Priorities

Saturday, March 28, 2009
As part of my Social Services in America class this quarter, students are required to select a social problem for long term discussion over the course of the quarter.

Some of the problems selected include universal health care (my own selection), mental health care, childhood obesity, drug addiction treatment availability, homelessness and global warming. Each student is making a case for their own social issue, and discussion ensues as to what society's obligations should be, etc.

However, I seem to be the only person who is bringing up the issue of cost.

Now, the older I get, the more I lean towards a tax-and-spend liberalism,* and I've always been a huge supporter of the PAYGO requirement in the Federal budget. The need to determine how the hell you're going to pay for your bread and circuses before you move forward strikes me as a fundamentally sensible approach. Too bad the requirement was not renewed by President Bush's rubber stamp Congress so they could get their unfunded Medicare Part D bill passed.

Ahem. Got off track there for a moment.

The point is, while I think you can make a case that each of the social issues detailed above is worthy of our attention as an equitable and rich society, how do you determine which of these will receive the funding they need in order to address the problem?

I realize that the answers to such questions have been the subject of debate for many, many years, and one of the points of my education is to help me work through that decision making process in an ethical and defensible way.

So how come I'm the only student who is asking where the money will come from? Surely people don't think that every worthy social issue can be funded on an unlimited and thorough basis - choices have to be made, and the basis of those choices defines us as a society. Defending the issue that fires your imagination and means the most to you should also include an actionable plan on how you're going to fund your initiative.

Or am I just being a wet blanket, with all my talk of "how much, and who pays?"

_______________

*This distinguishes me from the so-called "fiscal conservatives" who have run their budgets with huge deficits since 1980, excepting President Clinton.

25 comments:

Ilya said...

Everybody else in your class is the aforementioned "fiscal conservative", possibly? :)

Thordr said...

Personal area of interest of mine, unfortunately, most of my friends don’t really like to think about it, out of sight, out of mind I guess. My personal views are that all medical care should be free, there are enough functional medical systems at government expense to work out a system that would work on the scale of the U.S. Of course I want to toss in free education through the graduate level too. I see two levels to paying for this, one is service, I think two years (or more if you wish to make a career of it) federal service; armed services, Americorp., Peace Corp.… just serve something other than yourself for a couple years, after high school. That would teach some responsibility and discipline, and provide a pool of labor each. I’ve been accused of being a socialist, or a fascist for saying such. As to the cash, personally I’m willing to pay much higher taxes so that my child can benefit from such. I graduated college back in 95 with $60k of debt, so basically I had to pay for a house, just to finish my education, if I had gone on to grad school, ugh. Politicians say a lot about how we need more education, then they cut the funding for schools, it’s a nice soft target for spending cuts, the results of such don’t really show up for about a decade. I pay about 27% of my income in taxes currently, I’m willing to double that, I could still live my moderate lifestyle on the rest, most people could, but are not willing, in fact, they even scream and get red in the face at the idea.

Steve Buchheit said...

That's because you're a conscientious dirty, dirty liberal. Most people who've never had real experience think things need to be done just because they need to be done, and then are amazed that not everybody agrees with them. It would be great to build homes for all the homeless, but what would that do to the housing market and who would pay for it?

For me the health care issue is a simple matter of we've experienced nearly two decades of the cost of not doing it. Our industries are choking on the cost. Conservatives love to talk about how we need to lower our corporate tax burden because other countries have lower taxes and our higher taxes make us less competitive. fortunately I'm now hearing voices talking about how those other countries with lower taxes have a more distinct fiscal advantage by having either a government run health care system, or a highly regulated system, along with mandating universal coverage. Which usually leads to a sputtering and then reiteration that we need to lower the corporate tax rate (one hit wonders they are).

Janiece Murphy said...

Thordr, I guess I'm a fascist, too, or at least a conscientious, dirty, dirty liberal, as Steve accuses.

Every study and statistic I've read on the subject of health care indicates that something's got to give on this subject, or our government will be non-functional and non-solvent by 2100.

We can afford to do this, and in fact, can't afford not to - why is this so hard to understand?

