David Lewicki, a young pastor in PCUSA:

I would even go so far as to challenge the primary theological premise put forward by organizations like Sojourners: that good health is God’s will for every person created in God’s image. Good health is an eschatological ideal—crafting public policy based on eschatological visions comes close to saying we don’t really need God to usher that future in—we can handle it ourselves, thanks. Eschatology is God’s future transforming our present; God’s future is not something we work toward incrementally by our own efforts. When evangelicals support a strong Israel on the notion that they’re setting the stage for the coming apocalypse, progressives complain. When progressives say that we should create a government-sponsored universal health care system because, in Revelation 21, “pain will be no more…” that’s OK? For the last decade and a half, evangelical Christians have crudely translated religious convictions into public policy, blurring healthy boundaries between faith and politics. Now, turnabout seems like fair play.

Sickness and health are interwoven human conditions that both serve as effective tutors of the virtues of gratitude and dependence upon God’s grace. When we claim that “good health is the will of God,” referencing eschatological truth in the service of policy-making, we risk invoking an even more damaging falsehood: that bad health is not the will of God. As a pastor whose life will always be wrapped up with helping people wrest meaning from the agony of illness and death, I simply can’t go there. God’s will is there, too.

I want every person to have access to health care when they need it for a price they can afford to pay. The stronger arguments for universal, single-payer care are secular arguments—a strong democratic republic should extend health care to all because it creates a strong and competent citizenry. I’m not convinced that the Christian faith points us in a clear direction when it comes to shaping public policy solutions to accomplish that objective. I don’t want to be shamed into supporting a policy when a faithful person could well stand in opposition to the Obama plan.

Read it all here; there is quite a bit more.

Charles,

Thanks for posting this. I would prefer a single-payer system, but realize that the political climate is against that. So I think reforms that will control the growth of costs and make it possible for everyone to have insurance are overdue. I take offense, however, at the use of “socialized medicine” in the discussion, especially since we rarely if ever refer to socialized police and fire protection, military, mail delivery, or schools. There are many vital services which we do not leave to the marketplace alone and a decent argument can be made that health care should be one of them.

Daniel

I would be for a single payer system except for one thing.  The single payer system is run by human beings.  It has been my experience that government is the least effective and least efficient (or among the least) means of solving any problem.  Health Insurance companies are also run by human beings but competition tends to make them more accountable to their potential customers.  It doesn’t take too many “so and so died while being refused care by XYZ insurance” stories to get the Human Resources departments at many companies to not want to do business with that insurance company.  So, I would rather spread the risk (take out insurance if you will) and not have a single payor system.

We already have a very large single payer system - medicare and we have far too few doctors that will take new medicare patients because the government pays less than it costs to deliver the services or treatment.

Medicare is also run through with inefficiencies and with corruption and fraud.  A private insurance company has greater desire and means to detect fraud and waste and corruption and to deal with them than a government run organization.

When Congress uses Medicare or the VA for its health care and the healthcare of its families, then I will listen to what they have to say about reforming the system.  Right now, their attempts to reform the system have all been failures.

One of the problem with health care and the delivery of and payment for health care is that we have forced insurance to do what it was not designed to do.  Insurance was designed to spread risk and pay for unforseeable, catastrophic events.  Health Insurance should never have paid for “well baby care” or “annual checkups.”  These things are forseeable and are not catastrophic.  However, because of the entry of health insurance into paying for these services, the cost of delivering them has skyrocketed.  Every doctor in private practice has one or two (or more) full time employees whose sole job is to submit and track down insurance claims for every patient they see.  These employees have to be paid for and so the cost of the service goes up.

We should return to a form of catastrophic health insurance where anything over a relatively high limit in each year should be covered or where only certain diagnoses are covered. 

To cover the indigent, we should build and support community based clinics or contract with the various “doc in a box” organizations such as Care Now.  This should take the strain off of the county hospital emergency rooms and make the delivery of care cheaper.

YBIC,
Phil Snyder

Phil’s comments - with many of which I agree - are the kind that contribute to the discussion that needs to happen if we are to accomplish any real reforms. Sadly, proposals to pay doctors for consultations on advanced directives are being dropped because of all the talk about “death panels.” We put enormous resources into the care of patients during the final weeks of their lives, and many of those patients might have decided against such treatment, had they had the opportunity to discuss advanced directives with their doctors and their families. It is too difficult for unprepared family members to decide against costly procedures that have little chance of success.

While I have been in favor of single-payer systems, I do agree with Phil that competition can be good. That is one of the reasons that I think alternatives to insurance company plans - the government option or cooperatives - would be good.

I disagree with Phil about the covering of preventive measures like well-baby checkups. If there is to be any cost containment there need to be some incentives for preventive care. If coverage for such care is not provided, then I think other incentives, e.g., reduction in premiums, should be considered.

