Tuesday, August 21, 2007

Sicko

Last night I went to see Michael Moore's new(-ish) doco Sicko on the US Health system (amongst other things). As usual for Moore, there were more stories and stunts than statistics, more emotion than evidence, more amusement than analysis. Nonetheless, this film is worth seeing and talking about. Not only is it less bitter and nasty than his other work that I've seen, it also raises issues more directly relevant to Australia than Bowling for Columbine or Fahrenheit 9/11. With a health system more privatised than the UK, but far more public than the US, debates about the direction of Australian health care continue.

Since being diagnosed with cancer in December, I have received thousands of dollars worth of consultation, treatment and drugs, at almost no cost (a few dollars for the drugs). I give thanks for the public health system and taxation that has enabled this. Yet thoughout the process, I noticed many encouragements towards private health cover, with some messages advising that to do so would help the public hospitals by giving them more funds.

While this may be true in the short term, I am very hesitant about doing my little bit to encourage us closer to the US system. The more patients on private cover, the easier it is for the government to justify health cuts, thus downgrading the public system and giving more incentive for people to switch to private cover. And the losers are those who can't afford it. Though as Moore points out, this means we all lose.

I realise this is a very complicate issue and that I only have a very basic grasp of it, but I'd love to understand more.

Do you have private insurance? If so, why? Do you think this makes any difference to the system as a whole for you to 'vote' this way? Any opinions from those who work in the health system?
Dr Perseus performs a tricky piece of surgery. Twelve points for the first to guess the city in which this work is found.

20 comments:

Carlie said...

I used to work in admin in a major Sydney hospital and it was part of my job to talk to inpatients who had insurance - basically to convince them to use it, so that the hospital could get more money and make the Medicare budget stretch a bit further. It made sense at the time that if people had health insurance they should use it and therefore help the people who couldn't afford it, but I hadn't thought about the long-term effects, in terms of government funding. Given the way funding always seems to shrink maybe it wasn't such a good thing after all.

But if everyone stopped using their insurance the hospitals would have to shut from about September each year because that's about how far Medicare would get them!

CraigS said...

I have private healthy insurance because it is cheaper than the tax hit you cop if you *don't* have it...

byron smith said...

Craig: Yes - that's part of what I meant by incentives to have private insurance. But is that the kind of system we want to have? I think I would rather pay more tax to have a public system, since I would be helping those who can't afford it, rather than just covering my own back. But maybe I haven't understood something.

Carlie - Yes, as the system currently stands, I understand that the hospitals need the extra funding from private patients, but how dependent upon private funding do we want our hospitals to be?

Honoria said...

When I studied Health Promotion, we compared the world's major health care systems. Australia and Canada came out on top in terms of equity and equal access.

Most US hospitals are user-pay, which have the right to turn people away if they don't have private insurance. So US employment contracts often include health cover as an incentive. Years (?) ago, Hilary Clinton proposed an overhaul of the US system - more equitable, but the government would have born the costs. Her proposal didn't pass that point.

For Australia, Private health insurance is currently attractive, because you jump ahead of the queue and choose your doctors (and avoid potentially landing a junior doctor in training). But I think these pluses will be diminished if everyone had private health cover. (It's a bit like Pay TV: if everyone bought it, TV will eventually because as bad as free-to-air TV, except you'll be paying for it... I could have used also used Capitalism as an analogy!)

If the Australian system heads towards privatisation, chances are, it'll be the upper classes who opt for private over Medicare. But this means their taxes (the top tier of income) will no longer fund Medicare. Current professional standards of care are not sustainable on just a portion (the lower portion) of the populations' tax. The system relies on the taxes of the whole population.

(NB. my understanding of this issue is a few years old)

Just in terms of professionalism, an overall public system is just as good, if not better, than an overall private system. In Australia the doctors in the private sector work in the public sector too, so you're not missing out on expertise. The standard of public health care is very high. I'd much rather send my mother to a public Australian hospital than a private US hospital, or even a private Australian hospital.

byron smith said...

Thanks Honoria, that's really useful.
Australia and Canada came out on top in terms of equity and equal access.
Do you remember where the UK came?

Sicko addresses Hillary's attempt. I wonder whether the idea is now buried or whether it might get back on the agenda if she gets in?

Honoria said...

Not sure about UK's funding / equity. I think their system is more similar to ours (more public hospitals) than to the US.