And Ilya, the part I liked best about this was that one of my "probing questions" on the subject of universal health care was, "should health care be a not-for-profit business?" The responses I got was basically, "Doctors work hard and go to school for years, they shouldn't be required to provide their services for free!"

::head:palm::

vince said...

Bread and circuses, Janiece.

There is huge waste in the government budget, and that waste would go a long way towards paying for health care. Look at katrina, or Iraq. Billions have disappeared, and no one has been held accountable. We need to get control of where and how money is spent.

But you're right. If we are to have programs, they must be funded. TANSTAAFL.

Wendy said...

I suspect that like many class projects, most choose to ignore that fact that there would be costs out in the real world and create the project on a purely theoretical level.

Now, as one who has been without health insurance, and for the most part medical care, for almost 10 years, I can tell you it SUCKS. The local doc-in-a-box set-ups are pretty good around here, but so expensive that if you are forced by medical neccessity to patronize them, you can only afford treatment for the acute problem. The every day ones that eventually will turn into something else much nastier go untreated.

WendyB_09

Steve Buchheit said...

"Doctors work hard and go to school for years, they shouldn't be required to provide their services for free!"

I bet all those Doctors in Germany and Switzerland would be stunned to hear they had to work for free. Of course the possibility that we should shift over to publicly funded medical education probably wasn't even in their universe of possibility. (And I know someone who helps Americans go to Germany for the free medical school, Germany does it on the premise that some of them will stay).

I guess they also don't know that it's the insurance companies that are making the real money. Let them have their insurance policies change 10 our the past 12 years and see if they get it.

Random Michelle K said...

Actually, Wendy hit the nail on the head.

The thing about costs and health care is that we are already paying for health care for the indigent and needy--we're just paying for acute care instead of preventive medicine--and the costs differences are extraordinary.

Right now we pay for health care--we just don't do it up front. In the price of cars and other products manufactured where the execs haven't weaseled out of paying health insurance, the cost of health care is part of the final product cost.

But those costs are low compared to what the real costs of health care are versus what we pay when we receive medical care.

Thing is emergency rooms can't turn away indigent patients. So the costs associated with the care of the poor are written off my the hospitals and passed on to those of us who have health insurance or pay for health care out of pocket.

And let's consider those costs shall we? Which is more expensive? Providing someone with blood pressure medication and routine maintenance checks or treating them in ICU after the have a stroke?

Which is cheaper? Maintenance care and providing insulin or amputating the appendages of a diabetic whose diabetes is out of control.

And those acute care patients aren't likely to be or remain contributing members of society--hard to do so if you're suffering from paralysis after a stroke or have lost a food to gangrene.

We are ALREADY paying the costs of health care in the country. However, instead of paying for maintenance visits and well-child visits, we pay for emergency room visits and ICU stays and surgery and all the other costs associated with acute care.

Yes, the initial outlay will be expensive. There's not two ways about this. However, the long terms costs for maintenance care versus acute care, not to mention lost productivity from illness, will in the long run be cheaper than the current costs.

(And don't even get me started on the costs of private insurance versus Medicare. Overhead for Medicare is less than 5%. For some private insurance companies it can be upwards of 40%. That's 40% of your money going to salaries and bonuses or whatever else the company decides to spend it's money on.)

Womanji said...

Everyone has a great comment. And yes, where do you start? Which issue is more important or can be determined to be more important? How do we fix what we know to be wrong, yet there has not been a better way to manage the problem presented?

Janiece Murphy said...

Michelle, you're preaching to the choir in my case. As I mentioned, NOT doing anything will result in the U.S's insolvency, so really, the question becomes "pay me now, pay me later." Unfortunately, we have a tendency to jump on the "pay me later" bandwagon so we can have our goodies without having to pay up front.

Man, are we short sighted. Stupid, even.

mom in northern said...

A small aside here.
How is the current administration planning to pay for the HUGE bailouts they are pushing currently?

It is a very slippery slope you are planning to embark on...
Bail out one, bail out all???