Phil Snyder - 25 August 2009 09:04 AM

Medicare is also run through with inefficiencies and with corruption and fraud.  A private insurance company has greater desire and means to detect fraud and waste and corruption and to deal with them than a government run organization.

 

Private insurance companies only have a desire to root out fraud, waste, and corruption when it is beneficial to their bottom line. Private insurance companies care not one iota about the patient or the care thereof. It is all about their profitability, period.

You are quite right about Medicare being inefficient, and you are right about Medicare having issues with corruption and fraud, but lets not think for a moment that the answer to the healthcare dilema can be found completely within the “free market/private sector” solution.

IMO, the solution to the healthcare issue is going to have to come about via a complete reformation of the system as we know it, and the emergance of a “hybrid” system of private insurance, governmental programs, and stringent regulations.

FWIW, I agree with your idea about “catastrophic insurance” and “community based clinics”. I agree with the author of this article when he writes about “faithful people standing in opposition to Obama’s plan”; what I cannot agree upon is his blurring the lines between ill health being “the will of God” and role we have as people of faith in reforming our healthcare system.

The “profit” motive can be very strong.  In today’s society, most companies will see that bad press (denying care for someone because it costs too much) is bad for profits.  Insurance companies can face lawsuits for not following their own rules or the contracts.  The government can only be sued when it allows itself to be sued.

My own company is self insured and we pay a third party to administer our health care plan.  I know a person who had stage 4 lymphoma and our CEO personally directed the insurance company to pay for whatever the cost was.  But not everyone has the luxury of a self-funded plan. 

Remember, that employeer offered health insurance is, itself, a product of government regulation.  It came about as a result of the Wage and Price controls that started in WWII and were reintroducted in the 70s to stop inflation.  Since companies could not offer higher wages to attract talent, they offered “perqs” like health insurance.  This “emergency” measure to stop higher wages from turning into higher costs and to stop feeding the illusionary “wage and price sprial” became the standard way to provide health insurance.  It seems that government caused the problem to begin with and now is offering yet another solution that will probably make it worse.

There should be incentives to well person care, but covering every single procedure such that there is only a small copay is not the best way to do it. I like the idea of lower premiums if you meet a set of well person care guidelines.

As far a competition between government and the private sector, that never works out too well.  Government has a lot of coercive resources at its disposal to force the competition (private industry) into bankruptcy.  Only when congress and the government are required to follow their own rules and regulations will government run health insurance even have a chance of being fair.

YBIC,
Phil Snyder

Phil Snyder - 25 August 2009 10:51 AM

As far a competition between government and the private sector, that never works out too well.  Government has a lot of coercive resources at its disposal to force the competition (private industry) into bankruptcy.  Only when congress and the government are required to follow their own rules and regulations will government run health insurance even have a chance of being fair.

The President has mentioned UPS and Fedex as examples of companies that have done well competing with the Post Office. I am not aware of any attempts to force them into bankruptcy, nor of any history of the government trying to do that with other companies.

Would you want to use a healthcare process that has the same reputation for service as the USPS?  Are you aware that it is illegal for UPS or FedEx to deliver to the mail box?  It is also illegal for them to deliver first class mail.  The USPS consistently loses money every year - it is not a “revenue neutral” organization and has little incentive to become more efficient (doing things the best way) or more effective (doing the right things).

If we are going to have some competition, then we need to be sure that the same regulations and reporting requirements etc. apply to the government option as to the private sector option. 

YBIC,
Phil Snyder

It is illegal to put anything other than USPS mail in a mailbox and has, I believe, been so for far longer than UPS and Fedex. First class mail is, by definition, a USPS service. Fedex and UPS have become quite good at delivering letters. In spite of its ineffiencies, USPS continues to be a convenient way to send letters and, at times, a less expensive way to send other things. Will a government option fill a need in the healthcare field? I don’t know, but there are gaps that the market hasn’t filled and that is costing all of us money as the uninsured get costly and often free care in ERs.

There are several questions we need to address, but first I would like to split Health Care into three basic categories

1.  Catestrophic care - This is care that is unplanned for and very expensive.  This includes big things like strokes, heart attacks, and cancer.  It also includes accidents (such as falls) and other unplanned for things that can have a huge impact on a person’s financial well being. 

2.  Chronic care - this is care for people with chronic conditions such as diabetes, arthritis, asthma, and mental/emotional disorders that require expensive medicine. 

3.  Primary care - this is “normal” doctor stuff - such as annual physicals, doctor visits when sick (flu or colds or other things), sever acne, etc.

Now, the first is what insurance was designed to cover.

