Monday, October 28, 2013

Justice, Charity, Healthcare and the U.S. Constitution

Justice, Charity Healthcare and the U.S. Constitution

I promised my friend Danielle, that I would try to write something which I think is not being very clearly stated in the public dialogue around the politics of the Affordable Care Act (which should perhaps have been called National Health Care).  The Constitution of the United States is a very supple document;  a blue-print, establishing the way our government is supposed to run.  It has this nice balance between the Houses of Congress, and the Judiciary and the Administrative branches.  I am pretty rueful that most high schools no longer offer civics classes, or American government.  In my school years, it was mandatory that students begin to learn and try to understand their role in our government.  This became even more urgent to me, when we were going through the Watergate scandal and the impeachment of President Nixon, while I was in the Peace Corps.  It was inconceivable to the Paraguayans, and the strongest possible argument that we actually ARE a democracy, when we told them that none of us had voted for him, and almost all of us were opposed to our role in Viet Nam. They could hardly believe it would be possible to get a job for a government when you voted for the other party.
The United States Constitution starts out "We the people, in order to form a more perfect union" and goes on to list other vital parts of the functions of government, including "provide for the general welfare".
When conservatives say they uphold the Constitution, I think they are actually LYING-- in so far as they do not want to "provide for the general welfare" through the establishment of national health care. The idea of forming a "more perfect union" is that the society over time should be improved.  We the people want to have a seamless interaction as much as possible, in getting the most out of the social interactions as citizens.  We understand that some of what we want may take time, and needs to be worked toward.  When the Emancipation proclamation happened, President Lincoln knew that it was the most important legal thing that had happened to the country since the beginning of the nation, and that it had to be ratified to keep the country together, and for the nation to function.  They had to pound it out, in the blood, sweat and tears of the Civil War.
Lately we have had the evidence that the taxpayers had to bail out the banks, in the 2008 crash,  to the tune of something like 80 billion dollars, because that is how the whole banking world worked, and no one wanted to watch the financial ruin of the country and possibly the whole world.  We also have seen that companies like Walmart are paying their workers sub-standard wages, which force the workers to need food stamps and Medicaid--- effectively putting them into needing to be SUBSIDIZED by the taxpayers for the basic necessities of life.
The other thing that we know is that Social Security has been a great boon to the elders in our country.  Prior to Social Security, a few people had enough income saved up for their retirement years, but most people either died soon after retiring, or became dependent on their children-- needing them to earn the means of continuing to provide for the elders as they aged.  Many were living in penury.  The Bible speaks often of the duty of providing for the widows and the orphans.  The widows are the elder women, who were dependent for food, housing, healthcare-- and often were so self-effacing that they would die of anemia due to eating only tea and toast.  No sweet granny would want to take the food from the mouths of her grandchildren, and food scarcity persists in being one of the very difficult things for people in poverty.  As Americans have stayed healthy into their 70's and 80's, their needs for adequate food, medical care and housing have also expanded past the time of natural retirement.
When the ACA was proposed, the conservatives refused to let the idea of a Single Payer medical system even come to a vote.  The kind of system that Medicare is, which had an overhead of 2% administrative costs, is the most efficient and cost-effective--- FOR the taxpayers, who are THE PEOPLE, who are trying to form a more perfect union.  The insurance mega-business forced the Congress to keep them in the loop, instead of cutting them out.  Many insurance companies take 40, 50 or 60% profits from the dollars paid for the healthcare policies people buy.  The problem also was made worse because some of the cost was offset by businesses, on behalf of employees, for SOME of the employees, in SOME of the companies.
Health care costs rose for many reasons-- the aging of the population, the increase in effective and sophisticated medications which could save lives, more expensive healthcare in hospitals and nursing homes;  and ALSO, the increased administrative overhead-- which profits led many people to have good returns on investments in the healthcare sector of the stock market.