Personally I think if the health industry and that includes the drug companies did a better job of policing themselves it would not be necessary for this to even be an issue the government needs to address.

The finanical industry is about to find this truism out big time.

Janiece Murphy said...

Mom, that's a very good question, and one most economists are discussing.

The consensus of opinion seems t be that spending the money is bad, but not spending it would be worse.

As for the health industry "policing themselves," I have to say I disagree. Expecting them to do so (when they're in a for-profit business model) is naive. And even if they did, there would still a segment of the population who would be without coverage. Such an outcome is unacceptable to me.

Steve Buchheit said...

mom in northern, I believe the "policing themselves" was a part of the social agreement in '94 as the Clinton Healthcare Plan went down in flames. We also tried the POP and Managed Care route as well. So far it hasn't worked out as promised. Since then Mutuals have disappeared and become for profit entities (I say this as holding stock in Wellpoint from the dissolution of Anthem's BC/BS mutual), charitable hospitals have been sold to for profits, and the FDA has allowed the pharmaceuticals to run the process (including paying the generic pharma companies to not produce medicines that have run out of patent protection or by slightly changing formulation).

As for the bailouts, it's mostly a matter of unfreezing the credit markets which is the real crisis (brought about by the Troubled Assets problem). Without credit flowing businesses quickly loose the ability to function which drags the economy further into the bucket. Also, since January some 20 banks have been allowed to fail (and have been taken over by the FDIC). That unregulated (and under-funded) credit paper was allowed to circulate is a ship that has already sailed. Allowing that corporate paper to default (as happened last summer and early last Fall) lead to the freezing of the credit markets. Not allowing AIG to default on their debts would have started a new ice age in credit. So now we're forced to gamble and hope the economy recovers before the bills come due.

That we are printing money to pay for the bailouts (well, somewhat we're just reducing amounts that the Federal Reserve held in reserve) is slightly less onerous than the failure to publish essential documents on the circulation of US Currency as the previous administration did in 2007-2008. As for the "precipitous" fall of the value of the dollar, it's nothing compared to what happened when they failed to publish those documents.

For proof I direct your attention to the price of oil. Traded in US Dollars, the price of oil is a fairly accurate barometer of the value of US currency (even despite any jury-rigging of production OPEC is able to do, which usually isn't worth the paper they print on as their members routinely ignore quotas and pump all they can). Last summer oil was trading at over $130. While the slumping economy has resulted in lower use of oil, we're talking less than 10%. And now we see oil at $55, up from $43.

Janiece Murphy said...

Steve, FYI - Mom in Northern is extremely well versed in how the energy market affects other aspects of our economy, as she worked in that industry for many, many years.

Frank said...

The problem as I see it is not who pays for healthcare but the cost. One way or another, we pay the costs. And the costs are out of control.

So then the question becomes who can better control the costs?

But once we consider that question, we have reason not to put cost control in the hands of the Government who may have a different agenda than the individual has.

For instance, in the Netherlands where the Government is in control of health care they have instituted the Groningen protocol.

Under the Groningen protocol, if doctors at the hospital think a child is suffering unbearably from a terminal condition, they have the authority to end the child's life. The protocol is likely to be used primarily for newborns, but it covers any child up to age 12....

A parent's role is limited under the protocol. While experts and critics familiar with the policy said a parent's wishes to let a child live or die naturally most likely would be considered, they note that the decision must be professional, so rests with doctors.

Also consider that there is a movement within the US and elsewhere among academics and other wonks who believe that your ability to access health care should be limited to your ability to contribute to society. It's generally referred to as ethical utilitarianism. Utilitarians believe that moral virtue is based on usefulness. From a utilitarian perspective, the best decision is that which serves the greatest good of the greatest number of people.

Clearly those who implemented the Groningen protocol are utilitarians of one sort or another. But extend this to anyone who has a serious injury that leaves them unable to work, and thus contribute to society. If utilitarianism become the mechanism for controlling health care costs, such people could be at risk. As would the old. And others.

