Monthly Archives: December 2016

What is society’s responsibility for health care?

Adrian Anthony (A.A.) Gill, a Scots writer, died yesterday, December 10, 2016, at age 62, as he was receiving treatment for lung cancer from the National Health Service (NHS) in the United Kingdom. 

The system denied him life extending immunotherapy, specifically a drug called “Nivolumab,” AA Gill faces up to his cancerbecause it was too expensive: £60,000 to £100,000 a year for a lung cancer patient. This is four times the cost of chemo. 

Today, The Sunday Times [London] published his final article, “More life with your kids, more life with your friends, more life spent on earth — but only if you pay.” It is poignant, and, I think, must reading for distributists concerned with health care solutions. (The article is free to read, but you must register with The Sunday Times for access.)

Two excerpts:

Everyone standing for whatever political persuasion has to lay a sterilised hand on an A&E* revolving door and swear that the collective cradle-to-crematorium health service will be cherished on their watch. 
*“A&E”: ‘Accident and Emergency’ is the British term for a hospital’s emergency department.

We say [the NHS] is the envy of the world. It isn’t. We say there’s nothing else like it. There is. We say it’s the best in the West. It’s not. We think it’s the cheapest. It isn’t. Either that or we think it’s the most expensive — it’s not that, either. You will live longer in France and Germany, get treated faster and more comfortably in Scandinavia, and everything costs more in America. 

Distributist History: 

The distributist, Hilaire Belloc, did not like the idea of state sponsored social insurance, but saw it enacted shortly after he left parliament in 1910. (The National Insurance Act of 1911  provided health and unemployment insurance to some, but not all, workers.) Belloc feared that it would render people ‘servile’ to the state.

Quo Vadis? (Where are you going?)

What are the limits to health care?   How do politics, economics, faith and technology interact to determine what a society, a family, or a friend owes to the sick?  When is it correct to deny care and who has this authority?

Again, Belloc, who was a founder of the distributist movement, despaired of solutions that involved the state. The distributist principle of subsidiarity would seek solutions at the most local level possible; it would not call for a ‘common modality’ (that is, “one size fits all”.)


Note:  The last sentence of the posting containing Gill’s article reads:
“AA Gill began taking nivolumab after writing this article”
No additional information was offered.
 


 If you get into the article, you might want to know about these:

“Attlee”: Clement Attlee was Prime Minister of the United Kingdom from 1945-1951. The National Health Service Act of 1946 was passed on his watch. It created the current National Health Service. He was both preceded and succeeded in office by Winston Churchill.

Charing Cross Hospital” is a teaching hospital built in 1973. It is located in west London.

Health Care is a train wreck. Distributist ideas can (and must) fix it.

This post summarizes previous posts on distributist ideas for improving the health care system. Then it recommends two attainable public offices in Colorado for a Distributist who is ready, willing and able to act.


1. Please understand why health care is deeply troubled.

1. US health care is the most expensive in the developed world.

2. For all it costs, US health care ranks last among wealthy countries.

3. US health care is more “socialized” than not. The taxpayer pays for 64%; the private sector pays the remainder.

4. US health care consumes 17.2% of Gross Domestic Product, an amount nearly double that of the average of OECD member nations. (The OECD is the Organization for Economic Cooperation and Development. It is made up of developed nations.) 


Here are some numbers:
(Most of the data below is from: Himmelstein, David U., and Steffie Woolhandler. “The Current and Projected Taxpayer Shares of US Health Costs.” American Journal of Public Health 106, no. 3 (March 2016))

US Health Care Exp 2013 and 2024Total US health expenditure in 2013 was $2.919 trillion. Of that, $1.8774 trillion, or 64.3%, was tax-financed. Himmelstein and Woolhandler project that in 2024 US health expenditure will rise to $5.425 trillion, with $3.6421 trillion (67.1%) tax financed. 

In 2013 total health expenditure was $9267/person (17.2% of Gross Domestic Product.) OECD vs US health care spendingTax funded expenditure was $5960/person (11.2% of GDP). The 2013 OECD expenditure averages were 8.8% total, 6.5% tax funded.

