attention!

(The article is not yet available without charge, but a summary and paid access to the full text are available here. For Dr. Fojo's web page see here.)

Massacusetts Insurance Costs and Federal Health Reform

Our national approach to health reform is likely to draw on the reform process Massachusetts launched in 2006.

By the measuring rod of coverage, Massachusetts is doing significantly better than the other 49 states. "Only" 2.6% were uninsured in 2008, compared to a national average of 15%.

But by the measuring rod of cost containment, Massachusetts is - so far - a flop. Today the Boston Globe reported that the state's major health insurers plan to raise rates next year by approximately 10%, double the projected national average of 5%. (For the Boston Globe article, see here.)

Massachusetts is pursuing a high risk/high gain approach to health reform. Many political folks say "let's control costs first and then extend coverage." Given our pathetic national passivity about getting serious about health costs this approach is as likely to lead to real action as the sinner's promise to change his ways as soon as the Messiah approaches. Massachusetts' strategy has been to extend coverage first, hoping recognition that the accomplishment will go down the tubes unless costs can be controlled will act as a kind of Viagra for policy that catalyzes ability to overcome our national cost-containment impotence.

Massachusetts has proved that a combination of (1) requiring individuals to have health insurance (or pay a "fine"), (2) subsidizing insurance access for low income folks, and (3) requiring insurers to "pay or play," will (4) substantially lower the number of uninsured. But these accomplishments won't be sustainable unless (5) the state gets a grip on health care costs.

In 2008 Massachusetts created a Special Commission on the Health Care Payment System to "investigate reforming and restructuring the system to provide incentives for efficient and effective patient-centered care and to reduce variations in the quality and cost of care." (The key word is "efficient," a politically correct way of referring to cost containment.) The Commission issued its report in July. The state also contracted with the RAND corporation to develop a menu of cost containment strategies and to determine their potential impact on the health care system in Massachusetts.

Now the really important aspect of health reform in Massachusetts gets underway. The Special Commission and RAND have both recommended radical payment reform - moving from a predominantly fee-for-service system to a system of global payments. The Commission envisions "Accountable Care Organizations" of clinicians and hospitals caring for populations under a budget. The Commission understands that getting from here to there will take time and allows for a transition period of 5 years.

Our way of budgeting for health care in the U.S. is a farce. Rather than deciding what we want to spend we put our finger to the wind, ask what the system is likely to charge, and then create next year's "budget" based on our prediction. In the 1990s we asked health insurers to manage the system actively. For a time that worked - the trend slowed. But a system in which insurers put reins onto providers can't work - there's too much distrust of insurers, and it's too easy to vilify them as uncaring bureaucrats.

What we need is a system in which clinicians and their patients collaborate to manage care. I know first hand that this approach can work well from decades of practice in the Harvard Community Health Plan HMO, a non profit program that cared for a population within a budget. (Norman Daniels and I have described how doctors, patients, and other stakeholders can collaborate this way in "Setting Limits Fairly: Learning to Share Resources for Health.")

In 1630 John Winthrop gave a sermon to the Puritans who were about to found the Massachusetts Bay Colony:

For we must consider that we shall be as a city upon a hill. The eyes of all people are upon us. So that if we shall deal falsely with our God in this work we have undertaken... we shall be made a story and a by-word throughout the world. We shall open the mouths of enemies to speak evil of the ways of God... We shall shame the faces of many of God's worthy servants, and cause their prayers to be turned into curses upon us til we be consumed out of the good land whither we are a-going

If Massachusetts steps up to the plate and implements what the Special Commission and the RAND consultants have recommended it will become a learning laboratory for the U.S. system. If it succeeds in doing the job right the state will be a city upon a hill!

For those who are interested here are the principles the Special Commission recommended to the state:

1. As currently implemented, fee-for-service payment rewards service volume rather than outcomes and efficiency, and therefore other models should be considered.

2. Health care payments should cover the cost of efficiently provided care, support investments in system infrastructure, and ensure timely access to high quality, patient-centered care. Additional payment should reward and promote the delivery of coordinated, patient-centered, high quality health care that aligns with evidence-based guidelines where available, and produces superior outcomes and improved health status. Performance measurement should rely on reliable information and utilize uniform, nationally accepted quality measures.

3. Provider payment systems should balance payments for cognitive, preventive, behavioral, chronic and interventional care; support the development and maintenance of an adequate supply of primary care practitioners; and respond to the cross-subsidization occurring within provider organizations as a result of the current lack of balance in payment levels by service.

