Presidential Politics 2008: Health Care Proposals

With the election drawing near, I have decided to attempt to discuss the current Presidential election,restricting myself to the two candidates' healthcare proposals. Besides, as a working physician (16 hour days and the like), I don't have time to go into much else.

I had initially contemplated doing an objective detailed analysis of each of the proposals by Senator Obama and Senator McCain, and then providing my opinions and analysis of each one. However, while doing my research, I realized that I could not do objective justice to one of these proposals, as it violates the fundamental idea that healthcare is not a right. So I will not provide detailed analyses. I will present a brief summary of each plan.

Both candidates include in their plans the expected and now-standard political boilerplate of trying to save money through preventive healthcare and through the use of "health information technology". Preventive healthcare, with the notable exception of vaccinations, actually costs more in the long run, something that flies in the face of logic but which can be easily shown through economic modeling, something that exists in the medical literature as far back as at least 1991, when I first encountered it. Healthcare information technology, meaning for the most part what most laypeople would call electronic medical record systems, is another of those thought experiments in cost reduction which theoretically ought to work, but which has yet to be proved true in the real world, and then the theoretical savings accrue only to the payers (i.e., the insurance companies and the government), with all the costs devolving onto the providers (the doctors and hospitals). It is remarkable how much of the peripheral fluffy stuff around the centerpieces of these two men's plans are similar. But the centerpieces are where the real meat is.

The main part of the McCain plan centers on the idea of transferring the tax benefits of providing health insurance to workers from the employer to the employee. This would take the form of a refundable tax credit of $2500 for an individual and $5000 for a family. The employer costs of the health insurance would be passed on to the employee as a taxable benefit. Since the national average for a family plan in the USA is $12,000, this at first glance seems to not be in the employee's favor. But let's do the math. Assuming the employee is in the 25% marginal tax bracket, his added income tax for this $12,000 is $3000. The employee thus spends "$12,000" on his family plan, pays his $3000 extra income tax, but then he gets back a $5000 tax credit, thus netting him $2000 (extra take home pay) which he must save in a tax deferred Health Savings Account to be used to pay for healthcare expenses not covered by insurance. All the usual benefits of using the HSA system continue to apply -- tax deferred, interest accumulates, can be used later in life, and can be passed on to his heirs upon his death. If one does further math work, one will see that as employee income goes down into lower marginal tax rates, the amount of tax paid decreases and the amount left over for the HSA actually increases. The converse is also true; as salary increases, the amount left over for the HSA decreases. Thus lower paid employees actually benefit more under this plan.

The McCain plan also includes proposals to allow people to buy health insurance from companies not located in their home states (something not currently permitted) and to thus be able to shop for better rates, and to allow small businesses to form associations or cooperatives so that they can get better group rates for their employees. There are some other somewhat important proposals, but this is the most important part of his plan.

The Obama plan centers upon a mandate for all "large" (not defined on the candidate's website; how large is large?) employers to provide health insurance meeting specific government-determined benefit levels. Any employer not wishing to provide employees with insurance will be required to pay into (i.e., they get fined) what is called "the new public plan". The "new public plan" is never specifically described in the proposal on the website, but it is implied (very important to remember that this is implied) that this plan will in some way entail allowing such non-covered employees the ability to buy insurance from plans offered through the Federal Employee Benefits system, using the money from the pool of collected fines. "Small" employers (again not defined; how small is small?) would be provided specific tax incentives in the form of business tax credits equalling the cost of the insurance premiums to encourage them to provide their employees with coverage.

Have you ever wondered why there is a Medicare Part A (hospitalization) and a Medicare Part B (outpatient services) and a Medicare Part D (the accursed drug benefit), but there isn't a Medicare Part C? Wonder no more. There actually is a Medicare Part C, but it hasn't been activated yet. The government, at the instruction of legislation which I'll bet was passed by Democrats (and I'd even be willing to name the specific Democrat, but I won't until I can verify it), has assigned the name of Medicare Part C to that future system that will provide government healthcare to those people who are not eligible for coverage under Medicare Parts A, B, and D or Medicaid. It is the name assigned (well over ten or fifteen years ago) to that system they intend to create to plaster the gap between Medicaid and current Medicare, thus establishing a defacto single-payer government controlled system.

How much do you want to bet that Obama's "new public plan" is not a smorgasbord of insurance plan options but is actually the now-activated Medicare Part C?

Independent analysis by the Cato Institute, the Heritage Foundation, and others have concluded that the telling feature of the Obama plan is the fine that is to be levied. If it's set at a level such that the fine costs the same as the health insurance, there is no impetus for "change". If it's set too high, employers are encouraged to provide private insurance to their employees. And if it's set too low, employers are enticed to dump their employees into the "new public plan". If the "new public plan" is Medicare Part C, then this simply is a huge, poorly disguised back door into a single-payer government controlled healthcare system, something that has been the goal of the liberal left for many, many years. We know Senator Obama is the most liberal member of the Senate. Thus one can logically conclude that his healthcare reform proposal is nothing more than a way of achieving that goal.