 

In Colorado, nearly 1/4 of the population is on Medicaid. ( Medicare and Medicaid are only a portion of taxpayer financed Colorado Medicare and Medicaid Expenditurehealth care . The Department of Defense, the Veterans Administration, and tax credits/deductions to support the purchase of health care are also taxpayer supported.)


 2.  Consider worthy ideas.

 The efficiency of the health care system in the US is determined by very, very large “players”: the government, big pharmaceutical companies, and big insurers to name three. Market mechanisms do not seem to be able to control expenses. Distributist John Médaille says that there are too few competitors to make that possible. 

The cost of health care (17.2% of GDP) compared to that in other developed nations (8.8% of GDP on average) is high. It is not competitive. Therefore it is not sustainable. 

It is hard to imagine that anything will ‘reset’ the fundamentals of this system, short of jubilee. Revisions to payment systems like those Bernie Sanders and ColoradoCare proposed do not address the most dysfunctional features of the health care system: monopoly and monopsony. 

 John Médaille has made suggestions regarding cost containment. One of these suggestions concerns revisions to pharmaceutical licensing law. These changes, moving from a ‘patent’ based system to a ‘manufacturing license’ based system, would be challenging to implement. Think of it as moving from medallion taxis to Uber when all the medallion cabs are owned by Wall Street lawyers. 

John Médaille’s other suggestions concern three particulars of the practice of medicine: training, licensing, and supervision. 

3. Take action in Colorado.

 In Colorado, there is a place from which an engaged citizen can effect the practice of medicine and its costs, perhaps importantly so. This is the Colorado Medical Board which operates under the Department of Regulatory Agencies (with much autonomy.) 

The Colorado Medical Board is charged with “regulating and controlling the healing arts, which include establishing and enforcing [licensing standards for medical practitioners.]” The board consists of eight Medical Doctors, three Doctors of Osteopathy, one Physician Assistant, and four members of the public. Members are appointed by the governor for a term of four years. Recent deliberations included the use of licensed aestheticians to carry out procedures in medical offices. 

A similar group, the Nurse-Physician Advisory Task Force for Colorado Healthcare (NPATCH), has been established to improve and recommend codification for matters that involve the relationship between physicians and nurses, such as physician mentoring for nurses who are to become advanced practitioners. The Governor appoints the Task Force’s 12 members, comprised of five physicians, five nurses and two consumer representatives. One physician is a representative from the Colorado Medical Board, and one nurse is a representative from the State Board of Nursing. 

This board and this task force are places where distributist ideas (like John Médaille’s ideas on training and on licensing) can inform policy… and a cursory review of recent deliberations suggests that these ideas might be welcomed! 

One last thing.

There is a new federal program that is soon to insinuate itself on the practice of medicine. The Federal Government wants to “improve the efficiency” of medical practitioners who serve the elderly through Medicare and children through CHIP (Children’s Health Insurance Program.) Beginning in 2019, physicians are to be paid based on the outcomes of their care. This program has been authorized by MACRA – The Medicare Access and CHIP Reauthorization Act of 2015. 

It is controversial. The reporting requirements are substantial; concern has been raised that they will overwhelm small medical practices. The final regulations are 2400 pages long. The introduction to the regulations contains a list of 72 new acronyms. 

There are three interested parties in medicine: the medical practitioner, the patient, and the payer. The payer makes the rules. 

I now digress to make a point. The federal government uses its power to reduce costs, not by improving efficiency (again, US health care is the most inefficient in the developed world), but by reducing benefits: 

A person born before 1943 could retire with ‘full’ Social Security benefits at age 65. Persons born 1943-1954 must wait until age 66. Those born in 1960 or later will wait until age 67. Is there any reason to think that similar economies will not now be sought by controlling the practice of medicine under Medicare? To repeat: physicians will increasingly be paid based on the outcomes of their care. What outcomes? 

John Médaille has suggested the establishment of medical guilds. He urges competition between medical fraternities to achieve efficiencies and excellence, rather than the dreary meddling of the federal bureaucracy. A full exploration of this idea is more compelling than ever.