There were doctors and many people from many walks of life benefitting in each part of this system, and so it was difficult to tease out what the truth is, for the WHOLE society to see.
Still, many doctors believed and fought for the ACCESS to care--- because poor patients would not even come to see a doctor if they couldn't pay for the visit, or the medications.  Different states had different rules and variable strength of their Medicaid programs.  Also, about 40 years ago, in order to lower costs, the mental healthcare needs were SEPARATED from the total healthcare needs of patients, so most mentally ill people had NO care, as most of them were poor, due to their diseases;  and many doctors who would otherwise have treated these patients, could not afford to take care of them, in their dire poverty.
So to me, the answer had to come from that first sentence in the Constitution, that WE THE PEOPLE, in order to FORM A MORE PERFECT UNION, would endeavor to provide more reasonable healthcare to the WHOLE population.  As the ACA gained momentum, the insurance giants wanted to keep their power and money, so they gave a little, in order to gain a lot--- the law would force everyone to purchase insurance.  The doctors in every medical society and in every specialty tried to see how to help themselves stay solvent, and still be able to see the patients they needed to see, with rules which are medically sound.  In states where there are more progressive doctors, like California, and where systems like Kaiser Permanente had already built a program with "economies-of-scale" to help keep costs down, it was reasonable to use their data as the benchmarks for the new rules of engagement.  At least for the beginning, it would allow a predictable assessment of costs, and a way to tell people how to compare "apples-to-apples" in what they were being promised in the healthcare exchanges.  Finally there would be transparency,  and at least some real competition between the big insurers.
Now as we go forward, the smaller frictions are going to have to be ironed out, also depending for vitality  on that  urge to "form a more perfect union" and to "provide for the general welfare".  For the last 4 years, we have been waiting with baited breath for January 2014, hoping people will not die while waiting for the exchanges to open up, and hoping that families will not go into bankruptcy as someone becomes significantly ill.
 Those of us in gynecology and obstetrics were adamant that women's health be covered--- pregnancy and miscarriages, and pediatric care of premature babies can be super-expensive.  Family planning is expensive, as the pharmaceutical industry got HUGE concessions, which allow them to charge top dollar for things which should have been under "economies-of-scale" bargaining.
As we go forward, the new science of "Health Care Delivery"--- as defined by Paul Farmer MD and Jim Kim MD at Partners in Health and for the World Bank will help change the economics to make sense of the concepts of economies of scale.  I believe this will bring in a whole new era of cost-reduction, and that PUBLIC HEALTH will again be the queen of the sciences.  Our attempts during the past 20 years to get to this moment, looking at the future of healthcare FOR ALL, will seem like bumbling around in the wilderness, like the journey in the desert in the Book of Exodus.  
I rejoice, that of all the unfairness of the last 100 years, the failure to address the needs of patients for mental healthcare are finally about to be addressed: to  become part of their total healthcare.   We are not going to act like people are jigsaw puzzles, and only certain parts are worthy of our medical attention.
Physicians are also scrambling to avoid bankruptcy, as many of the older ways of practicing medicine are dying.  We are fearful and anxious.  But the doctor-patient relationships will come back, stronger than ever, when we actually ARE COVERING the WHOLE patient!   As a woman in medicine, I am glad to have lived long enough to see some of the changes which will help doctors to also be healthier and more sane, and to have healthier families.
I do believe we will have to hold onto our hopes and dreams, as the new system is tried, and as new problems, which will not have been anticipated,  need to be ironed out.  The whole thing is do-able, as long as WE THE PEOPLE, intend to FORM "a more perfect union".   The intentionality is paramount.  We cannot assume that people who are fighting for their own piece of the jigsaw puzzle actually SEE the whole picture.  So I believe it is a good idea to keep that sentence in mind.  It is a good idea to remind ourselves and each other, that NO other government in history has accomplished so much for its citizens, in such a short time.  We MUST continue to cooperate, in order to live up to the promise our founding fathers could barely begin to see.
The United States' Constitution gives us a mandate, and a framework.  We have work to do;  and the work we do will help us be a light to the nations.