May 09, 2016

Health Care is Not a System

The Merriam-Webster dictionary has many definitions for the term system, but the most straightforward, and arguably the most applicable to our health care conversation is “a regularly interacting or interdependent group of items forming a unified whole”. The common wisdom is that our health care system is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation. We usually work ourselves into a frenzy arguing how the government should go about fixing the system, but I would like to take a step back and question the assumption that health care is, or should be, a system. This is not about splitting the hairs of semantics. This is about proper definition of the problem we wish to solve.

You could argue that we use the term system loosely to refer to everything and there are no nefarious implications to calling health care a system. We have a transportation system, an education system, a legal system, a financial system, a water system, a political system and so forth. Note however that we rarely talk about our food system or auto system, fashion system, hospitality system, etc. We call those industries. Starting to see a difference here? Good. Our government obviously regulates both systems and industries, but it regulates them differently. And systems have distinct characteristics that industries seldom have, such as built-in (systemic) mechanisms for discrimination, and institutionalized (yep, systemic) corruption aplenty.

When we begin by assuming that health care is a system, we assume that health care should possess those same characteristics. We assume that health care in Beverly Hills will be, by design, different than health care in Flint, Michigan. We assume that health care delivered in private settings will be different than health care accessed in public settings. We assume that some areas will have sprawling, on demand health care hubs, while others will have none. We assume that public engagement in health care is for show only, while the billionaire class and its carefully constructed echo chamber get to make all our health care decisions. We assume that health care is, and always will be, rigged. And based on these assumptions, we proceed to fix our health care “system”.

You may be tempted to dismiss these thoughts as specious demagoguery, strawmen, soapbox arguments or just plain exaggerations. After all, health care system fixing includes such socially beneficent endeavors as expanding “coverage” for the poor (Medicaid expansion), subsidizing insurance for the less poor (Obamacare exchanges), granting insurance to the sick (preexisting conditions), and a steady drumbeat of accountability, measurement and reduction in “disparities” for “vulnerable populations”. To that I would respond by pointing you to several recent utterings from public figures empowered to effect health care reforms.

Medicaid for America

Let’s begin with the all-powerful Acting Administrator at the Centers for Medicare and Medicaid, Mr. Andrew Slavitt. The “acting” prefix is there, because for some reason, Mr. Slavitt is running the largest (taxpayer financed) health care insurance entity in the country without proper Congress confirmation. In a recent string of tweets, Mr. Slavitt refers to our “beloved modern Medicaid program” as “America’s healthplan”, proudly reminding us that Medicaid is 72 million strong (“Working people, families, majority white...”) and growing. I think it’s safe to assume that Mr. Slavitt himself is not receiving his medical care through "America’s healthplan", and neither does anybody he associates with.  It is also safe to assume that an accomplished executive like Mr. Slavitt, who is Harvard and Wharton educated, understands all too well that the size of Medicaid is inversely proportional to the prosperity of the American people. If the sheer notion of a senior political appointee in the Obama administration being ostentatiously proud to see working families forced to beg for public charity is not triggering a fire alarm in your head, then I don’t know what will.

One could argue that since Obamacare expanded Medicaid to people above official poverty levels, perhaps a bigger Medicaid does not necessarily imply more poor people, but a more generous society. One could make such argument, if federal poverty levels were a realistic measure of poverty, or if we didn’t have other sources of information. The grim reality is that even middle class Americans are now lacking the ability to purchase decent medical care, or insurance instruments for the same, and hence the Obamacare exchange subsidies for cheap insurance, which is marginally better than Medicaid in some ways, and substantially worse in other ways.

In another insightful tweet, Mr. Slavitt observes that “In exchanges, consumers vote with their feet and with their feet they say unaffordable care is a deal breaker”. Note how elegantly, inability to pay for nice things due to being destitute in general, is now framed as a preference, something you vote for with your feet. This is precisely how establishment henchmen convinced us that we vote with our feet when we shop at Walmart while decently paying jobs are being vacuumed from underneath our very same feet. Being poor and unable to afford eclectic amenities prized by the elites is a consumer preference, one very short step away from arguing that being on food stamps or sleeping under a bridge are merely choices some consumers make.

Health care in America is expensive. Expensive, though, is a relative term, and if America’s working class didn’t see its income consistently go down the 1% drain, perhaps health care would seem more affordable. But American health care is also expensive in absolute terms. Mostly it is expensive because each service and each item is priced higher than anywhere else in the world. Tackling the pricing problem is guaranteed to upset the masters of establishment henchmen, so they worked hard and found a couple of other alternatives to generate cheapness, just in case the voting with feet thingy blows up in their face (as it seems to be the case right now). The trick is to deflect scrutiny from real issues, and assign responsibility (blame) to doctors and the people in general.

The Return of the Broccoli

I’ve written compulsively about the apparent war on doctors in the past, and I am certain I will be writing more, but the war on people is a much more intricate subject. It’s relatively easy to separate a quarter of one percent of people from the herd, paint them as for-profit mass murderers and sic the hungry mobs on them. But then how do you subdue the mobs? For that, my friend, we have government. We have behavioral economics. We have the experts and pundits in that echo chamber. And we have the righteous souls who innocently light the fuse of every calamity.

I’m old enough to remember the debates preceding the Obamacare litigation in front of the Supreme Court, culminating with both Justice Scalia and Chief Justice Roberts pondering whether the government has it within its enumerated powers to make you buy broccoli. Before the broccoli debacle, the same libertarian lunatic fringe wondered if government can order Americans to lose weight, or if the government can mandate that we buy certain products from certain manufacturers. Of course Obamacare and its mandate to buy health insurance or be penalized by the IRS survived these outlandish challenges, and the IRS is doing its best to rake in those penalties. It must be doing a great job too, because it sounds like IRS services for mankind could be drastically expanded.

Steven Findlay is an expert health care policy journalist, with an illustrious record working for the Consumers Union, and one of the handpicked advisors who shaped the Meaningful Use program. Mr. Findlay recently commented on The Health Care Blog, making the following statement: “Hell, I’d support tax breaks for people who quit smoking and/or can document to the IRS that they exercise 3 times a week for an hour each time!” Hell, indeed! But if the IRS can collect penalties for failure to purchase insurance, and grant tax credits for buying Pella windows, why not offer tax breaks for making your body more productive and more efficient?

Was Mr. Findlay writing in jest? Perhaps, but note that Obamacare is already empowering health insurers and employers to offer “incentives” and “discounts” for a variety of wellness schemes, which are essentially paycheck penalties on sick and “non-compliant” people. And note also that these types of shell games are only effective if you are poor enough and forced to vote with your feet every time someone reaches for your empty wallet. I wonder if voting with your feet would be an IRS approved form of exercise…
This is the glorious power of systems. This is the power of a “regularly interacting or interdependent group of items forming a unified whole”. This is why health care must become a system where the “items” regularly interact in formulaic pathways. This is why free range actors randomly affecting the system cannot be tolerated by the centrally installed array of levers and signaling networks.

This is why independent medical practice must die, small hospitals must be euthanized, and managed population health must encompass the entire nation (minus the elite caretakers) down to the minutest detail. This is why each one of us must be systematically tagged, numbered and catalogued in the vast repositories of “precision medicine”. And this is precisely why health care must never be allowed to become a system.

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