With regard to professional standards, UK hospitals are about
20 years behind Australia. I worked in the UK as a nurse for a year in 2005 and my sisters as doctors, in both private and public hospitals. My sister said "it was like working in a warzone. No one knew what was going on". A lot of the time, it felt like we were in damage control mode. There was only one hospital that I would have sent a relative to (The Heart Hospital). There's not much evidence based practice or professional development, post qualification. This may a symptom of the chronic nation apathy towards work or their resistance to change and initiative.

UK has a major funding crisis. And critical staff-shortages, which means an over-reliance on locum work. In 2005, about a third of the nursing staff were agency. This means that a third of the staff potentially doesn't know where things are or what the hospital protocol is. Plus they are paid ~3 times more than regular staff. This breeds further resentment. The government tried to force agency nurses into permanent work by closing down agencies (by making accreditation very difficult). Haven't heard how successful they have been in doing this.

ndefalco said...

Byron, I think you have to start at a philosophical level before asking pragmatic or ethical questions. Think about this: The governmnent, through power of police/military enforcement, forces its citizens to pay taxes. They have no choice. They MUST pay. Because of this incredible power, we must do what we can to limit the government in what it can do.

Here are some guiding principles when it comes to whether or not we should let the government force us to pay for poor people's health care;

1. Always protect individual liberty. (Taxing citizens to pay for healthcare DOES take away individual liberty. I cannot choose to spend money that was taken away from me through taxes.)

2. Never let the government do what private citizens can do just as well if not better. (The U.S. has a rich history of taking care of the poor without the aid of government.)

3. The more power you give to a centralized government the easier it is for them to become corrupted. (Private hospitals can become corrupted, too. The big difference is, I can always go to another hospital. I can't always move to another country.)

4. Never force citizens to do what they would otherwise voluntarily do. (You said you would rather pay the taxes to help out the poor. Well, here's a stupid question: why aren't you giving that extra money to the poor anyway? Why are you waiting for big brother to pry it from you hands?)

ndefalco said...

Here are some ethical concerns to think about as well:

1. State-sponsored abortions. If you are not a big believer in abortions than you would never choose to send your money to an abortion doctor. With tax-payer funded healthcare, you'd be forced to.

Actually, you could switch abortion out with any number of ethically questionable procedures and it the problem still stands. At least in a private system you get a choice.

2. Healthcare for those who overdose on recreational drugs. Should the tax payer be forced to pay for them or not?

3. Healthcare for those who make poor lifestyle choices. Should the tax payer be forced to pay for people who refuse to stop smoking, quit eating fatty foods, etc.?

4. Healthcare for the "mentally sick". I don't even want to go into the ethical quagmire of psychotropic medicine.

All of this is wrapped up in choice. Under a private system you have it, under a public system you do not.

ndefalco said...

Here are some practical issues to consider:

Hilary Clinton wants tax payers to foot the healthcare bill. How will she do this? By taxing the whole country fairly? Well... not at first.

She's said only those in upper tax brackets (herself excluded) will foot the bill. This means anyone making over $250,000.

Problem is, rich people don't have all this money lying around in big piles where nowhere to go. Rich people got rich by DOING SOMETHING WITH THE MONEY. When rich people do something with their money, jobs get created. Jobs with benefits. Like... health insurance.

This isn't rocket science. Besides rich people will find creative ways to not pay the tax increase. They will simply pass the buck on by not creating the new jobs, raising prices, lower wages, etc. In a roundabout way, we will pay the tax increase and the rich will stay rich.

ndefalco said...

One more thing to think about:

The poor who we keep speaking of as being the primary beneficiaries of public healthcare are individuals. They are not "the poor".

Some of these individuals whom I've met qualify for medicare. They also qualify for the $5,000 credit limit that they maxed out on their VISA card. They also have qualified for cable tv, cell phones, x-boxes, and the daily run to Burger King.

The relatively few individuals that are not blowing their money and are still too poor to afford healthcare can be taken care of by private charities/churches.

The ones mentioned above (they do exist- I've worked with many families on a counseling level that are exactly like that) don't need public healthcare. What they need is to get their priorities in line.

And guys, let's not be ignorant here. Typical health insurance companies are not the only way to have your health needs covered. Try out Christian Healthcare Ministries or Samaritan's Purse. My wife and I had an account with CHM for about a year and only paid $130 a month (65 each).

byron smith said...

ndefalco - thanks for your thought-provoking responses!

