Now that the New York Times is no longer hiding content behind its wall of silence, it is possible to get the current liberal line on issues directly from one of the sources. In the case of health care, Philip M. Boffey is the go-to person on the editorial board. In today's Times he introduces what is surely going to be a major Democratic talking point for the upcoming election season, ie, the Democrats are not proposing to socialize health care. The Democrats will benefit enormously if they can couch the debate over health care as a debate over access and insurance, which is a bit of a smokescreen, and to that end, the arguments as laid out by Boffey have a superficial plausibility that lends itself well to the kind of sound-bite campaigning that our current system seems to reward:
The Socialists Are Coming! The Socialists Are Coming!
The epithet of choice these days for Republicans who oppose any expansion of government’s role in health care programs is “socialized” medicine.
Rudy Giuliani has used the “s-word” to denounce legislation that would enlarge a children’s health insurance program and to besmirch Hillary Clinton’s health plan. Mitt Romney has added a xenophobic twist, calling the Clinton plan “European-style socialized medicine,” while ignoring its similarities to a much-touted health care reform he championed as governor of Massachusetts. Other conservative critics have wielded the “s-word” to deplore efforts to expand government health care programs or regulation over the private health care markets.
Our political discourse is so debased that the term is typically applied where it is least appropriate and never applied where it most fits the case.
The best part follows:
No one has the nerve to brand this country’s purest systems of “socialized medicine” — the military and veterans hospitals — for what they are. In both systems, care is not only paid for by the government but delivered in government facilities by doctors who are government employees. Even so, a parade of Washington’s political dignitaries, including President Bush, has turned to the National Naval Medical Center in Bethesda, Md., for checkups and treatment, without ideological complaint. Politicians who deplore government-run health care for average Americans are only too happy to use it themselves.
Nor are they eager to tar the vast array of government hospitals and clinics that serve our nation’s veterans. For one thing, the veterans’ hospitals, once considered a second-rate backwater, now lead their private sector competitors in adopting electronic medical records and score well for delivering high quality care at relatively low cost. Even when the veterans’ hospitals were rightly criticized this year for their part in the disgraceful failure to care adequately for soldiers injured in Iraq and Afghanistan, there was no clamor to junk or privatize the system, only demands to make it better.
Mayor Michael Bloomberg startled most New Yorkers two years ago when he asserted that the city’s public hospitals are “better than the great teaching hospitals” all around them. Although some deemed his praise hyperbolic, the city’s billionaire, entrepreneurial, free-market-enriched mayor thought he knew quality when he saw it, even if it was socialist at its core.
The country’s vast Medicare program is one step less socialized — a “single-payer” program in which the government pays for the care and sets reimbursement rates, but the actual care is delivered by private doctors and hospitals. When Medicare was launched in 1965 it was routinely denounced as socialized medicine, but it has become so popular that politicians deem it the third rail of American politics, sure to electrocute anyone who tries to cut it or privatize it. No politician is eager to brand 43 million beneficiaries as socialists at heart.
Readers of my Blog know that I agree with the formulation that health care can be:
• Universal
• Affordable
• High Quality
Pick 2 out of 3
Nothing in Boffey's article shows any recognition of the ongoing collision of wishes and reality that is the essential issue involved in the health care debate. And, sad to say, things are inevitably going to get worse before they get better. That is the nature of technology and especially, information technology. The cutting edge in medical science is incredibly complicated.
First, a digression:
Implicit in Boffey's article is the idea that the behavior of Physicians is somehow independent of the manner and nature of their compensation. In the National Naval Medical Center in Bethesda, the Doctors are members of the military and have made the calculation that their various forms of compensation (financial and otherwise) are adequate to maintain their participation. In the VA system, Doctors are salaried employees and make a similar calculation. Doctors who depend on patient's insurance and Medicare or Medicaid likewise have to make that calculation. As the cost of operating in such a system increases for the Physician (in lower compensation, higher expenses incurred in dealing with negotiating the arcane insurance reimbursement labyrinths, greater impediments from the bureaucracy that seems to exist primarily to impede the delivery of quality health care while creating ever more paperwork responsibilities for Doctors) those who can easily opt-out do so in increasing numbers, with more Doctors everyday deciding the deal they have made with society no longer makes sense. Generally, the most talented Doctors are among the first to find other approaches or areas of interest, whether renouncing any involvement with the insurance/Medicare/Medicaid systems, or leaving the field altogether. I haven't even touched on the "tax" that the liability lawyers have imposed on the Medical System, in terms of liability insurance and increased costs from all the marginal tests Doctors order as part of defensive medicine.