The second is also what insurance was designed to cover, but this is where pre-existing conditions come in to play.  New pre-existing condition coverage is kind of like getting into an automobile accident without insurance and then purchasing a policy and asking your new insurance company to cover the accident you just had.  I believe that we, as a people, should do something to help with chronic care.

The third is one of the reasons that health care is so expensive.  First we expect insurance to cover significantly more that it was designed to cover.  I believe this kind of care should be covered by the individual - with some form of community clinic to help the indigent.  There could even be some form of shuttle bus to take people from the ER to the nearest community care clinic.

The question then become how best should we, as a people, provider for coverage for 1 and 2 - especially for those who cannot afford them.

I submit that the federal government (or government in general) has not incentive to combat fraud, waste, and abuse.  Indeed, there is almost a dis-incentive to combat them because the larger a program’s budget is, the more prestige the government employee(s) in charge of it has.  My father was an Air Force officer and he remembers being urged to spend all the money allocated to him (and a bit more) so that next year, the budget would be increased.  If he spent less than was allocated, the budget would be decreased.  This is how bureaucrats think.

So, I recommend that we provide vouchers to private insurance companies for type 1 and 2 care and let the person choose who will best serve their insurance needs and allow them to purchase additional insurance at additional cost.  The insurance companies who provide the insurance would meet strong regulatory oversight regarding their decisions.  The people would have legal recourse against the insurance company and we would not have federal bureaucrats makeing health care decisions.

What do you all think?

YBIC,
Phil Snyder

(tounge in cheek)

One of the largest costs of health care is care provided towards the end of life.  Heroic measures and operations to stop internal bleeding etc. all cost a great deal.  I’ve read that something like 20% of a person’s lifetime cost of care is spent in the last two weeks of life.

So, what is the solution?

Kill everyone two weeks early!

(/tounge in cheek)

That last was added as “black humor” and not intended as a real solution.  We do need to, as persons and as a society, determine how best to solve end of life care issues.  Hospice has gone a long way towards this problem.  Paliative care has been a real partner in that process.  But do we want to ever get to a point where we claim that people have a duty to just shut up and die?  Should we ever give the impression that a person should refuse treatment just because it cost more than the person dying and we don’t think that you will live long enough to repay the investment?  Part of our Christian witness should be the care of those least able to care for themselves.  Our society has ceased to see people as persons, but it sees them as functions and when you have little or no functional part to play in our society, we deem you unworthy of society’s protection.  Today, we see society encouraging or refusing to discourage mothers from killing their unborn children.  Do we ever want to see society encouraging or not discouraging children from killing their elderly parents?

YBIC,
Phil Snyder

Do we ever want to see society encouraging or not discouraging children from killing their elderly parents?

No, but I do want to see parents and their adult children talking about advance directives. I have seen situations in which a person’s desire not to be reusciated was not honored, sometimes because it was not expressed clearly enough, but often because a son or daughter overruled the dying parent. It is, I think, far more likely that children will approve heroic measures than that they will allow them to be discontinued. The question is not about killing elderly parents but about encouraging thoughtful consideration of advance directives.

I am also in favor of advanced directives and not using heroic measures when the quality of life will be almost non-existent.

I am reminded of when my younger brother died.  Paul was about 25 years old and had suffered for Lupus (SLE) for the majority of that time.  He had had surger a couple of days before and was not conscious when I got the call that he was going to die.  Even when unconscious, he bit through the bite-blocks.  My sister, father, and I asked about removing life support because Paul wouldn’t have much life to live anyway.  The doctor said (and very wisely I might add) that Paul was going to die soon anyway.  Removing the life support would result in some guilt on our parts (apart from the normal guilt at the loss of a loved one) and he would rather spare us that.

There also has to be a very strong line between withdrawl of care and active measures.  The first is letting nature take its course.  It is natural death.  The second is causing death.  The first is moral and can be a positive good.  The second is always always sinful and objectively evil.  Note, I am not talking about death as a side effect, (e.g. death is the result of enough pain medication to relieve suffering), but of purposely giving an overdose of medication so as to cause death.

Advanced directives are good and moral and should be a decision between the person, the family, and the doctors.

But I still don’t want to see them required or forced on anyone or a default position that if you don’t have one, we assume you want to have the plug pulled.  I also don’t want the deciding factor to be monetary.  “Well, mom, we just can’t afford treatment anymore, so we’re going to pull the plug.”  While that may be a true and valid statement, it can often morph into “Well, mom, we find the cost of treatment too high or too inconvenient, so we’re going to pull the plug.”  Deciding to let a person die or to cause a person’s death because the cost (monetary or personal) is too high for you is sinful.

Issues surrounding death and life and end of life are very touchy - especially when you bring money into the equation.

