Reply to Bishop X: Health Care Manifesto

By critiquing Bishop X’s views on health care and social justice, I intend first to clarify my many points of agreement; and only then to make practical and pointed distinctions which may be worth arguing.  I’m taking him at his word: he wants to stimulate a vigorous debate among citizens, religious leaders, and political leaders of our state.  And we share the same goal: to get more bang from the buck from our health care dollars, and to make Americans as healthy as they are willing to be.

On the following points I am in complete agreement with the bishop:

1. In a country which spends upwards of $4,000 per citizen on health care each year, it is shameful that any citizen should not have a personal health insurance policy which affords access to preventive care, and frees him from the fear of ruinous medical expenses.
2. Men and women of all colors, all nationalities, all ethnic groups, all levels of education, and all levels of material wealth are precious in God’s sight, and valuable, at least potentially, to one another.  Some people, of course, do not come close to their potential.
3. Many problems in America can be traced to social isolation and our loss of of community.  “...the poor are no longer the neighbors, co-workers, or friends of middle-class persons.  Instead they have become ‘those people’ about whom I don’t care.’” This is true, and a result of the demise of the small town and the neighborhood.  Ironically, that in turn is a result of anti-discrimination laws and prosperity.  The inner-city African-American community suffers desperately from a lack of black role models, because the role models moved to the suburbs.  While this effect may be regrettable, I’m sure the bishop is not advocating forced relocation.
4. Community support systems need to provide alternatives to institutional care for the aged, the terminally and mentally ill, and other persons with special needs.
   I believe that promoting principles 2 and 3, and achieving goals 1 and 4, would solve 95% of the health care problems in America which are within the power of institutional authority.
   On the following points I am in partial agreement with the bishop:
5. “Many illnesses are preventable if we accept the fact that health maintenance requires understanding of the unity of the human body, mind, and spirit.  The whole person needs proper nutrition, exercise, the challenge to learn and grow, and an acknowledgement that this is a lifelong process.”  While I agree with his general sentiment, health maintenance results from a coupling of an understanding mind and a well-exercised will.  If I could dispense will in a pill, most of my patients could maintain their health.
6. “All human beings deserve the best we can give them.”  I will reserve my comments on deserve, which is an issue of justice, for later.  It is certainly true that I owe every patient my best effort on their behalf.  But all human beings is far too broad a claim in a finite world; we Kansans do not owe Tanzanians quadruple bypass surgery, and I’m not at all sure that we owe 82-year-old Kansans quadruple bypass surgery.
7. “We no longer look at the less fortunate and think ‘There but for the grace of God go I.’”  If the bishop were a Calvinist, believing that even our will to do good is wholly dependant on the grace of God, he might have a complaint.  But Methodists as a matter of theology, and all men as a matter of practical living, feel that the exercise of free will is fundamental to the dignity of the human condition; and if will is free, it is free to be abused.  The society I observe is exquisitely sensitive to the needs of the handicapped or disabled of all sorts and conditions.  Paul Krugman is right that our society thinks “Why should I be taxed to support those people?”  But by “those people,” we mean people who willfully neglect or abuse their bodies, not a kid with Down’s syndrome or a Vietnam vet with post traumatic stress disorder.
8. “The cost of health care to our state is a train wreck waiting to happen.”  Health care is expensive, and our present system is wasteful.  If the bishop thinks that costs must be contained-- and this is not clear from his speech-- then we must acknowledge that more immunizations for poor children means less rounds of chemotherapy to buy another three months of existence at the margins of life.  Either we must argue, as Christians, that health care spending trumps all other priorities, including education, housing, transportation, and public safety; or we must accept, as Christians, that rationing of health care is inevitable.  If the latter, there is a big devil in those details.
9. “All children of Kansas must receive adequate nourishment if we expect them to function well in school and in society.”  Good nourishment is extremely important, but I do not believe it is essential.  Here’s the problem.  My wife volunteered to serve breakfast for six years at an inner-city school, before she started her non-voluntary teaching schedule.  The children were offered good food, but they usually tossed it and ate the junk.  They obviously ate junk at home, too.  Bill Self says freshman guard Sherron Collins, a MacDonald’s All-American in high school, ate nothing but junk food his whole life until he arrived at KU.  It didn’t stunt his development.  Now as Christians, what would the bishop have us do?  Make them eat their oranges?  On pain of what?  Spiritual-sounding, feel-good goals often run smack into the wall of personal freedom.  Personally, I’m not going to wring my Methodist hands about problems like poor food choices.  I’ll reserve hand-wringing for starvation, which is exceedingly rare in America.  I have seen one starving child in my entire medical career.  He was suffering from kwashiorkor, or protein-calorie malnutrition.  His parents were well-to-do but dumb vegetarians who didn’t make sure the kid got all the essential amino acids.
10. “Professional health care personnel should be recruited and appropriately educated to meet the health care needs of all persons.”  It is universally acknowledged that the primary misallocation of health resources in Kansas and America is an overrepresentation of specialists at the expense of generalists.  Efficient health care systems worldwide are built on a broad base of primary care, which the American Medicare payment commission--dominated by specialists-- systematically subverts.  What kind of nut would take on the toughest job in medicine-- that of the general internist-- when he or she can make twice as much money doing two simple procedures and treating six diagnoses as a gastroenterologist?  There is a real problem here, but it is not that women and minorities are underrepresented.  Three-fourths of medical school applicants claim that they want to be family physicians, but after four years of medical school, who wants to make half as much money while being liable for missing one of three thousand diseases which you are responsible to recognize?
    On the following point the bishop is hopelessly confused, but he has a lot of company:
11. “Social justice,” as espoused but never defined by Christians, is a biblical and philosophical myth.  If the bishop believes the “whole Bible,” and reads it carefully from front to back with an contextual eye for Justice, this is what he will find: We should always pay our debts.  We may offer a bribe, if we live in a society not ruled by law, but we should never accept one.  We must respect the property rights of others.  If we serve as judge or jury, we should be impartial; neither the rich nor the poor should get special consideration.  We must not oppress others, by using our position of power to coerce them to make contracts not of their free will or in their best interests.  We must provide the necessities of life for widows and orphans, representative of a broader class who through no fault of their own are unable to provide for themselves.  And for all the poor, we owe the opportunity to earn their keep with dignity, even if it is the modern equivalent to gleaning after the harvest.
    