As far as the future stream of Doctors who will be needed to care for all these patients, allow another digression:
My daughter is in her second year of Medical School (costing somewhere north of $50,000 a year) and not only is the quantity of material to be ingested beyond reason but the quality (the complexity) of the information needed to be mastered is impossible for most lay people to comprehend. Furthermore, while Biology is clearly well on its way toward becoming primarily an information technology, with all the benefits that will accrue from the emerging Medical Moore's Law (doubling times for speed and power in combination with halving time for cost of computation) the cutting edge in information technology always entails a spike in costs. As Medical science gains the ability to work on fundamental molecular biology, there will be a high premium for the limited number of people with the requisite skills and intellect to be able to engage in the work. Although Medicine remains a noble profession with significant non-monetary rewards, when picking from a very small pool of very smart young people, the ability to attract the best and the brightest will certainly be related to the ability to reward them for their commitment and dedication. My daughter is interested in surgery as a career, especially reconstructive surgery, a part of Plastic Surgery. For her to become a Reconstructive Surgeon will require 4 years of Medical School (graduating with a debt of ~$200,000) followed by a 6 years Residency (which may require an extra year or two commitment to do research) and perhaps a year or two Fellowship. Once out of training she will spend several years doing rather unappealing basic Plastic Surgery (which includes surgical repair of bed sores in debilitated patients) in order to become established in her field. Since she is young for her class, that means she can expect to do the work she really wants to do by the time she is in her mid to late thirties, young for a Plastic Surgeon. If she wants a family (which she does) and wants to earn a comfortable living sometime in the near future, there are many better options available to bright young people today than Medicine. If Medicine becomes ever more unappealing, those whose interest in Medicine is less enthusiastic will find other ways to fulfill their wishes to engage in useful and productive work.
Most of my daughter's classmates are rather naive about economics. They also are quite idealistic and commensurately unrealistic. As such, they accept without question that everyone has a right to quality health care. And who would argue with that laudible desire? Their professors by and large focus on their medical education and most of them are full time Academic Physicians with minimal experience in the real world. As such these young men and women have no understanding of the world in which they will enter practice. As we have seen for the last 20 years (perhaps longer) there are only a limited number of ways to save money in the health care system. You can deny services, overtly by rationing or covertly via insurance rejections, or you can cut compensation, the preferred mode of cost cutting by government and private insurance companies. Since everyone knows that "all Doctors are rich", cutting compensation for rich people is always a popular idea. Plus, Doctors, with their own complicity, has been devalued significantly over the years. Who needs a Doctor when you can diagnose yourself, based on TV commercials, health food stores, the internet, and other quality sources of medical information. (There is a fine line between augmenting your knowledge with information from the internet and replacing your fallible, though well trained, Physician, with a fool for your Doctor.) Once these idealistic young Doctors discover that earning $100,000 does not allow you to live very well once you have subtracted your loan repayments and are trying to catch up with your friends who went to law school or for MBAs, their tolerance for all the parts of Medicine they weren't taught in school is likely to diminish rapidly.
As we make Medicine less and less appealing, we will see less and less of our best and brightest going into the field. This would be a tragedy at a time when Medical science is on the brink of discoveries and treatments that will revolutionize our understanding of ourselves and our health. We need these bright young people to work on bringing the best possible future of health crae to fruition.
I am sorry to say that most of the approaches to universal health care advocated by Republicans and Democrats (with the Democratic proposals being significantly worse) will lead to a diminishing supply of the best and brightest flowing into Medicine.
One more thing worth pointing out about Boffey's article, the exception that proves the point. He suggests that since our politicians flock to government run health care providers this somehow proves that such a system should work for all of us:
Even so, a parade of Washington’s political dignitaries, including President Bush, has turned to the National Naval Medical Center in Bethesda, Md., for checkups and treatment, without ideological complaint. Politicians who deplore government-run health care for average Americans are only too happy to use it themselves.
I can't tell if Boffey is merely a fool or an idiot. The Soviet Union, that epitome of paradisaical socialism right up until it collapsed of its inherent failures, boasted a health care system second to none for the apparatchiks who were able to access it. Cuba has a wonderful system of health care for people with the right connections, which includes only a tiny fraction of the population. Only an idiot would suggest this model would work for the entire country. Of course Politicians get state of the art care in Bethesda! Does that really surprise Boffey? Does he really not understand why that happens? We can either give health care to everyone, including the illegals some of the Democrats are so eager to treat, in which case everyone except the elite should expect to begin receiving substandard health care within the next 5-10 years or we can struggle to maintain a system which allows most Americans to get excellent to merely very good health care, with some people receiving less access than we would like. Eventually, even the elites will find themselves receiving substandard care, but no one will notice because it will be compared to a possible future of health care that will not exist.
We might have to amend the earlier formulation. We can have health care that is:
• Universal
• Affordable
• High Quality
• Entering a time when amazing and accelerating advances in health care, initially available to few but eventually to all, will be coming on-line.
Pick 3 out of 4.
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