4. Differences in health care payments should reflect measurable differences in value (cost and quality). Payments should be adjusted for clinical risk and socio-economic status wherever technically possible, and should promote greater equity of payments across payers and providers, to the extent that this is financially feasible.
a. Differences in health care payments should be transparent, including across different payers.
b. Costs associated with desired investments in teaching and research should be paid outside of base payments, and should require provider accountability for how such payments are spent.
c. Costs associated with desired investment in special “stand by” capacity should be accounted for in the payment system.

5. The health care payment system should be structured in such a way as to minimize provider, payer and patient administrative costs that do not add value.

6. Payment reform must consider how:
a. Some payment methods may require certain organization of the service delivery system, and
b. Health benefit designs either support or limit payment reform.

7. Health care per capita costs and cost growth should be reduced, and providers, payers, private and public purchasers and patients should all share in the savings arising from payment reform.

8. The health care payment system should be transparent so that patients, providers and purchasers understand how providers are paid, and what incentives the payment system creates for providers.

9. It will be necessary to consider the diversity of populations, geography and providers across the Commonwealth when designing payment reform to ensure high quality, patient-centered care to all populations and geographic regions in the Commonwealth.

10. Implementation should be phased over time with:
a. Clear and attainable deadlines;
b. Planned evaluation for intended and unintended consequences; and
c. Mid-course corrections.

(See here for the RAND study, and here for the Special Commission on the Health Care Payment System report.)

Obama's Speech - Good Ethics and Good Politics

President Obama hit a home run last night. His speech brought together the three roles we need our president to take in the health reform process - educator, ethicist, and tough politician.

1. President as educator. As a public we've been clueless about health care. How many times have we heard "the U.S. has the best health care in the world!" Many of our local settings are superb. President Obama mentioned two - Intermountain Healthcare in Utah and Geisinger in Pennsylvania. These were the right kinds of examples to give - integrated systems with strong primary care and careful attention to efficiency and cost management. We were spared from hearing another worshipful invocation of a once in a lifetime high-tech miracle as the definer of what we do best.
   
   




2. President as ethicist. The cancer of the U.S. health system is our rampant narcissism and neglect of our common interests. Individuals are being cheated unless they receive whatever they want. Physicians are being mistreated if each individual isn't allowed to command whatever resources he believes are called for without being questioned.
   
   I like to use the metaphor of cancer for our health system - by letting costs explode we let health care invade and destroy so much of our capacity for creative action. President Obama used the deficit, and the specter of the depression we almost fell into - "our health care problem is our deficit problem - nothing else comes close." In other words - we choose between our thoughtless commitment to a wasteful system that produces mediocre results and a parched, deficit-ridden public life.
   
   Sadly, Ted Kennedy can no longer be part of the end game in health reform, but happily the president channeled him to bring out the moral imperative behind the insistence on universal coverage. Reading from Senator Kennedy's letter was a proto-religious act - a message from a loving person sent from the other world.
   
   




3. President as tough politician. Channeling Ted Kennedy was a rhetorical triumph, but to go from rhetoric to a meaningful piece of legislation, Obama must channel Lyndon Johnson as well. He came close to naming names in his reference to "liars" with regard to the cynical efforts to manipulate the public by shouting"death panel," "government takeover" and "socialism." In the speech he evoked the persona of a don't-mess-with-me Chicago politician in an effective manner, but he'll have to emulate Johnson's combination of one-by-one persuasion and bludgeoning to move the legislature to create and pass of a bill.

It's too early to evaluate what the principles Obama laid out will look like when they take on legislative flesh. The angels and devils will be in the details of how the exchange(s) and public option are structured. I was especially interested in the president's vague reference to a commission of physicians and other experts who would identify areas of waste in our bloated system. That could mean managed care, which to me - if done well - has always seemed like the right way for a health system to go.

Wendell Potter on For-Profit Health Insurance

Wendell Potter, who retired last April from his job as head of communications for the CIGNA health insurance company, has been in the news since then as a whistle-blowing critic of the insurance industry. Today I belatedly read his June 24 testimony to the U.S. Senate Committee on Commerce, Science and Transportation (see here) watched his July 10 interview with Bill Moyers (see here).

Potter is especially clear about the way short term considerations drive the behavior of for-profit insurers:

The top priority of for-profit companies is to drive up the value of their stock. Stocks fluctuate based on companies’ quarterly reports, which are discussed every three months in conference calls with investors and analysts. On these calls, Wall Street investors and analysts look for two key figures: earnings per share and the "medical-loss" ratio - the ratio between what the company actually pays out in claims and what it has left over to cover sales, marketing, underwriting and other administrative expenses and, of course, profits.