    “Social justice” does not imply equality of result.  It does not imply that our stomachs will not growl, or St. Paul would not have commanded, “If a man will not work, neither shall he eat.”  It does not mean that the chronic alcoholic outranks the kid with congenital biliary cirrhosis on the liver transplant list.  Just because everybody does not have a high-definition television set, or a bedroom for every sibling, does not make our society unjust.  Justice means getting what you deserve, not what you want.  It means getting what you are owed, not what you think you have a right to.
     
    Understanding biblical justice involves understanding the distinction between the deserving and the undeserving.  According to the biblical understanding of justice, in both the Old and New Testaments, when we suffer because of our bad choices it is a good thing.  I know that because I believe the whole Bible, and the Pentateuch and Proverbs preach that lesson from start to finish.  It is part of God’s loving discipline, and as the writer of Hebrews reminds us, it is always painful.  The deserving poor, who suffer through no fault of their own, have a claim to our help as a matter of justice; they have have a right to it.  The undeserving poor have no such right.  How this confusion came about is a long story, and it is of little importance here, because there is another biblical law which gets us to the same place without trying to manipulate us through false guilt.  (A pastor with the unlikely name of Rousas Rushdooney once wrote a book which I never read with a title which says it all: The Politics of Guilt and Pity).
    
    Micah exhorts us to do justly and love mercy.  Justice is a matter of right, and it can be commanded.  Mercy is a matter of the heart.  To love mercy is to want to follow Christ’s example by doing good to the undeserving, as He did to us.  Mercy cannot be commanded; in fact, commanding mercy may harden the heart, by inviting scorn, cynicism, or ridicule of sentiments which are patently false or manipulative.  What my patients need from me is a heart of mercy, which brings us back to the subject of health care policy.  A lot of them are knuckleheads.  They abuse their bodies regularly and willfully.  It’s not a matter of ignorance.  They know better, and they admit it.  Well-intentioned outsiders like the bishop talk as if education were the answer.  Doctors know better.  It is not the fault of physicians or legislators that 20% of mothers giving birth in Kansas do not receive prenatal care, just as it is not the fault of teachers that 30% of adolescents do not graduate from high school, and it is not the fault of pastors that 50% of marriages end in divorce.  There is, in fact, such a thing as sin.  And what the undeserving sick require is mercy, manifested by love, and patience, and seventy times seven opportunities to start making the right personal choices. 
    
    I’m going to get back to this point as it relates to health care policy, but first I need to shed some light on a critical issue which is almost always ignored in discussions such as this.
    
    
12. The bishop appears to understand that choices must be made, that priorities must be debated, when it comes to health care expenditures.  I deduce that from his repeated use of terms like “basic” (as opposed to “comprehensive”) when referring to societal obligations.  No one is advocating face lifts, orthodontia, or breast implants as a matter of right.  The problem is that many difficult choices confront us every day of the following type: If a drug like Plavix which costs $125 per month reduces the risk of stroke by an additional 3% over the protection provided by aspirin for 10 cents per month, should society be required to fork over the difference?  How about if an additional course of chemotherapy for multiple myeloma, at $20,000, offers an additional 5% chance of remission for a 78-year-old?  Should a 62-year-old smoker with severe emphysema, who continues to smoke despite continuous oxygen therapy at home, be offered her fifth intensive care stay for respiratory failure at $50,000?  Does society owe a 360 pound diabetic who lives for chocolate $400 of medicine for month to overcome her food choices?  When a family physician can treat adolescent acne at an appointment for a sports physical, should the mother be allowed to insist on a visit to a dermatologist?
