Equality

As it is written, "He who gathered much had nothing left over, and he who gathered little had no lack."  2 Cor. 8:15

The Patient Protection and Affordability Act (aka ObamaCare) is one of the largest wealth redistribution acts of recent memory. In short, it seeks to achieve equal access to and equal benefits from the US Health System, for all US citizens. For those with access to the best and latest, we are finding it harder to get timely and convenient appointments, caregivers have less time to give us, rules are being imposed as to when or even if we can get the professional advice we seek, or scans and labs we think we deserve. And we're paying more. For those who live life near the poverty line, our benefits and choices may have expanded, but all amidst a growing concern the delivery system we've created cannot sustain. And the "Equality for all ideology" is being brokered through an ever expanding set of rules imposed by a growing Federal Bureaucracy. Lawmakers seek money and votes for any consideration of concession - while the burden these rules place on citizens and the delivery system slowly implode. The winner, US Government? The looser, US Citizens?

Inherent to any system that aspires to create equality is a sub-system of number counters who ultimately certify, through numbers, if the system is fulfilling the equality objective. And mathematicians even back to Archimedes, in his essay The Sand Reckoner, realized the limits to counting was a function of the size of the universe defined, the then known size of 10 to the 63rd power. Years later another mathematician, Carl Gauss, introduced infinity, simply defined as not finite, and therefore not determinable by counting or measurement. To use math for all that we do, the certainty behind the numbers is within limits. Equality is therefore only achieved within limits. As we constantly adjust the math to new limits, it enables us to begin exploring the universe yet still find our return.

Ideology is a first cousin to theology, but without reference to God.  It is therefore not surprising the concept of equality as written from an ideological perspective has inherent limits when viewed through a theological lens. Let's examine: And Jesus answering said unto them, Render to Caesar the things that are Caesar's, and to God the things that are God's." Mark 12:17. Later, Paul says, "at this present time your abundance being a supply for their need, so that their abundance [the poor person] also may become a supply for your need, that there may be equality." 2 Cor 8:14. Isn't it interesting that the only direct reference in scripture to equality frames the poor and rich as equally needy of one another? In both passages, the focus is on our individual responsibility, poor or rich, set within the present time period (i.e. limit).

When US Citizens elect public policy officials and empower them to function as "equality watchdogs", society is ultimately weakened rather than strengthened. The focus and objective of government is to appease the greed of the electorate through limited, measured, and funded short-term successes.  We effectively take God off the table and render policy making a finite objective that future generations may suffer greatly from and seek to change.  Even more distressing, we redistribute wealth through an ever enlarging labyrinth of channels and the money barely ever benefits the poor.

As we enter another season of elections, remember the problem is we're inviting government policy to usurp individual responsibility and making all accountability to "Caesar". Caesar wins while the citizens hope Caesar will pass on and give man another chance to finally get it right. And the cycle repeats. The only real solution is for mankind to recognize their misdirection, to dismantle the size and scope of government itself, through reconnecting our ideology to our theology.  We each need to rely on the eternal hand of God to manage much of the accountability of man toward one another, through reliance on the infinite wisdom of Him. Without an understanding of equality in the context of infinity, we are left solutions where the wealthy and the poor are never brought together in this world to meet one another directly and for equality to take root. Rather, the public policy brokers take most of the wealth transfer and leave nothing for the poor or the wealthy to mutually benefit. Equality is not achieved and new limits must be set.

I'm confident we've lost our way and God is at work in the hearts and souls of His people.  Most caregivers I've known are answering a call in their own hearts and minds - doing with what they have and the ingenuity they can muster, knowing all will soon need care from others. The work of our policymakers annoy, distract, and demoralize, making others think twice about care-giving. All government policy, social or otherwise, enriches some while disenfranchising others. Let's kick off this election season with a new attitude.  Elect all new representatives who aspire to be humble but prayerful servants of the electorate, who praise and worship God, and who promise to dismantle policy based on it's harm with no promise to substitute new policy in it's place until they share how they've been impassioned by God?  Would this be cool or what?

Few Purchase High Risk Pool Insurance

The establishment of a federally-funded temporary high risk pool is among the components of the Affordable Care Act that were implemented early on. By design, the federally-funded high risk pool provides transitional coverage to 2014 for the currently uninsured with preexisting conditions.  Of course, effective January 1, 2014, the Affordable Care Act prohibits health insurers from basing coverage or pricing decisions on health status, assuming the Act is not repealed. High risk pools exist currently in 35 states.

Illinois identified approximately 1.4 million eligible members for the Illinois Pre-Existing High Risk Pool (IPXP).  The Illinois enrollment experience to date of this federally subsidized program offering good insurance for those who currently don't have it, is only moderate at best.  Currently there are fewer than 5000 members, less than 0.5% of those eligible.  There are four different pricing options from which to choose, and the benefit designs also cover much of the costs related to pharmaceuticals.  The Illinois experience is typical...once prospective members realize they must still pay a premium and additional out-of-pocket costs, they opt to remain uninsured.

