Monday, May 18, 2009


In light of President Obama’s efforts to reform health care in the United States, and given the fact that I’m teaching a graduate course on Health Care Policy this summer, I decided to dedicate the next four blogs to health care reform.

This initial installment will suggest that the conceptual framework underlying much of the health care reform debate is based on discourse that is overly-idealistic and incompatible with health care as it currently exists in the United States. I shall, therefore, propose an alternative model of discourse: Health Care Realism, or the Real Model. Although the Real Model has already begun to take root (whether we like it or not) the lingering remnants of the Ideal Model continue to cloud our thinking.

The long-prevailing Ideal Model is rooted in the ethereal belief that health care is a moral system rooted in the Judeo-Christian and Hippocratic virtue of “care.” Historically, this model implied on systemic paternalism, which has been long embedded in doctor-patient discourse. Paternalism generally posits a rights-based moral relationship between “fatherly” physicians and “childlike” patients. Within this ideology, physicians are represented as self-sacrificing, duty-bound moral agents dedicated to healing their patients. In other words, patients have an inviolable, “right” to health care and physicians have a corresponding “duty” to provide it.

One of the corollaries of many duty-based (or rights-based) moral arguments is the underlying assumption that moral imperatives always trump economic imperatives. In other words, if it’s the right thing to do, then we are morally required to do it, regardless of how much it costs. This web of discourse is usually anchored by the Judeo-Christian and Kantian belief human life is of infinite value and that the cost of preserving it is morally irrelevant. Once it is established that a patient “needs” medical treatment moral discourse ends and the cost of filling that need becomes morally irrelevant. Throughout most of the twentieth century, this complex equation based on interlocking rights and duties contributed to spiraling health care costs, as physicians liberally prescribed non-competitively priced products and services (owned by other providers) to their needy, price-insensitive patients. This meant more tests, more drugs, and more hospitalization and a feeding frenzy for providers.

As long as health care providers were able to earn a comfortable living by charging non-competitive prices to price-insensitive payers, and as long as patients were insulated from those prices, the Ideal Model appeared to be a “win-win” arrangement. The Ideal Model began to erode in the 1990s when government programs (Medicare and Medicaid) and quasi-private insurance companies (Blue Cross and Blue Shield) became increasingly price-sensitive. That’s when physicians were first saddled with the added responsibility of serving as duty-bound “gatekeepers.” So while patients expected paternalistic physicians to selflessly, provide health care; public and private payers expected them to reel in costs. This steadily eroded public trust in physicians and the gradual collapse of the Ideal Model.

Although many physicians and other health care professionals and institutions still attempt to live up to the Ideal Model, the real world always has a way of undermining all otherworldly ideologies. After all, in the real world, health care providers are just as “worldly” as the rest of us. They must earn a living to support themselves and their families. Most must pay back enormous college loans, malpractice insurance and other business expenses (not to mention local, state, and federal taxes!) They also have personal mortgages, car payments, and also hope to save a few bucks for their children’s college education. Health care institutions are equally worldly. Hospitals, research laboratories, and colleges and universities still have to pay their employees, stockholders, suppliers, insurance companies, and lawyers.

As health care reform unfolds over the next year, lingering remnants of the Ideal Model will continue to obfuscate health care discourse as Idealists focus debate on providing “universal access to high quality health care at a reasonable cost.” My next three blog entries will discuss access, quality, and cost from the standpoint of idealism and realism.

Friday, May 1, 2009

The Swine Flu Epidemic and Personal Liberty

As the Swine Flu Epidemic threatens to upend civilization as we know it, I thought it would be worthwhile to squeeze in one last blog before we all revert back to hunter-gatherer lifestyles. Although this specific strain of influenza originated in non-human species (swine and birds) we’re not supposed to call it “swine flu,” for fear of adversely affecting the pork industry. Fact: You cannot catch swine flu from bacon, sausage, or pork chops! Thank God! So let’s call it by its less-threatening name: “Type A H1N1 Influenza.” So what should we make of this impending epidemic and the various governmental responses? First of all, let’s face the unpleasant reality that human beings have been dying from “seasonal flu” since the Pleistocene era. According to the Centers for Disease Control about 36, 000 Americans die every year from seasonal influenza: mostly the very young, very old, and very unhealthy. If you trust the Food and Drug Administration’s oversight of clinical trials, there are anti-viral drugs currently on the market that moderate symptoms, and perhaps shorten its duration. There are also flu vaccines available. Unfortunately, it takes 6 months to manufacture these vaccines and therefore, every year the World Health Organization guesses which three strains might be presnt in any upcoming flu season in various regions. Last year, I had the flu shot, but caught a strain that was not covered by the immunization. So although modern science has developed vaccines and drugs may help you avoid getting the flu and perhaps lessen its symptoms, there is no cure for it. Viruses evolve much faster than clinical research. They also have an uncanny ability to survive on hard surfaces for over 24 hours. Despite these daunting limitations, governments, have the power to drastically reduce infection rates, and limit the number deaths. Of course worldwide, governments have already been actively working to limit the spread of the new strain of influenza. Egypt has ordered the extermination of its entire pig population (although there is no evidence of pig to human transmission). Many governments have banned public gatherings: closing down border-crossings, restaurants, mass transit, schools, sporting events, and air travel. Even Joe Biden’s family is avoiding all air travel. Indeed, modern governments are deeply committed to the reduction of all public health risks. And there are a lot of other risks out there as evidenced by the recent spike in apocalyptic warnings. Over the past few years, governments, scientists, and the mass media have issued a steady stream of urgent warnings predicting: terrorist attacks (especially on airlines), global warming, bird flu, SARS, global recession, and an endless series of food, drug, and toy recalls. So far, the human species has survived the onslaught! My question is this: “Is there a point where the social and economic costs wrought by public health initiatives outweigh benefits?” Governments certainly have the power to eliminate not only the impending flu epidemic, but all future “flu seasons.” Simply shut down schools, public transit, sporting events, shopping centers, restaurants etc. In short: let’s just stay home 4-5 months a year. Maybe that’s a bit extreme. When we leave the house let’s just wear rubber suits, gloves, and gas masks. Once we eliminate the threat of infectious diseases and save those 35,000 lives, then let’s address those other threats to human life. What about those notoriously dangerous automobiles? Solution: 25 MPH speed limits, body armor and helmets. Or, better yet, walk! Breast cancer: no smoking and mandatory mastectomies for all females at puberty. Heart disease: veggies, no meat, compulsory exercise. Libertarians do not doubt the fragility of human life and do not deny that many risks can be easily avoided. However, one of the most serious risks we humans face is the unbridled expansion of the powers of government in pursuit of an idealized vision of public health. If there is no objective threshold for public health initiative, and if we accept the moral principle that human life is of infinite value and that government has a moral obligation to protect human life at all costs, what would our risk-free lives be like? A long, risk-free life at home playing video games and watching old videos may not necessarily be a life that’s worth living.