    These are the choices which confront those who would reform our health care system.  Any discussion which does not begin with an answer to the following question is an exercise in pious posturing: who is going to choose, and what are the tools of the choosing?  There are four possibilities.
    1. The Government.  We can consider two ongoing experiments.  One is the military/VA system, which in my view makes fair and reasonable rationing decisions.  As a military physician I didn’t get everything I wanted for my patients, but we certainly took care of the high priorities.  Of course, this was a population accustomed to taking orders and sharing sacrifice.  The other example is Medicare, which is extremely popular with people not accustomed to taking orders because for its beneficiaries it is the cheapest, most comprehensive insurance program in the country.  It is also extraordinarily expensive, and the costs are borne by 27 year old single mothers trying to raise 2 kids on $31,000 per year, through the Medicare payroll tax, and cost-shifting from everyone with private insurance.  Hospitals can’t survive on what Medicare pays them.  Blue Cross makes up the difference.  Even so, Medicare will bankrupt the US Treasury long before Social Security.  A fundamental problem for the Medicare system is that the commission which decides payment levels is permanently dominated by procedural specialists; primary care physicians, including internists, pediatricians, psychiatrists, and to a certain extent OB/GYNs, are consistently outvoted.  This is why simple procedures like colonoscopies, which could safely be performed by technicians with a high school diploma, are reimbursed at princely rates, and primary care residencies go begging for money and applicants.
    2. Insurance Companies.  This is the system which gives us health care inflation at three times the rise of the consumer price index.  We have plenty of examples of greedy for-profit insurance companies, and these turn our ethical stomachs.  But even non-profit insurors cannot stand up to the insatiable demands of consumers in a free market.
    3. Physicians.  Back in the 1980s we had a noble experiment based on Health Maintenance Organizations.  The idea behind the HMO was this: give doctors the money which would be spent on health care, and make them ration it.  For several years primary care physicians like myself were given millions of health care dollars to manage.  If we did well, we earned salaries rivaling pathologists and anesthesiologists.  If we did poorly, we were going to have trouble making our rent.  I can tell you, this was a challenge for my deodorant, but it worked pretty well.  We brought health care inflation to a screeching halt, but it wasn’t a pleasant experience.  When I caught a neurosurgeon charging for bilateral carpal tunnel releases when he only did the left wrist, it was an ugly scene.  When I called a general surgeon because he charged for a comprehensive physical exam when, according to the patient, he was in the room only two minutes, he got pretty huffy.  But what doomed HMOs is that the system damaged the essential trust between physician and patient.  Every time I advised a patient that a consult or a procedure was unnecessary, I know what they were thinking: is he just trying to line his own pocket?  I hated that part of it, and so did patients, and when we junked it, inflation came roaring back.
    4. The Last Chance: Patients. If the demands of patients bankrupt systems based on rationing by government or insurers, and the fears of patients eliminate systems based on rationing by physicians, then perhaps we ought to consider a system where the rationing agent is the patient.  In this model, an insurer provides a high-deductible policy with low copays for preventive services, as well as a large cash stipend with the patient’s name on it.  If the stipend is not spent, it rolls over, tax-free, from year to year-- not like the cafeteria plans where we scramble to use up the money before October 1st because we will lose it.
       