Part of the uninsured problem in America is simply a matter of personal choice to go bare. The law prohibits providers of emergency services from with-holding life sustaining care, so everyone needing urgent care can get it.  The costs associated with uninsured care are passed to those who can pay, including the taxpayer.  We all know other examples of deadbeats in our lives and it is indeed rare that government regulations are very effective as a remedy.  Left to our own creative ways, however, we will deal with deadbeats in all sorts of ways hopefully still in keeping with legal, moral and ethical standards. Peer-to-peer confrontation and holding one another accountable where accountability is appropriate (i.e. moral), is usually more effective than enacting more law.

Whether or not the Supreme Court upholds the individual mandate, there will be many who simply will not buy the insurance nor pay the penalty/tax. The Pre-Existing Uninsured High Risk Insurance Products are showing us what is to come.  While some of the public policy intent behind the Patient Protection and Affordable Care Act is to provide us a better system of care, the failure to follow solid free market economic principles will result in a cost-prohibitive outcome.  

Supreme Court Arguments Make Us Think

The Supreme Court arguments this week should be reviewed by all of us interested in thinking through reasoned solutions to the rightful role insurance products should play in our society. I won't even attempt to summarize what is done so much better elsewhere. Rather, I will simply remind us that insurance is not and never has been an appropriate vehicle for social reform.

The economic problem of health care cost in the US emerged from a complex interplay of market forces and the desire of politicians to leverage those forces for political gain. Mr. Obama may have gone over the top for a political power grab but he is just one of a long line of politicians to take advantage of this sector of the economy for personal objectives.

Health insurance is designed to help individuals avoid bankruptcy in the event of personal high cost events. It is not a product suitable to cover the costs of everyday needs and wants of a society. While insurance pools the resources of many to cover the catastrophic costs of a few, it is not an appropriate tool for achieving what some envision as the ultimate tool of social justice.

We will reign in health cost in the US by having government play a much smaller role in regulating the industry, getting government out of paying for so much of the services, and allowing employers to more easily make affordable contributions to benefit pools while employees pay the difference. By connecting the individual buyer directly with the seller, we will reduce the skyrocketing costs of largely discretionary services. While easily conceptualized, this is a tough pill to swallow and politicians, many market players, and many consumers won't like the personal economic impact. This is precisely why the formula will work but also the reason behind the resistance. But by making insurance the tool of social reform, more of us are appeased in the short run while we ultimately loose our economic strength and freedom as a Nation. I hope and pray the Supreme Court decision helps us all rethink our real priorities as a Nation.

Affordable Care Will Be the Goal for Most

Over the past few weeks we have begun to see coverage mandates that will make up the benefit designs on Health Exchanges in 2014.  This week, HHS adopted the IOM non-evidence based recommendations to include all forms of contraception as a preventive benefit, "free" of any out-of-pocket copays or deductibles.  Whether or not we even believe appropriate as a "preventive benefit", generic birth control pills are rather inexpensive, the branded products are not.  Yet, after August 1, 2012, all will be covered at no individual cost.  This is a wonderful opportunity for Pharma to accelerate their advertising of branded pills and raise the cost of this benefit for all responsible for paying premiums. For taxpayers who will subsidize the purchase of health insurance for some, and for the rest of us who purchase our plans without subsidy, the price of our insurance premiums just went up for all.

Universal coverage for disease prevention where no out-of-pocket costs are expected makes sense where there is good evidence the intervention will help the individual and the larger public.  Childhood immunization is the classic example as the intervention clearly effective at disease prevention as well as the spread of disease in the population.  It is much less clear whether cholesterol screening, diabetes screening, etc. should be "free" of individual responsibilty to pay a portion at the time of service.  But it is truely a stretch to say that society should foot the bill for all forms of pregnancy prevention, a condition that is hardly even considered a disease.  Using the underlying arguments in favor of such coverage, we could argue virtually everything we contemplate in health care prevents something.  Don't we contemplate an appendectomy to prevent a ruptured appendix and possible death?

For health care to remain affordable for all, benefits must primarily target the financial assistance necessary for an individual and family to weather a catastrophic event.  Secondarily, it is appropriate for benefits to support the use of preventive services that benefit both the individual and society at large.  Some of these preventive benefits may deserve consideration of no out-of-pocket costs but most should arguably require some responsibility from the individual. 

When President Obama argued for administrative simplification of health care, this was a code word for social reform and the same benefits for all, at a cost supported by society. It is important for all of us to think carefully about the benefit mandates that we will hear more and more about over the ensuing weeks.  Nothing is free and the question is when and how should individuals take responsibility for their own health costs?  In general, universal mandates increase the cost for us all, ultimately making health care unaffordable.

The Fun is Just Beginning

My Mom is age 88 and lives in an Assisted Living arrangement in Richmond because of her dementia. Other than the non-skilled care she requires, she looks healthy and takes only a baby aspirin and thyroid medication each day. Mabel (an assumed name) is 86 and lives in the same facility, requiring non-skilled care due to her disabling rheumatoid arthritis. Otherwise, Mabel is pretty healthy as well and remains so mentally alert and sharp that she has become the eyes and ears for many of the residents on their wing. Mabel and Mom eat three meals a day together and recently I had the opportunity to visit for a few days.