Because of this incredible power, we must do what we can to limit the government in what it can do. ... Always protect individual liberty.
Why is this? I'm not sure I follow the logic. This would only be absolutely true if individual freedom is the highest good and government power always a bad thing. I agree that governments ought to be responsible in their taxation, but where raising taxes will contribute to the common good, then they should go for it. The common good is more important than individual freedom (of course, I believe that healthy political freedoms contribute to the common good, but this is why I value them). Freedom is a relative, rather than an absolute, good. And certain kinds of freedom are more important than others.

Never let the government do what private citizens can do just as well if not better. (The U.S. has a rich history of taking care of the poor without the aid of government.)
I am no expert on the US, but it seems to me from the outside that there is a greater problem with poverty in the US (both absolutely and proportionally) than in Australia. I would love to see studies on this topic. I am not persuaded that private enterprise will always deliver a better outcome.

3. The more power you give to a centralized government the easier it is for them to become corrupted.
Governments will always be corrupted (to differing degrees); this is a reason for accountability (ironically - more government!) and checks and balances, not simply for minimising power. It is unchecked, unregulated power that is most easily corrupted.

4. Never force citizens to do what they would otherwise voluntarily do. (You said you would rather pay the taxes to help out the poor. Well, here's a stupid question: why aren't you giving that extra money to the poor anyway? Why are you waiting for big brother to pry it from you hands?)
I'm not waiting. I do. But I'd rather be paying it to a publically accountable government than to an insurance corporation whose primary goal is to turn a profit.

I am not a fan of abortion, and am saddened by the abortion rate in Australia. I am also saddened by the choices made by those who end up addicted to lifestyles that are unsustainable (whether via drugs or rampant consumerism). But I believe that a human being in need should be cared for where possible, rather than simply and immediately abandoned to the effects of their foolish choices (though there may come a point where this is necessary). This is not only about giving people second and third chances, but also avoids the even greater social cost of not giving people second chances.

Fair taxation: what is your suggestion?

As for 'the poor', good point. I agree they are individuals, many of whom have made (and continue to make) self-destructive choices. Many are not. And perhaps we should also be asking about our culture of Burger King and cable TV.

I'm glad to hear there are Christian insurance companies.

Thanks again for taking the time to respond. Peace.

ndefalco said...

"The common good is more important than individual freedom (of course, I believe that healthy political freedoms contribute to the common good, but this is why I value them). Freedom is a relative, rather than an absolute, good. And certain kinds of freedom are more important than others."

I'll try and make my one and only response to your response brief. I'll let you have the last word.

I believe you're wrong when you say freedom is relative. The Common Good presupposes liberty. How can you even have a discussion about what the common good if you are not at liberty to say/develop it? Liberty is the one crucial element for any ideology to survive (except those that contradict liberty). So, the opposite is logically true: Freedom IS absolute and the common good is relative to how much freedom you have.

Besides, let me ask you a question: Which common good are you referring to? Malcolm X's common good? Adolf Hitler's? George Bush's? Everyone has a different version of the common good. We Christians certainly have our version. Since the government's main responsibility in your view, is to achieve a comon good, then the way that plays out is a race to put "your man" in office to implement your common good. Why is this bad? Because it is certainly plausible in this scenario to have a person in office whose common good may oppose individual liberty. For example, I hear in Australia certain pastors have been jailed for speaking their mind about homosexuality. Regardless of what you think of those pastors, they have the God-given right to say what they want without government intervention. But, SOMEBODY thinks their common good ideology should trump that pastor's right to free speech.

The same is true in the U.S. concerning property reclamation. The federal government now has the power to say to a family, "You must move so we can put in a highway. You have no choice. You will accept our price and move." Again their version of the common good trumps individual liberty.

What do I think the main responsibility of a FEDERAL Gov. is? Simple: preserve liberty through-

1. military/ police defense.
2. a legal system.

Local governments would have more leeway in what else it would provide (such aas roads) simply because it is easier to move to another city than it is to move to another country.

ndefalco said...

my one and only response part 2

So, as you can see, the common good of health care can and does trump individual liberty (by making you pay taxes to a system you do not agree with).

You also said: "Fair taxation: what is your suggestion?"

A national sales tax. Get rid of all forms of corporate and residential income tax. ESPECIALLY the withholding income tax system.

A national sales tax allows you to put your money into investments/savings before it is ever taxed. And then when you do spend money, every receipt will have the amount of tax you're being charged (highly visible, therefore accountable, unlike imbedded corporate taxes which you never see and withheld personal income tax which is hard to keep up with).