It wasn't very long ago, in this very country, when eugenics was a philosophy that was all the rage. And with modern techniques, such thinking, in a different form, could get popular again. I mean how appealing would it be to attempt to genetically engineer people who are inherently healthy. And strong. And smart. And how much experimentation would it take to obtain such a result? If it was even possible.

Now you may implicitly trust the current party and say to yourself none of this would be allowed by the good guys.

But the problem is that political control changes over time. And if you give the government this power, you give to the government no matter who is in control.

And tomorrow it could be that the "bad" guys are in control.

Janiece Murphy said...

Welcome, Frank.

You make some good points, and while I don't think the Netherlands is necessarily the model we want to use for our own health care conundrum, there are other countries who manage to have universal care without falling into the utilitarian trap you mention.

We can certainly take the best of each system that works to devise our own plan.

And you are certainly correct about allowing the government to have too much power - never a good idea.

Steve Buchheit said...

Janiece and Mom in northern, I didn't mean to be pedantic.

Nice to see you here Frank. For those who maybe worrying about the Groningen protocol, here is a New England Journal of Medicine article on it. For those who don't want to read the whole thing. In all cases the parents have to agree with the medical staff. There are 3 categories of child that would qualify. The first two are patients who are simply denied life-prolonging treatments (or have them removed after further diagnosis). This would be the same as having a DNR (do not resuscitate) order here in the US. My own mother had one that had to be rescinded for her open heart surgery (it's now back in place). The third category covers children who may survive without life-prolonging treatment, but have a prognosis of lifelong suffering and poor quality of life. Here again the parents must agree. In this 3rd category, because death is not "natural" there is automatically a coroner's inquest, and the district attorney presents the case to the College of Attorneys General (4 prosecutors), which makes a determination to prosecute or not. A judge makes the final decision.

Also to keep in mind, the Netherlands has legal voluntary (patient selected) euthanasia for anyone over 16 years of age. This is their culture of acceptance. In the US only two (I believe) states have ratified euthanasia for terminally ill patients (and I believe they all have to be of majority). Our culture is fundamentally different in this case. And in all cases it isn't the government making the decision to end life prolonging treatment, it's you (as yourself or the parents) and your doctor's decision.

As for Ultilitarianism, Frank I really can't believe you're making this argument. This would be like arguing that society was in jeopardy from nihilism or existentialism. To claim this was a valid concern would be the same as people who would deny freedom of assembly and speech (that pesky 1st amendment) because Neo-Nazi's may march, somewhere, someday. Or that we should deny the right to bear arms (that pesky 2nd) because some nut goes crazy shooting up a nursing home. Ultilitarianism's last major flower was at the turn of the 20th century. It's greatest legacy lives on in the form of cost-benefit analysis as made by MBA's who only have theory and no practical experience.

As to the claim of rationing, which the Utilitarianism argument falls to, it's already happening. The decisions are already being made by private market bureaucrats and administrators. And those decisions are being made on the basis of costs, not on necessity. Anyone who has ever had to fight their medical insurance company to gain the coverage they are legally entitled to through their contracts knows this.

Janiece Murphy said...

No harm, no foul, Steve.

Mom rarely comments, so you had no way of knowing her background.

Frank said...

Hey Steve,

With regards to the Groningen protocol

In all cases the parents have to agree with the medical staff.

This is not what the article says. What is says is that in the cases that have occurred, the parents were consulted and all agreed. It does not say that the parents had to agree for the procedure to advance. In fact the article says:

"Legal control over euthanasia in newborns is based on physicians' own reports, followed by assessment by criminal prosecutors."

No mention of the parents. The physicians make the decision and the legal system reviews the decision.

As for Ultilitarianism, Frank I really can't believe you're making this argument. This would be like arguing that society was in jeopardy from nihilism or existentialism. To claim this was a valid concern would be the same as people who would deny freedom of assembly and speech (that pesky 1st amendment) because Neo-Nazi's may march, somewhere, someday.

I don't think so. Once you give the government the power, the government will use the power as it sees fit. This is not to say that the power will not be used with restraint, but it does say that things may go along merrily for many many years and then gradually, over time, based on many small seemingly rational decisions, you end up with a monstrosity. To say it could never happen is to deny historical instances of government enforced population control through medical processes.