In my opinion, this would then be the beginning of the long, inevitable, and irrevocable decline of the greatest healthcare system on Earth.

Now, the McCain plan isn't perfect. It has its fair share of defects and holes. For example, the system in the plan allowing states to work together, either in cooperatives or by copying the state system that seems to work best, in order to provide a back up system for people who can't get or can't afford insurance (e.g., the unemployed or unemployable) lacks guaranteed funding and seems not-well-thought out. Some critics complain that by taking the tax benefits away from the employers, they will lack incentive to provide the insurance and the number of uninsured will increase. But in my opinion, this criticism fails to consider that the employees are not going to take the loss of this benefit without something in return, likely higher wages, with which they can still buy insurance on the open market and still get the tax credit.

I believe that the most important thing that can be done to help reform the current healthcare financing problem we have in this country is to dissociate health insurance from employment. Right now, employees don't own their health insurance; their employers do. So who do you think the insurance companies are responsive to? The employers, who want reduced costs even at the price of fewer benefits, higher copays, or both. Dissociating insurance from employment, thus giving ownership of the insurance to the employees, will make the employees the proper client of the insurance companies, who will then have to be responsive to the needs and demands of the employees, not the employers. Not to mention the fact that if employees own their own policies, their insurance is ultimately portable from job to job with no gaps in coverage and no fear of the dreaded pre-existing conditions exclusions clause.

The McCain plan is the first small step toward separating health insurance from employment. for that reason alone, it gets my vote. The Obama plan is nothing more than a slide downward into mediocrity and rationing, and will lead to the end of any further innovation in the healthcare industry.

Blog Action Day - 10/15/08 - Poverty and Health -- Lack of Money May Not Be the Real Problem

Once again it is October 15, and Blog Action Day has rolled around for the second time. This year the issue for discussion is poverty. This blog, focusing on medical and scientific issues from a usually political point of view, doesn't exactly lend itself to this issue, but let's see what I can do.

Debility due to malnutrition.

That is the definition of poverty.

What's that you say? You think poverty has a different definition? Well, that's because you don't use my dictionary.

The medical definition of poverty is exactly that: debility due to malnutrition. Says so right in the medical dictionary. I can't blame you for thinking I've gone off my rocker (but do recall I am certifiable and could go postal on you at a moment's notice). The word poverty had a different meaning to me as well until about two minutes ago when I looked it up in the medical dictionary. The definition that first came to my mind was probably the same you thought of: the state or condition of having little or no money, goods, or means of support; condition of being poor; indigence. Believe it or not, the medical world is actually concerned about this more common definition, as poverty affects the health of our patients in many ways.

Researchers are also focusing on how poverty ('low socioeconomic status') influences health. From the Center for the Advancement of Health:

Socioeconomic status is one of the strongest predictors of health and longevity. It is not poverty or wealth alone that is the factor: researchers have found that at each step down the socioeconomic ladder, health is poorer on average and people die younger.

The most obvious way that this could happen is through less access to medical care. But this is apparently not the only reason:

The influence of socioeconomic status on personal health cannot be explained solely by access to good health care. Also playing significant roles are health behaviors (diet, exercise, smoking, abuse of alcohol and drugs) and stress associated with disparities in income, wealth, education, and occupation.

Further analysis uncovers more surprising findings. Lack of money isn't the real problem either:

When people think about socioeconomic status and health, they assume it's abject poverty, that there's a threshold at the poverty level, a point above which your needs are met and everything should flatten out. But that's not how it is.... Even at the upper socioeconomic levels, where everyone has good housing and adequate nutrition and their physiological needs are met, there is still a difference in health and well-being between those at the top and those just near the top, and there's a gradient that follows on down to the bottom of the economic ladder.

And it isn't just where you are right now. There is a cumulative effect of being economically disadvantaged that follows you throughout your life:

We've learned that the health of older individuals today shows the strong footprints of their economic histories from decades earlier. My colleagues and I asked how many times over the last 29 years they had been living at income levels below 200 percent of the poverty line, which used to be the standard cutoff for "disadvantaged" levels. Then we looked at their current health and found that the cumulative burden of economic disadvantage was visible in all of the outcomes.

It even begins before you are born:

We see the intrauterine transmission of social class as a biological phenomenon: children born with lower birth weights, less than optimal placental weight and head circumference have worse futures. These often represent the effects of prenatal malnutrition and poor medical care, stress and a whole variety of other things experienced by people who are poor. We think that what these studies are showing is the tracking of disadvantage through the uterus into birth outcomes and subsequent disease.

