Thursday, October 29, 2009

Politics, Parasites and a Proof-of-Principle

Now that Max Baucus and Senate Finance have finally pushed their bill out of committee, there are at least five legislatively viable approaches to healthcare reform floating around on the Hill. (Also see this, but quickly, it's all getting dated even as I write.) Given the current political picture, there’s every reason to believe that Congress will push through some sort of healthcare reform legislation, perhaps before the end of the year.

President Obama will sign it, and I’d like to think that he’ll be holding his nose when he does so. That’s because the bill he gets is almost certain to be at least 50% fecal matter by weight.

Oh, sure, there will be a lot of laudable stuff in the final bill. It will cover more people by making healthcare coverage more affordable, it will possibly put something remotely resembling a leash on the for-profit insurance companies, it will probably mandate EMR (which I consider to be a Good Thing) and, most importantly, it will demonstrate an incredibly important proof of principle: health care reform is actually possible.

Remember, a huge array of powerful actors were dead set against any reform at all, right from the git-go-- extremely well-monied and reactionary interests, people who don’t know the difference between a pneumonia and a blister, who would be perfectly happy to let you die in the street if it saved them a dollar on their taxes, the kind of folk who are generally in it for themselves and eat their young. The fact that anything even got out of committee, given the carefully staged town hall outbursts, gazillions spent on disinformation, and hysterical bullshit about "death panels," is something akin to a legislative miracle.

So yeah, the final bill will have a lot of reasonably tasty stuff in it. It will also be at least 50% shit. And what happens, exactly, when you mix tasty stuff with shit?

Still, I’m one of those guys who likes to think that the glass is only half full of shit, and there is a glimmer of hope that the complex, corrupt, mysterious and intensly Kabuki-like process of legislative reconciliation now underway will actually improve on the bills that have come out of committee.

I also play Mega Millions on a regular basis. (I won $3 this morning, woo-woo!).

But hey, there’s always next time (see Proof of Principle, above). And so, for next time, and for the Mega-Millions part of me who hopes against hope that something useful will come out this time, I humbly offer, in all its glorious simplicity, Sullydog’s Overriding Principle for Meaningful Health Care Reform.

Ready, Nancy? Harry? Barack? Olympia? I know you’re reading this.

Brace yourselves.

Here it comes.

Don't spend health care money on people who don't do health care.

That’s it. That’s all there is to it. And from a physician/patient perspective, it really makes a lot of sense. It’s really just a polite way of saying that parasites are very bad for you and must be exterminated without mercy. Huge segments of the health care economy are parasitical, sucking resources out of the system without giving a damn thing back, except increased costs, perverse incentives, and toxic administrative burdens. If a new health care system were to put even a few of these helminths out of business, that would be a prime indicator that something had been done right.

Just to be clear, I'm not talking about people who run hospitals and clinics, critical administrative and support personnel--although truly meaningful reform would reduce the need for administrative support. It takes a lot of people to do billing and wrangle with HMOs. No, I'm talking about the real bloodsuckers, the people who line their pockets with American healthcare dollars and don't actually do anything to promote or support patient care--people who, in fact, weaken the entire system and put our patients in jeopardy.

There are plenty of barnacles on the hull of US healthcare, but two groups deserve special attention. I don't think I'll get any argument from most people on the first genus of tapeworms that should be in our crosshairs: malpractice lawyers.

Now, from my tone, you might prematurely surmise that I'm hostile to all malpractice lawyers, or that I think the medical malpractice tort system is a bad thing in and of itself.

So, just to be sure there's no mistake, that nobody misconstrues what I'm saying here, let me just clarify by saying that you would be absolutely right. That's exactly what I'm saying.

This is a destructive, malignant, greed-based industry that has been capitalizing on human suffering and sucking the life out of our health care system for quite long enough. The entire enterprise deserves to leave skid marks on the bowl. Our medical malpractice tort system does notimprove the quality of care, does not justly redress errors, has been a principle driver of increased waste and costs, and has poisoned the art of clinical decision-making almost beyond recognition. Other, more rational, more effective, and more just alternatives are readily at hand to mete out justice and provide compensation and care for injured patients. These are not opinions, they are facts, and they constrain malpractice attorneys, as a class, with a direct and categorical moral duty to find a way to serve the public interest rather than harm it, as they are doing now. They can do this by evolving into homeothermic chordates and working on new methods for just and proportionate patient redress, or by devoting their skills to another branch of the justice system. Or they can remain in an evolutionary cul-de-sac, in which case we should force them to trade in their pin stripes and Porsches for a nice shelter and a soup kitchen. Either will do. If health care reform puts thousands of ambulance chasers (and malpractice insurers, and professional expert witnesses, and various and sundry other vermin) out of business, I will not shed one bitter tear. They're bloodsuckers. They deserve to be eradicated.

The second superfamily of parasites that needs to be exterminated make up that vast, vile and suffocating biofilm known as the Health Insurance Industry. It's time to don hazmat suits and go to work on these guys with a pair of pliers and a blowtorch.

A lot of sturm und drang has erupted over the now-moribund prospect of a Public Insurance Option, much of it having to do with such a public program's ability to insure more Americans at less cost by undercutting premium margins and exploiting unfair advantages (such as lower marketing costs) over for-profit insurance. Horrors! These “unfair advantages,” it is said, would gradually suck all the oxygen out of the insurance market, and ultimately put HMOs and other private health insurers out of business.

Really? Wow. When can we get started?

Let's review the physiology and life cycle of a typical member of the species insurances profitales parasiticus, shall we? This loathsome creature spawns in that celebrated, dog-eat-dog, Darwinian space known as the Market, which is a great ecosystem for predators and even for wary herbivores, but a really shitty environment for sick people. Once it has affixed to a host (also known as a policyholder), it will feed on premiums until the host sickens, is injured, or is weakened by lack of employment. At that time, the worm detaches and scurries away as fast as possible, to search for another victim while its decimated erstwhile host is consumed by the various scavengers and saprophytes of the Market (and the malpractice tort system—an excellent example of synergistic parasitism).

That's it. That's how this whole system works. For-profit insurers collect premiums from policyholders. That's their blood meal. If they can keep it in their belly, they get nice and fat and rich. And the only way they get to keep it is by limiting or, better yet, denying compensation when somebody gets sick. Think about that: they've already got your money. The fundamental incentives of the free market mandate that theykeep as much of it as possible. As private corporations, it is in fact their duty to their stockholders to keep as much of it as possible--no matter how sick you are.

There is just no getting around it: anybody who has private health insurance places their insurance company in an immediate fiduciary conflict of interest the minute they get sick or injured. That's because the duty to compensate the patient's care is at direct odds with the duty to maximize profits. And that's how we end up with a system like the one we have now--a system in which the insurance marketplace is supposed to provide coverage, but the overriding economic incentives of the insurance marketplace are to deny or limit care. It's perverse. It's immoral. It's evil.

Of course, if Congress cared whether something was perverse, immoral or evil, we'd be living in a different world. Instead, let's focus on the fact that this system doesn't work, that it leaves millions without access, and that it's also stupid and wasteful, because it means that billions of dollars a year are spent lining the pockets of an industry that doesn't actually provide health care--people who actually deny health care for a living.

It's so simple. Don't give healthcare money people to don't do healthcare. What's so hard about that?

Why do we put up with a system that’s dysfunctional and wasteful and immoral, just because it makes a lot of people insanely rich and powerful?

Oh. Yeah, right. Never mind, don't answer that. I'm off to buy another Mega-Millions ticket.

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