As to the claim of rationing, which the Utilitarianism argument falls to, it's already happening. The decisions are already being made by private market bureaucrats and administrators.

Yes, this is true. But it is not the government making the decision for political reasons. That, to me, is the danger.

A health care company can and does limit their cost liability. And you know that going in. And health care is rationed in a practical sense by what a person can afford for coverage or by their ability to pay for medical care beyond that.

But that is something completely different from having a single point of contact for medical care whose decisions can be based on political or ideological foundations.

The fact of the matter is health care rationing must be done whether it is by private companies or the government. It is simply unaffordable to give everyone everything they want. I remember back in the day when we never thought about what health care cost. I had a company-supplied medical plan and there was zero cost to me. None. People would go see the doctor for a cold because it just didn't matter.

And health care costs rose as a result. And that cost got passed down.

Add to that the fact that new medicines, diagnostic tools and procedures just keep adding to the cost of a doctor visit.

And, of course, no one wants to die.

No one can afford to not ration medical care any more. The only question is, in whose hands to we put that decision of how and when to ration.

I, myself, am not big on trusting governments as frustrating as private medical companies can be.

But that's just me. And that's how I will vote.

Ultimately, we'll get that which has the most support.

Janiece Murphy said...

Frank, for me, the crux of the issue on the subject of rationing is the ethical dimension of "who decides."

Right now, the required decision is made by some bureaucrat in a business who makes the decision based on what they consider to be the cost benefit analysis of providing treatment. Because such a system is biased toward those who have money and against those who don't, it offends my sensibilities. Please note here that I don't believe health care should be a for-profit business.

You say you do not want the government to make this decision. So the question becomes, if not the government, then who? An accountant? A business person who cares more for his shareholders than he does for his patients?

Health care costs will have to be controlled, but I think the ethical dilemma of "who decides" will have to be determined first.

Frank said...

Health care costs will have to be controlled, but I think the ethical dilemma of "who decides" will have to be determined first.

Precisely.And for where I sit Government does not have a great track record in this area. Just take the area of Eugenics.

In the US

...eugenic supporters included Theodore Roosevelt, pre-1960's Democratic Party, the National Academy of Sciences, the American Medical Association and the National Research Council. Research was funded by distinguished philanthropies and carried out at prestigious universities.[citation needed] It was taught in college and high school classrooms. Margaret Sanger founded Planned Parenthood of America to urge the legalization of contraception for the lower classes. In its time eugenics was touted by some as scientific and progressive, the natural application of knowledge about breeding to the arena of human life. Before the realization of death camps in World War II, the idea that eugenics would lead to genocide was not taken seriously by the average American.

Eugenics was supported by Woodrow Wilson, and, in 1907, helped to make Indiana the first of more than thirty states to adopt legislation aimed at compulsory sterilization of certain individuals.[54] Although the law was overturned by the Indiana Supreme Court in 1921,[55] the U.S. Supreme Court upheld the constitutionality of a Virginia law allowing for the compulsory sterilization of patients of state mental institutions in 1927.[56]

Beginning with Connecticut in 1896, many states enacted marriage laws with eugenic criteria, prohibiting anyone who was "epileptic, imbecile or feeble-minded" from marrying. In 1898 Charles B. Davenport, a prominent American biologist, began as director of a biological research station based in Cold Spring Harbor where he experimented with evolution in plants and animals. In 1904 Davenport received funds from the Carnegie Institution to found the Station for Experimental Evolution. The Eugenics Record Office opened in 1910 while Davenport and Harry H. Laughlin began to promote eugenics.[57]

One of the earliest modern advocates of eugenics (before it was labeled as such) was Alexander Graham Bell. In 1881 Bell investigated the rate of deafness on Martha's Vineyard, Massachusetts. From this he concluded that deafness was hereditary in nature and, through noting that congenitally deaf parents were more likely to produce deaf children, tentatively suggested that couples where both were deaf should not marry, in his lecture Memoir upon the formation of a deaf variety of the human race presented to the National Academy of Sciences on 13 November 1883.[58] However, it was his hobby of livestock breeding which led to his appointment to biologist David Starr Jordan's Committee on Eugenics, under the auspices of the American Breeders Association. The committee unequivocally extended the principle to man.[59]