YBIC,
Phil Snyder

I have seen situations in which a person’s desire not to be reusciated was not honored, sometimes because it was not expressed clearly enough, but often because a son or daughter overruled the dying parent. It is, I think, far more likely that children will approve heroic measures than that they will allow them to be discontinued.

This is also a reaction to the litigous nature of our society.  If it comes down to spending someone else’s money (Medicare’s, and insurance company’s, or another person’s) or putting up with the hassle of a lawsuit, guess which way most people (let alone most doctors) are going to go.  Even if the lawsuit is without merit, the doctor (or more likely the doctor’s insurance company) will still have to pay to defend himself and, thus, his insurance premiums will go up. 

Now, if we had some tort reform so that the judge (or a jury) could find that there is no basis for the lawsuit and that the plaintif should pay for the defendant’s legal expenses plus a fine (the fine to go to the state) and plus a reasonable fee for professional time wasted (time in court and time preparing for a trial is time that a doctor cannot be seeing patients) then that would go a long way to solving the kind of problem you cite.

YBIC,
Phil Snyder

Phil, I believe it is absolutely critical for any health care strategy—whether public or private, single- or multi-payer—to offer *strong* incentives for preventative care.  I’m a manager in the benefits department of a large retail company and our medical plan, spartan as it is, provides all employees with completely free checkups each year as well as mammograms, prostate screenings, etc.

It’s easy to see why. It’s much, much more cost effective to pay for 1,000 mammograms than to pay for 2 cases of advanced breast cancer. Not only do we save money on health claims, but also on reduced Short Term Disability claims, leaves of absence, etc.

In fact we recently began providing free maintenance drugs for chronic conditions such as high blood pressure and diabetes. Why? Because, financially, it’s cheaper to pay for the drugs (and make sure people take them) then to have employees face a catastrophic illness because the maintenance drugs were too expensive for them.

We also build in wellness incentives: employees get a break on their premiums if they do things like take a Health Risk Assessment and talk to a disease management professional regularly; or if they stop smoking, or join Weight Watchers, or join (and use) a health club.

My point it that stong incentives for healthy living and preventative medicine are a critical component of any health plan; not only because they are good for the enrollees but because they save money for everyone.

This is an interesting discussion.  I grew up and spent my first 30 years in Canada under the Canadian medical system, and my last 12 years in the US under the American system.  This experience has led me to have mixed views on the health care situation.  I am inclined towards universal coverage but believe that private management is critical.  There are also a number of serious moral and ethical issues with government run health care (i.e. paying for abortions), and other moral and ethical issues (i.e. should government pay for elective operations).

A few basic thoughts on comparison.  It is much easier to go to the doctor in Canada - you just have to go and show your health card (sort of like an ATM card).  It took me quite a long time to adjust to the US system of so much paperwork and rigamarole just to get medical care.  There are also definite differences in flavor between the two systems.  Let me provide some personal or family examples.  When I was a student down in the U.S., I had primary medical coverage in Canada and emergency coverage in the US.  Once I developed tendinitis in my shoulder and went to a US medical clinic.  I had X-rays taken and I was told that I would most definitely require surgery and that I would need to see my doctor in Canada as soon as practicable.  So I was back up in Canada a few weeks later and I went to my doctor.  She asked if my shoulder still hurt and I said “no, not now”, to which she said “well, then there’s no need for surgery.”  And that shoulder has never bothered me since.  Another story concerns my brother who needed heart surgery (in Canada).  He was on a wait list and his health was in danger but he kept getting bounced and bounced down the schedule till my father finally contacted the government health ministry and his local MLA (elected representative) and my brother was immediately scheduled.  In the US, I think that these sort of procedures are done in a much more timely fashion.  But in the US there seems to be a lot of money wasted on needless tests and operations done to avoid litigation.

Phil - thanks for your post setting out the division into types of care: 1. Catastrophic care;  2. Chronic care; and 3. Primary care, though I would suggest to you that Primary care is also a proper subject of a health insurance plan, just as dental care is.  Furthermore, in light of Scott’s post, much of preventative care will come under Primary care.  We might add a fourth category of elective care for non-medically necessary procedures.  So I think that we need to look at three different types of insurance for these three kinds of care that Phil mentioned, and another way to deal with “elective” procedures.  Certainly standard insurance type programs covering everyone (whether via Phil’s suggestions or other) for catastrophic care; a different coverage for ongoing chronic care; and a mix of low-cost clinics and/or dental-like insurance programs for primary care.

One issue that perhaps needs to be aired is how to deal with individual behaviors and choices that lead to higher medical costs.  I read something recently that obesity accounts for a very large proportion of health care costs as it is a leading cause for many diseases.  How to account for that?  Do we add sin taxes to fattening foods?  Or simply follow Scott’s suggestion of encouraging preventative care and healthy decision making?