       This weekend my wife will drive me to the airport, where I will board a $49 Southwest Airlines flight to Midway in Chicago.  For $52 I will rent a car one way to a distant suburb, where I will pick up a 2002 Grand Cherokee with 39,000 miles for $11,900.  It was the best deal on cars.com within 500 miles of Topeka.  And while I have lots of more important or more enjoyable things to do with my Saturday, it’s worth it to me.  And if my neighbor wants to drive to Aristocrat Motors in Shawnee Mission this Saturday to pick up his $89,000 Mercedes, that bothers me not at all.  After all-- it’s his money. 
       
       There are two equally effective ways to prevent colon cancer.  By one technique, you go on a rather restrictive diet for three days, fish three samples of stool out of a toilet and smear them on a card, and take them to your doctor.  There you will get a sigmoidoscopy, which is an uncomfortable procedure without anesthesia.  If the sigmoidoscopy is normal, and the blood slides are negative, you are done.  Otherwise, you will get a colonoscopy.  This costs, including the chance of a colonoscopy, around $600 per patient.  The other way is to just get a colonoscopy, which you will not even remember due to twilight anesthesia.  That costs $1500.  Which will you take?
       
       If the money is coming out of our pockets, some of us would fly to Chicago for the Jeep.  Others would drive to Shawnee Mission for the Mercedes.  But if somebody else is paying for it, almost everyone would drive home in a Mercedes, just like almost everyone asks for a colonoscopy.  We don’t shop for value in health care, because for 60 years we have been taught not to.  That is the fundamental scandal, and that is what must be addressed in health care policy.  Until Americans learn to treat medicine like any other scarce commodity, it will be undervalued and overutilized.
       
       When I tell a patient that he can save 85% on the cost of treatment for hyperlipidemia by cutting an 80mg tablet of Lipitor into four pieces and taking one piece twice a week, that patient thinks I’m a hero if he is paying cash.  If he is paying $30 for a three month supply, he thinks I’m some kind of nut.  I could give you a hundred primary care examples of this kind of irrationality.  This is the root of the problem, and the bishop doesn’t see it.
       
       But it’s more than money.  Because so many problems in health care are now self-inflicted wounds, I need every carrot and stick in my arsenal to push my patients to diet and exercise, rather than ask for a pill or a procedure.  They need to know that if they exercise stewardship over their bodies, they will feel better physically; they will be doing their duty, spiritually; they will profit, monetarily; and they will be contributing to the good of their community, socially.  I need to harness guilt, avarice, pride, and selfishness in the service of virtue.
       In order to do that, I need a health care system which puts self-interest back in the hands of the individual.  That will mean giving money, a lot of money, to the health savings accounts of the poor.  I don’t care how much it costs, because whatever it costs, it will be less that the present chaos.  Unlike many progressives, I believe that the poor are just as shrewd as the rest of us, and if given the incentive, they will exercise more good judgment and self-discipline than if they are taught that breakdown maintenance is an entitlement of “social justice.”
       
       In the final analysis, I think that most Americans will choose Jeeps over Mercedes, if they are given the incentive to do so.