Obama bureaucrat critiques Trump health care
Donald M. Berwick (below) makes an intelligently-stated case to the effect that American health care has been damaged by actions of the Trump administration. Like all Leftist writing, however his leaves out half the story.
He is probably right in saying that the administration has been hasty in winding back some aspects of Obamacare but he does not ask why. His default explanation appears to be that the Trump adminstration is evil, a typically brainless Leftist claim. What he takes no account of is that the Donks rammed through the ACA legislation with not one skerrick of bipartisan consultation or support. They treated the GOP and its reservations as beneath contempt. What did they expect of that? What they now have to live with is the GOP treating their baby with contempt. It's not Christian but in the real world contempt breeds contempt. Conservatives often do turn the other cheek to Leftist attacks on them but the Left cannot expect that to go on forever.
And in his third point he says :"Modern health care, for all of its flaws, espouses and generally tries to act on science as its guide. Much of the US public is not so sure. The reasons for that doubt lie beyond the scope of this essay, but the effects on public debate and political positioning are strong"
He is right about that but again he glides over the causes of it. The current "replication crisis" in medical and psychological research found that up to 70% of research findings were "unreplicable" or "wrong" in layman's terms. What are people supposed to make of that?
And then, on top of that, we have the vast global warming hoax that goes on despite scientific findings against it purely on the basis that "the experts say so". Throughout the world, the conservative side of politics mostly thinks global warming is a lot of hokum. How can you expect respect for science in that situation? It is thoroughly deplorable that science has become so disrespected but it is not conservatives who have created that disrespect.
His final point is that the intervention of government is needed to ensure proper healthcare for all. He is probably unaware that libertarians challenge that. In the Victorian era very good health insurance was available to the worker -- though friendly societies. Most occupations had a body associated with a particular occupation to which they could subscribe for a modest sum. And if the subscriber got sick he could go to the society doctor and get treated for free.
But there were always some feckless people who did not contribute and their plight caused a gradual intrusion into the issue by way of government hospitals being set up which would treat the uninsured. And that binary system continues to this day in most countries.
In Australia, where I live, the contrast between the two systems is stark. As with all "free" hospital systems, care is rationed in non-monetary ways, principally by waiting lists -- so much so that some people die while waiting. In my State (Queensland) there are in some cases even waiting lists to get on waiting lists. There was one notorious case in Queensland where a man waited seven years for a cataract operation, during which time he could not see well enough to read and TV was rather mysterious too. The impact on his life of such poor "care" was obviously severe.
But 40% of the Australian population is privately insured, despite the availability of the "free" system. They have heard many reports of what the free system is like. And they get private care as good as anything in the world. When I needed a cataract removed, I had private insurance so waited barely a week for an appointment to a private eye hospital and my treatment was brilliant. I experienced minimal discomfort both during and after the procedure. And when I got a sudden and very painful attack of kidney stones I was on the operating table same day -- and paid zero "deductibles". So there is an alternative to government healthcare and and it makes government healthcare look prehistoric.
But what about the 60% of Australians who do not take out private insurance? Health insurance is very cheap in Australia -- from as little as $150 per month -- so even people in humble employment can afford it. Many people on low incomes choose to spend that $150 on beer and cigarettes instead but that is their choice. They get the "free" government care. And the Australian system is well settled and accepted. It is not a political football, as it is in the USA. Any propositions to change it are greeted with widespread outrage.
So Dr Berwick would do well to broaden his horizons. Government healthcare is and always will be inferior healthcare. It is best avoided. Working on ways to get more people into private health insurance is the logical course to pursue. Obamacare theoretically did that but in practice it has de-insured many -- with rocketing premiums and stratospheric deductibles.
When I served as administrator of the Centers for Medicare & Medicare Services, hardly a day passed—and never a week—without a direct request or instruction from a congressional office or White House official bearing on clinically relevant decisions, such as coverage for a new technology, payment levels for a care sector, interpretation of a Medicaid regulation, classification of a hospital as “rural” or “critical access,” measurement and reporting of quality, or, most famously, coverage for physician counseling on end-of-life care options. The private lobbyists were equally relentless, pleading their cases, usually for more money, directly or, more often, indirectly through congressional offices.