What causes this? Stress, or rather, a particular kind of stress:

There's this gnawing issue of social ordering, about being higher or lower in the social hierarchy, that affects health. You find it no matter what indicator you use, whether you use income, occupation, or education. We're studying this in animals, because animals on the low end of their hierarchy also display worse health than higher-ranked animals.

How does this work? It isn't clear. It may be through more than one mechanism:

One concept is what we call reactive responding. The lower you are in the socioeconomic hierarchy, the more you have to respond to stimuli that are immediate and emotion-driven and that don't give you much chance to plan your response. Often, the stimuli involve some kind of threat. So your immediate response is quite negative.
You develop negative expectations that may become self-fulfilling prophecies, which themselves create more physiological arousal. The system can become hyperactive and not turn off. Or, it may give up and not turn on at all, so you have almost no reaction to even serious threats. That also turns down the immune response and puts you at risk. We need to understand a lot more about the mechanisms involved.

But what does this do to the individual? Is this it -- or only one aspect of it?:

According to the article, the question Farah et al. set out to investigate is the extent of low socioeconomic status on neural structure.
She and her colleagues have investigated the issue by trying to tease out which aspects of poverty alter specific cognitive skills, such as memory, language, and the ability to delay gratification. The researchers studied a group of African-American children of low socioeconomic status, who had been tracked from birth through high-school graduation by Hallam Hurt, a pediatrician at Penn.
Over the years, Dr. Hurt's team had assessed the home environments of the children, monitoring how nurturing parents were, and how intellectually stimulating the homes were—for example, whether the children had access to books and visited museums.
Farah et al. reportedly found that cognitive skills were linked with particular features of the environment, such as how "intellectually stimulating" the home environment was.
To test why, the researchers did MRI scans of the children. They found that students raised in nurturing homes generally had bigger hippocampi, the portion of the brain associated with forming and retrieving memories. The discovery dovetails with previous research in rodents, which showed that rats raised in a stressful environment develop smaller hippocampi.

And even more troubling is this finding:

In recent years there's new literature that shows that it's not just how much money the people in a particular area have that predicts how healthy that population will be. It's also how fairly the income and wealth are distributed. In geographic areas with more egalitarian distribution of income there's better health, and that effect is actually independent of the average level of income or the relative poverty rates in the area.

Of course, all of this does not provide any solutions or cures for this problem. In fact, if health disparities follow a gradient up the socioeconomic spectrum from bottom to top as suggested above, it may not matter if we get rid of abject poverty (for lack of a better term). The only thing that will change is the types of problems we'll see along the raised-up spectrum. But at least this information points in some intriguing directions about how to help reduce suffering. And points out that, at least in regards to health, in poverty, a lack of money may not be the real problem.

I Couldn't Say It Any Better -- Listen Up, Obama

I couldn't say it any better, so I won't try. From National Review Online, Bill Whittle says:

… what is a right? How do we know? What’s the difference between the right to free speech — which is enshrined in the Constitution — versus the “right” to health care, which is not? Well, back in the day, we would simply say that a right has legal authority — it’s in the Constitution and therefore it’s a not just a right, it’s a birthright. So why shouldn’t we amend the Constitution to include the rights to health care, food, housing, education — all the rest? What’s the difference between the rights we have and the “rights” Obama wants to give us? Simply this: Constitutional rights protect us from things: intimidation, illegal search and seizure, self-incrimination, and so on. The revolutionary idea of our Founding Fathers was that people had a God-given right to live as they saw fit. Our constitutional rights protect us from the power of government.

He goes on to say:

But these new so-called “rights” are about the government — who the Founders saw as the enemy — giving us things: food, health care, education... And when we have a right to be given stuff that previously we had to work for, then there is no reason — none — to go and work for them. The goody bag has no bottom, except bankruptcy and ruin. Does that ring a little familiar these days? Because isn’t the danger here that if you’re offered something for nothing… you’ll take it?

And then he reaches the only logical conclusion:

Only it’s not something for nothing. “Free” health-care costs us something precious, and no less precious for being invisible. Because there’s a word for someone who has their food, housing and care provided for them… for people who owe their existence to someone else. And that word is “slaves.”

To that final statement I will add the following addendum:

When the people become enslaved by owing their existence to someone else, then that doubly enslaves those that must provide their serivces to the enslaved.

I refuse to be a slave, much less a slave to a slave.

Senator Obama, Hear This!

Just got through watching the second Presidential debate, and I couldn't believe that Tom Brokaw would point-blank ask whether the candidates thought that healthcare was a right or a responsibility.

Senator Obama said it was a right. Senator McCain said it was a responsibility.

Senator Obama, hear this: Healthcare Is Not a Right!!!!

Not that I needed the assistance, but my choice of who to vote for is now as clear as a CSF beertap.