To win the favor of powerful analysts, for-profit insurers must prove that they made more money during the previous quarter than a year earlier and that the portion of the premium going to medical costs is falling. Even very profitable companies can see sharp declines in stock prices moments after admitting they’ve failed to trim medical costs. I have seen an insurer’s stock price fall 20 percent or more in a single day after executives disclosed that the company had to spend a slightly higher percentage of premiums on medical claims during the quarter than it did during a previous period. The smoking gun was the company’s first-quarter medical loss ratio, which had increased from 77.9% to 79.4% a year later. (slightly edited)

The problem with investor ownership and for-profit insurance isn't the people. Over the years I've studied a number of for-profit companies. The people I dealt with and observed seemed just as caring and idealistic as their counterparts in the not-for-profit world.

And the problem isn't profit per se. Although in most of my years of clinical practice I was paid as a salaried member of a not-for-profit group, I did ten years of fee-for-service practice. As a solo psychiatrist I typed my own bills and gave them to my patients each month. They brought a check to a subsequent appointment and handed it to me. This ritual made it crystal clear that I was running a for-profit enterprise, albeit a tiny one.

I was entirely comfortable with the ethics of my for-profit practice. I set my fees and could lower them if I chose to do so. When discussing fees I said "the aim is to make an arrangement that is fair to both of us." The owner of the enterprise (me) and the investor/purchaser (my patient) could look each other in the eye. Parsing what mutual fairness entailed was often part of the therapeutic process.

Public companies are large, impersonal structures. In particular, the equity owners are investors guided by economic rather than caretaking values. They're not challenged by looking the patient directly in the eye and having to see and take responsibility for the impact of corporate decisions.

I run the ethics program at a not-for-profit health insurance company. Like all other participants in the U.S. system we're subject to market pressures for efficiency. I think that's a useful pressure, just as the pressure to make treatment affordable for my fee-for-service patients was. But we're not subject to quarterly conferences with investors whose only concern is with financial performance.

If you look at the video you'll see that Potter looks "corporate" and speaks calmly. His clear discussion of the structural impact of equity ownership on the health system is a valuable contribution. I hope we hear reverberations of his analysis in President Obama's speech tomorrow night!

The Paranoid Style in American Politics

In the course of trying to understand the eruption of rage against the non-existent "death panels" in the emerging health reform bills I went back to historian Richard Hofstadter's 1964 essay in Harper's Magazine - "The Paranoid Style in American Politics." The opening sentence reads "American politics has often been an arena for angry minds." How true!

Here's the essence of Hofstadter's argument:

I believe there is a style of mind that is far from new and that is not necessarily right wing. I call it the paranoid style simply because no other word adequately evokes the sense of heated exaggeration, suspiciousness, and conspiratorial fantasy I have in mind. I am not speaking in a clinical sense...It is the use of paranoid modes of expression by more or less normal people that makes the phenomenon significant.

Hofstadter cites examples in U.S. history going back to a wave of fear in the late 18th century that the Bavarian Illuminati - a group that espoused Enlightenment rationalism "spiced with the anticlerical atmosphere of eighteenth-century Bavaria" - were plotting to overthrow Christianity. Other examples include the anti-Masonic movement, anti-Catholic and anti-Mormon movements, late 19th century beliefs about a conspiracy of international bankers, and of course the fulminations of Senator McCarthy.

While Hofstadter emphasized that the paranoid style was not exclusively right wing he discerned a continuing belief in a "sustained conspiracy, running over more of a generation, and reaching its climax in Roosevelt's New Deal, to undermine free capitalism, to bring the economy under the direction of the federal government, and to pave the way for socialism or communism." Hofstadter's words in 1964 could be applied unchanged to what was being shouted at town meetings and broadcast on Fox in August.

Hofstadter's analysis offers an explanation for the intractability of public and political debate we are seeing in the health reform process:

As a member of the avant-garde who is capable of perceiving the conspiracy before it is fully obvious to an as yet unaroused public, the paranoid is a militant leader. He does not see social conflict as something to be mediated and compromised, in the manner of the working politician. Since what is at stake is always a conflict between absolute good and absolute evil, what is necessary is not compromise but the will to fight things out to a finish. Since the enemy is thought of as being totally evil and totally unappeasable, he must be totally eliminated—if not from the world, at least from the theatre of operations to which the paranoid directs his attention.

Hofstadter acknowledged that the term he chose to use for the style of mind he was describing was judgmental: "Of course this term is pejorative, and it is meant to be: the paranoid style has a greater affinity for bad causes than good." I'm not sure that he's right on this. Many people (like Hofstadter) on the liberal-left would admire whistleblowers like Ralph Nader, to whom the term "paranoid style" could certainly be applied.

