Thursday, March 23, 2017

Republican Realty Check

Listening to really psychotic patients on the psych ward when I was a medical student, I knew enough to keep my mouth shut.  Typically, they had their own deeply held beliefs which brooked no dispute. What was the point of questioning whether there really was a vast conspiracy of extraterrestrials  who wished this particular person harm, who sent radio waves in his direction so they could read his mind, who conspired with the ward nurses and orderlies to keep him from claiming his rightful throne as the one, true king of France? 

That's what the Republican Party has been like these past eight years--mutually validating their own beliefs, detached from reality, but really, why bother arguing with them? 

Now, they have to actually get a real, live health care bill passed and reality has a way of being very stubborn.
People don't like the idea of buying a health insurance policy which covers nothing but a week in the intensive care unit. They want their diabetes care covered, the visits to their cardiologist.

Even Ross Douthat (Doubt that?) has become desperate enough to offer a plan of his own, which he bases on solid conservative principles, "a coherent vision" as he calls it:
1/ "Health insurance should be, like other forms of insurance, something that protects you against serious illnesses and pays unexpected bills but doesn't cover more every day expenses. People need catastrophic coverage, but otherwise they should spend their own money whenever possible."
2/ "Because that's the best way to bring normal market pressures to bear on health care services, driving down costs."
3/ "Without strangling medical innovation."

So here's what's wrong with this:  The short answer is Mr. Douthat has not the faintest idea what he's talking about. (He's been listening to that famous lady in the parking lot who told Donald Trump vaccines cause autism, or maybe Ted Cruz or Paul Ryan or really, any Republican.)

But here's the long answer, if you are interested.

Health insurance for less traumatic and the less dramatic things prevents the catastrophes from developing.  
Even non catastrophic things, medically speaking, can be financially catastrophic. Take a single case which springs to mind. A 24 year old piano teacher in Brooklyn, bicycles to give his lessons to his students. One day he hits a curb, falls of his bicycle and strikes his wrist on cement. He has only catastrophic insurance. He considers going to the ER for $800, with another $200 for the X Ray and another $200 for the ER physician. He is not sure this is what the bill for his care will be, because, well, how do you ever know what such a medical bill will actually be? But that's what he can get from Professor Google, which is not so easy when you are trying to type with one hand. That bill will be close to a month's income for him.  Even if the hospital allows him to pay it off over time, there might be interest and he has rent and food to consider. 

On the other hand, if he does not go to the ER, he might be able to get an appointment with an orthopedist, if he could get a referral from an internist, but he doesn't have an internist because he's only 24 and has no other medical problems. The orthopedist office visit might be cheaper,  but his wrist is now the size of a grapefruit and he's got to give piano lessons the next day. If he needs a cast, it would seem prudent to act sooner rather than later. 
The 800 pound gorilla in the room

That is just one of a thousand examples.  The middle age hypertensive man who doesn't feel bad because of his hypertension,  but the $120 bill at the internist's office for his visit and his lab and his medications is painful.  Mr. Ryan would tell him that's money well spent, better than the new smart phone, but that new smart phone might help him in his night job as an Uber driver. That smart phone is a tangible benefit; treating his hypertension is only an abstract good. On the other hand, his catastrophic insurance will cover his ICU care when he has a stroke from his untreated hypertension. 

Then there is that great Republican mantra: Let "normal market forces drive costs down."
 This simply does not, never has and never will pertain to medicine. 
Medicine is not driven by "normal market forces."  Decades ago, Senator Ted Kennedy was bothered by complaints from his constituents about long waiting times for new appointments with doctors and about high office visit costs. So he said, well now the reason all this is happening is supply and demand, classic normal  market forces. So he got a law passed doubling the size of medical school classes, and within a few years the supply of doctors did in fact increase, nation wide, but waiting times for new appointments in fact quadrupled and costs quintupled. 

For several reasons:  All those new doctors did not flood into communities, opening up offices with lots of space in their schedules. They became specialists and rather than competing with each other, doctors cooperated and they started referring Mr. Kennedy's constituents to each other and now the citizen had four appointments with specialists where he had only one before and he  spent four times the hours waiting in four new waiting rooms. Normal market forces: supply and demand. Simple minded people with simple solutions don't work in the macroeconomics of medical care.

And, oh, "medical innovation." What exactly does Mr. Doubt that have in mind? Does he mean new drugs? As if reducing the health insurance coverage of the average citizen will somehow stimulate the drug company to spend money on research for a new cancer cure or a new drug for diabetes?  Or is he talking about say, laparoscopic surgery? Now there is a medical innovation which is actually a revolution. 
Healthy people paying for sick people: Who woulda thunk? What a scandal!

How did that big innovation occur? Was it driven by market forces?  
No, actually, it was driven by curiosity. Gynecologists had been using laparoscopy for decades, pointing their scopes south, ward the ovaries and uterus,  and over a few beers they told their general surgeon colleagues they might want to point that instrument north, toward the gall bladder and some surgeons in private practice thought: why not?  
They got some CEO's at local community hospitals to invest $10,000 on new equipment, which for those hospitals was not much more than they were spending on coffee and sandwiches for the doctors' lounge and presto:  A whole new world of surgery blossomed. 
Not driven by big business. 
Not driven by government. 
Not driven by normal market forces or even abnormal market forces.
Not driven by academic university hospitals. 
Just a bunch of open minded, scientifically trained humble local surgeons, with the souls of engineers. 

Go figure.

Do Paul Ryan, Mitch McConnell, Louie Gohmert, Jim Jordan or any of the "Freedom Caucus" know any of this?

What do you think? 

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