Saturday, November 01, 2008

This election, part 3

I wish that I had an answer to health care.  I think about it a lot because I have to and have had to for over 10 years.  Tom Brokaw, in the last presidential debate, hit the nail on the head by asking the candidates whether health care was a responsibility, a privilege, or a right.  The first two suggest that health care is a matter of proper insurance, while the third is focused on the idea of coverage.  In an earlier post, I suggested that the issue often elided in discussions of American health care is the fact that "insurance" is a business contract.

And how to unwind the health care industry from the insurance industry--that is, how to free compassion from business--is more complicated than it might appear on the surface.  Competition is essential in the development of doctors, drugs, treatments, and research.  Right now, many of the rewards that drive that competition are financial, although the academic community and its system of career advancement provide an alternative model to some R&D.  The prescription drug industry argues, of course, that it needs adequate compensation for the money it sinks into R&D.  

While Robert has benefited from this competition in terms of the development of reflux medications, I find the prescription drug industry's defense of itself problematic.  For years, we struggled with his debilitating reflux by using a solvent developed by academic researchers in which the prescription drug industry had no interest because the market was too small.  Finally, the industry adopted this application and it was available through insurance coverage.  But the price of this stuff without insurance is out of reach.  And, because prescription drug advertising has been deregulated, demand for these drugs was raised so high that insurance companies began implementing various checks on its use that make life difficult for those who really do need the drug.  

This is, perhaps, what some journalists and others mean when they discuss the "over-consumption" of health care.  But I wouldn't know whom to trust to set guidelines for such things.  Certainly not health insurers.  Congress is generally incapable, given its excessive partisan nature and the idiosyncrasies of, in particular, House members, of working toward such guidelines.  Our government is a matter of compromise, checks and balances, but compassion is in short supply when the focus of 2/3 of Congress is primarily on re-election--"compromise" tends to be predicated not on the needs of people who are chronically ill, but on the needs of healthy people and political ideology.

This is, perhaps, what people fear when they start talking about "socialized" medicine.  But how to provide meaningful incentives for human beings?  Compassion isn't always enough when it comes to paying for the infrastructure that medicine and health care require.

One of John McCain's solutions to the chronically ill has made me absolutely pray that he's defeated: the isolation of people with severe medical needs in group coverage that is predicated on state appropriations.  I can think of no greater recipe for disaster than that.  Wonder why it costs so much for your kid to go to State U?  Look no further than the cowardice of state legislators and the matter of state appropriations in an economic downturn, especially for people who don't comprise much of a voting block.  So, if they're willing to screw over the parents of college-going students, imagine what they'll do to the sick and dying.

There's a lot more that could be said here--I think I've already criticized McCain's plan to inadequately buffer the detachment of health premiums from jobs--but these are, I think, some top issues:

1. portability of health insurance
2. finding a cost vs. coverage metric that ensures meaningful, full, and compassionate care
3. fostering competition and excellence in the development of drugs and treatments
4. development of cost models and price structures that are sheltered from political favoritism (ha!)

In some ways, Obama's approach, which would examine creating larger groups, would be on the right track.  Robert is on federal health insurance right now, and it's the easiest coverage I've ever had for him.  He's a blip in the system and the contract negotiated is sane because the group is so large.  There's more to it than this--but, maybe, after the election, we can figure out how to make it work.

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