The politicization of decisions affecting clinical care was not confined to one political party. Conservative members of Congress pressed against almost every implementation detail of the ACA, with nary a single opening for rational, authentic inquiry about facts and logic. As quickly as they could, Republicans slashed the ACA investments in preventive care and services. Political opponents of President Obama promulgated uninformed and frankly ridiculous accusations about my agenda and beliefs as CMS Administrator but almost never engaged in any serious conversation about how to protect and improve the health of patients.
But also, one of the most liberal members of the Senate accompanied me to his technology-rich state in part to meet with a bevy of executives of medical equipment manufacturers, who explained the value of their products—in effect, a trade show for an agency head hosted by a US senator.
Purists might ask simply to “get politics out of health care.” That would be nice, but it is quixotic. Today, federal and state governments fund about 50% of all US health care (65% if coverage of government employees and various tax breaks are included).4 That proportion has increased from 31% in 1965.5 It would be inconceivable—indeed, irresponsible—for that level of public investment in any enterprise not to fall under government oversight, and, in a democracy, with such oversight authority come political pressures.
With government in the picture, politics has at least 4 on-ramps to health care.
First, and biggest, is money. Health care comprises almost one-fifth of the US economy. A nation that values entrepreneurship and protects private profits cannot expect that those motives will fail to engage the enormous financial opportunities through every possible channel of influence. The fragmentation of ownership, governance, and oversight of US health care makes it possible for a vast industry of political pressuring to flourish. With the US commitment, so far, to an enormously complex system of health care payment and provision comes the opportunity for every single organization with an economic stake in health care, whether motivated by private interest or public interest, to find multiple pressure points for influence.
Second is doctrine. The Federalists and Republicans at the birth of the nation became viciously divided as to the proper role of states and the central government. The North and the South became divided, and eventually fought a war, over attitudes toward slavery. Today, public discourse is also riven into factions according to deeply held beliefs about matters no less fundamental than human nature, individual responsibility, and the role of compassion in public affairs. Health care is an inevitable battlefield for that contention. The disputes take shape over laws, regulations, judicial decisions, and other governmental actions about assertions that reflect those underlying doctrines: assertions that health care is a human right; that richer people ought, through government, to help poorer people; that the rights of women should prevail over those of the unborn; and that health status is as much a collective responsibility as an individual one.
Third is trust in science and institutions. Modern health care, for all of its flaws, espouses and generally tries to act on science as its guide. Much of the US public is not so sure.6 The reasons for that doubt lie beyond the scope of this essay, but the effects on public debate and political positioning are strong. The current administration in Washington, exploiting public doubt, has in many scientific sectors, including medicine, weakened the commitment of agencies to use scientific evidence in exercising their duties.7 This has chilled action and research on such topics as environmental threats to health, US Food and Drug Administration guidance, and reports on risks from the Centers for Disease Control and Prevention.8 Weakening science through political action ultimately weakens care and harms patients.
Fourth, and finally, politics enters health care though attitudes toward solidarity. The commitment to mutuality—that government exists as a mechanism for acting on responsibilities for one another—is as deeply embedded in most other western democracies as it is fragile in the United States. The basic credo of physicians—to put the interests of patients before their own—at its best reflects a form of solidarity: that those who are fortunate are duty-bound to help those who are less fortunate. Opponents in Washington criticized me for making the assertion that in a civilized nation, the pursuit of health as a human right must be to some extent redistributional because poverty and ill health are correlated. That that logic could be questioned depends not on data—the data are incontrovertible—but rather on the degree of belief in the concept that ultimately, the nation is of one people, responsible in some measure for each other’s well-being, especially with respect to misfortunes not of a person’s own making. Government, and therefore politics, is the avenue for the expression or the negation of that sense of solidarity.
Physicians who want politics out of health care are going to be disappointed. If they value the principles to which they pledged as healers, then they ignore politics at their peril and their patients’. The sidelines are safe places for neither.