In my clinical practice I thought of paranoid style as an accentuated version of the vigilance regarding external threats that has been hard wired into our nervous systems over millions of years. I sometimes said to patients - "when our ancestors in the forest hundreds of thousands of years ago heard a rustling sound, some probably paid no attention and went about their business, and others thought 'that's a tiger' and climbed a tree...if it was a tiger we know who natural selection favored..."

I don't know whether the likes of Newt Gingrich, Charles Grassley and Sarah Palin believe the nonsense they've spouted about death panels (paranoid style) or are cynically appealing to their political base's hatred of government (duplicitous manipulation). I'd guess that it varies from person to person. In retrospect the administration should have read Hofstadter's essay and conducted a series of political "war games" in which they tried to anticipate and innoculate against the full range of fears that could be triggered by the health reform debate.

Demonizing the paranoid style only makes things worse. Sometimes the rustling in the forest was just the wind, but sometimes it was a tiger. Too much trust is just as dangerous as too much vigilance. I, like many others, was inspired by the President's wish for a "different kind of politics," but that aim should not lead to the delusion that the entire political spectrum can be drawn into deliberative discussion!

(If you want to see Hofstadter's full essay, it's here.)

Immigrant Health and Heart Transplants

I'm still jet lagged from 2 1/2 weeks in Europe, so when I woke up in the dark this morning I sought out the online New York Times for solace. Two articles yielded a larger story about health reform.

Eric De La Cruz was a student and part time disc jockey and graphic designer in Las Vegas in his early 20s when the symptoms of progressive cardiomyopathy - weakness of the heart muscle - began to cause symptoms of heart failure. The condition steadily got worse, and it became clear that the only hope for Eric would be a heart transplant. But neither of his employers provided health insurance. And, surprisingly, when he applied for Social Security disability benefits, which would have made him eligible for Medicare, he was turned down.

Eric did qualify for Medicaid, but in Nevada Medicaid covers heart transplants only up to age 20. At this point his sister began a Twitter-based effort to raise money, and within two weeks $1 million had been offered! Eric went to the University of Southern California for evaluation, but his condition was too far advanced, and he died on July 4.

The second article was from Massachusetts. The recession-driven shortfall in revenues and the requirement that the state stay within its budget necessitated cutbacks in the state's health reform program. (The program has led to the lowest uninsured rate in the U.S. - 2.6% compared to a national average of 15%.) The legislature decided to cut most of the $130 million dedicated to 31,000 legal immigrants. But by scrounging up some additional funding and developing a stripped down set of benefits, a relatively comprehensive insurance package will still be available to the legal immigrant group. It won't cover dental, hospice, or skilled nursing care, and will require higher copayments for non-generic drugs, but it would have covered a heart transplant for someone with Eric Cruz's condition.

After his death, Eric's sister Veronica De La Cruz said:

If my brother had been able to buy health insurance, he would never have been in this situation. No one should ever have to go through what we’ve been through. Eric should still be alive.

Veronica is half right. In a wealthy country like the U.S., a healthy young person like Eric should be eligible for a heart transplant. A heart might not be available, but that would be a tragedy, not an injustice.

Ben Kieckhefer, a spokesman for the Nevada Department of Health and Human Services, described the the state's policy clearly and honestly:

All insurance plans decide what things they are going to cover and what things they are not going to cover. Everyone in the state Medicaid program recognized the difficult situation the family was in, but we can’t just start covering something for one individual case.

Unless there is some form of universal or near-universal coverage, as through a single payer system or a requirement that individuals purchase insurance (as in Massachusetts) Eric would not - and should not - have been able to buy insurance. If we allow ourselves to wait until a need appears before we get insured, free-riding would be the rational choice for the individual to make, and insurance costs would be stratospheric in no time.

Affordable insurance depends on social solidarity, with the healthy contributing more than they receive and the sick receiving more than they contribute. In the U.S., however, talking about "solidarity" invokes fear of the other dreaded "S" word - "socialism."

And as the stories from Massachusetts and Nevada show, viable insurance also entails the equally dreaded "R" word - "rationing." Health systems must set limits. A society (like the U.S.) that refuses to ration in a thoughtful, ethically-guided manner, will (like the U.S.) end up rationing in a thoughtless, unethical manner. Whether a society prefers to limit high cost/high tech interventions as Nevada has done, or more mundane but nevertheless valuable services as Massachusetts chose to do, is the kind of policy decision that requires thoughtful democratic deliberation. Sadly, thoughtful deliberation is currently being drowned out by strident advocacy, pervasive misunderstanding, and lies.

(To read more about Eric De La Cruz see here. For the Massachusetts story, see here.)