On my last day in Richmond, Mabel expressed frustration over spending the entire day trying to schedule a mammogram, Pap smear, and routine blood work. The tests were all to be done at different locations and her son would need to take the day off work to drive. The logistics were simply maddening. Knowing much of Mabel’s medical history from talks we’ve had over the years, I asked her why in heavens name was she still getting such routine testing done. And the questioning made her even testier after spending an entire day on the task and furthermore, “I have the best doctor in the world who would not order these things if I didn’t need them.” She then reminded me the woman at the other table was 99 and still seeing her doctor regularly for tests, and there is another lady on the next floor up who is 104.

After letting the dust settle for a few minutes and to validate Mabel would still talk with me, I asked her if she thought Medicare would continue to cover these routine tests in the future as is done currently. To this question she declared her faith in AARP and said that today’s Medicare members had “paid their dues in full.” I guess this means Mabel expects no changes in Medicare’s benefit design and I think, for the most part, I agree.

Our government health payers have a difficult time reducing benefits. They reduce the allowed payments and let the free market system figure out the rest. Evidence based medicine is all well and good except for the fact that many well meaning groups don’t agree on the evidence, even when conducted under very expensive and extensive research protocols. There are always holes found in the data, allowing for sometimes great variances in interpretation. And for most medical practices, the evidence is truly weak or lacking all together. Regarding preventive health screening like what Mabel and I were discussing, I’m not aware of any study evidence on patients over age 75.

On a separate front, I read this week that Walgreens, in Illinois, was no longer going to service new Medicaid patients. The Medicaid reimbursement was simply too low and was below the cost of delivering the service. Plus, payments were months behind. Oh well, I’m sure someone will service these new Medicaid enrollees. When I was working in Chicago, we would see lines of patients out the door at the Stroger hospital pharmacy, in line for free medications courtesy of the Cook County Board of Health.

If the government and all health providers got together and agreed on how to spend the scarce resource dollar, maybe we could eventually brainwash the Nation and eliminate that large amount of wasted resources we keep hearing about…some estimate to be 70 percent of the medical spend. The problem is we rarely agree on anything, even when we’ve done the best we can do to study the question. Just look at the differences in recommendations from the USPSTF and the ACS, for example. So, is economic rationing really all that bad? We may find more people being served in a manner they believe is valuable, even if it includes a routing pap smear at age 88. By having the consumer pay out-of-pocket rather than simply squeezing the price to the level providers refuse to deliver, more people are likely to benefit. Having the ability for providers to balance bill a beneficiary for service not fully reimbursed by the insurer seems to me the logical solution.  Is Walgreens giving us an early sign as to where we’re heading with Medicaid? Thoughts?

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Moving on Down the Road

As Al Sharpton declared victory alongside President Obama this past week, he didn’t hesitate to openly declare and applaud the President as one step closer to “socializing America.” Access to healthcare services will expand and our Nation’s most vulnerable will be healthier for it. If Al said it, it must be correct.


We also read the story this week by Brian Wansink. Brian is the John Dyson Professor of Consumer Behavior at Cornell University, where he directs the Cornell Food and Brand Lab. He is author of over 100 academic articles and books, including the best-selling Mindless Eating: Why We Eat More Than We Think (2006). This week, he published research of how pictures of the Lord’s Supper have changed over the last 1000 years, with more recent pictures showing bigger plates, more food, and heavier apostles. The punch line seems to be that humans, without even trying, reflect life based on their own perceptions and biases. Even effort to replicate artwork done before us is jaded by our mindless sense of perspective bias.

So when we look at the CDC website on the obesity epidemic in the United States from 1988 to 2008, http://www.cdc.gov/obesity/downloads/obesity_trends_2008.ppt, I’m guessing President Obama will conclude our Nation of fat people is just a perspective bias and the increasing costs of healthcare are all related to bad quality and poor access to care.

I saw a well educated 51 year old lady in the free clinic this week. In 2007 her husband lost his job and, with both in poor health, they decided to move from Chicago to downstate Illinois, closer to two of their children. Her husband died earlier this year and only now was this woman “getting around” to her own health needs. Her medication needs were what prompted the visit to see me. Since 2007, she has not been taking her prescribed insulin, hypertensive medications, asthma drugs, or other diabetes drugs. She was not without financial resources, she just didn’t have insurance or the inclination to take responsibility for her health, given other priorities and the attendent costs. Because the neighborhood federally qualified health center does a means test and charges accordingly, this lady chose the neighborhood free clinic that didn’t ask about your financial status. I was aghast someone so apparently well educated, with some financial resources, with such significant health problems, would simply go without medication for almost three years.


Once our perspective shifts from repetitive external cueing, most of us simply develop a new reality and keep on moving down the road as changed people. I guess change comes quicker now than in the past, partly because of mass media and rapid deployment cycles for new goods and services. So what is the repetitive cueing needed to increase individual responsibility for our choices? More importantly, what are the opportunities for us to help lead the way? Thoughts?