During the 20th century, researchers became interested in the idea that mental illness could run in families and conducted a number of studies to document the heritability of such illnesses as schizophrenia, bipolar disorder, and depression. Their findings were used by the eugenics movement as proof for its cause. State laws were written in the late 1800s and early 1900s to prohibit marriage and force sterilization of the mentally ill in order to prevent the "passing on" of mental illness to the next generation. These laws were upheld by the U.S. Supreme Court in 1927 and were not abolished until the mid-20th century. All in all, 60,000 Americans were sterilized.[60]

In years to come, the ERO collected a mass of family pedigrees and concluded that those who were unfit came from economically and socially poor backgrounds.


And I don't think I need to go into detail regaring the Eugenics program in Germany in the WWII time-frame.

Or the Soviet Union's use of mental institutions in order to re-educate people who exhibited too much individualism or capitalistic traits.

I can enumerate other examples from other governments but you get my point.

From my point of view, Government should not be the decider.

Janiece Murphy said...

Frank, you are definitely welcome here, and I'm interested in your opinions, but please do not cut and paste articles from Wikipedia or other sources. I think you'll find this group to be well-read and willing to do their own research if a topic is not one they're familiar with.

So if the government doesn't decide, then who? Please bear in mind that the current system is unacceptable to me, based as it is on income rather than need and a defensible ethical determination.

Because for every government sponsored horror story you can bring up, I can bring up plenty of private company horror stories, as well. Hell, all you have to do is look at our current economic crisis (where there's plenty of blame to go around) to see that no one can really be trusted to any great degree.

To me, it's easy to say "the government can't be trusted with this power" without offering an acceptable answer as to who can.

So who is "trustworthy" in this context?

Frank said...

Because for every government sponsored horror story you can bring up, I can bring up plenty of private company horror stories, as well.

Yes but the question is only the quality of the horror story.

Yeah, a cold hearted bastard of an accountant is annoying, but even in the best case government-run scenario that will simply be replaced by a cold hearted bastard of a bureaucrat. So that's a wash.

What private insurance swimming in a marketplace of other private insurers can not do is practice political or ideological selection.

You can work the poor issue through private insurance. Clearly government is not the only solution to that problem.

So that's the general direction I favor.

Of course the details are a bit more troublesome.

Janiece Murphy said...

Frank, the devil is always in the details, to be sure.

Thanks for stopping by!

Steve Buchheit said...

Frank, as for your fear of government control of medical care, I will point you to several of the commentators on this blog having stories about the VA system (many of them being vets), one of several government managed health care systems. When an issue occurs, you'll see many people petition their government for change, and strangely enough in some circumstance the government does change. Private insurance companies have lobbied Congress and State Legislatures to enact tort reform to indemnify themselves from being answerable to their clients. For every horror story out of the VA, Medicare and Medicaid, I can point to several suits being brought against the insurance companies even though the tort reform only allows reimbursement of the medical costs (no legal fees, no damages). And yet insurance companies haven't changed their tactics and decision making processes. To change a government denial takes days/weeks/months, to force private insurance companies to cover new areas of medicine takes years/decades. Your government is more responsive to you than your private insurance company.

And you know the argument of the rationalization of eugenics in the past ignores that humans actually can learn and change. It would be the same thing as arguing that with removal of collective bargaining and moving to a system where each individual is valued on the basis of their skills and talents we are inexorably moving back toward slavery (where people were bought and sold as individuals), which also was once held high regard among intellectuals. That human trafficking is still big business (even in the US) shows a stronger link to having open slavery return to prominence than government control of healthcare leading to a return to eugenics.

The rationing, eugenics, "OMG central planning!" arguments are all a part of the FUD (fear, uncertainty and doubt) campaign being waged by the healthcare insurance industry.