It IS possible in the U.S. to keep is its current Medicare/medicaid coverage with a national sales tax and no income tax. But, when people see how much they are being ripped off tax-wise my prediction, along with many political theorists, there would be an outcry for tax cuts immediately.

In short, when the light is shown on the truth of the fraud that is taxpayer funded healthcare, it will go the way of the buffalo.

Concerning accountability you said: "Governments will always be corrupted (to differing degrees); this is a reason for accountability (ironically - more government!) and checks and balances, not simply for minimising power. It is unchecked, unregulated power that is most easily corrupted."

It is ironic that you said more government. But more so, it's hard to keep an increasingly corrupted centralized government accountable with an agency in the same corrupted system!

Private organizations have plenty of accountability, better I believe than the government keeping themselves accountable:

1. Free Market Competition. Customers/clients don't like what you are offering them, they can go to a competitor that will offer them what they want.

2. Third-party private organizations. A profession, like heart surgeons can form a nonforprofit organization designed to create and inforce certain standards. In the heart surgeons case it is the American Heart Association. If a hospital meets their standards they can boast of the AMA's approval.

3. legal/government accountability: In the case in which someone's liberty has been infringed upon (like fraud or a broken contract) the government then has the right to step in and penalize said organization.

Three ways in which private organizations have better accountability than the government.

ndefalco said...

Two more things and I promise I'm done:

1. Why don't all those in favor of a taxpayer funded healthcare system volunteer to be taxed to fund said system and let those who don't want to choose not? If not, then why are anti-choice in this matter?

2. When Jesus explicitly told his followers to take care of poor individuals do you think he had in mind government enforcement or individual volunteers who give only out of a willing heart (not because the government forced them to)?

byron smith said...

ndefalco - Thanks for your further thoughts. I'd love to answer them in greater detail when I get a chance. At the moment, however, I'd love for you to read this short document: the World Evangelical Alliance's statement on social engagement as published in Christianity Today recently. This document expresses the basic thrust of my thinking. I'd love to hear where you agree/disagree with it. We can discuss details of healthcare strategies (which is fun, and quite informative), but I suspect we may also have some theological differences at some point.

One brief point of clarification. You are quick to dismiss the concept of the common good, yet this idea is both biblical and has been at the core of much of Christianity's reflection upon society. I suspect you may be hearing something different to what I mean by it. I do not mean any kind of collectivism (yet nor am I speaking of individualism). I refer to what is truly best for each individual and for human societies and society as a whole. Of course this is vague, and of course there will be dispute over what it is, and each of us will grasp different aspects of it, because it is by nature complex, unable to be reduced to a single principle (like freedom). But it is still a useful concept to designate the goal of our striving.

Moffitt the Prophet said...

Florence, Italy

byron smith said...

Moffitt - twelve points.

ndefalco said...

I was going to allow you the last word and still will, but since you've asked me to read that statement and comment on it, I will.

On the surface, I can agree with everything it says. It's what it doesn't say that I'd like to know. And knowing the WEA's theological murkiness (IMHO), I'd probably end up disagreeing with the direction it wants to take.

Some things I'd like to ask the signees of that document:

1. What do they mean by "the common good"? A tax-payer funded healthcare plan? Sensorship? An unbalanced tax program? When anyone, including you Byron, use the phrase "the common good" you should be prepared to define it and explain why the rest of the world should buy into it or some compromised version of it.

2. When they talk about "the kingdom of Christ" are they aware of how abused that doctrine has become? They must give a doctrinal statement outlining specifically what their beliefs are (they may have done this already) for purposes of doctrinal integrity so people like me can make an informed decision.

3. Do they understand how unoriginal they sound? Rauschenbush covered this 100 years ago when it was called The Social Gospel Movement. I have an essay I wrote on the SGM and I'm actually writing a book with my brother on the subject. If you're interested in reading the essay, tell me how to send it to you and I will.

By the way, I disagreed with the SGM because I disagreed with it's theology. And if the WEA thinks it will get away with sounding more conservative, well, let's just say I hope Christians have learned from history and won't be fooled again. They leave the same bad taste in my mouth as the Social Gospel advocates did when I read them.

It's not that I don't think Christians need to influence their culture, it's just that by pushing for legislation that cares about the "common good" is like caring about the wallpaper while the house is burning down around you. Just go about DOING the common good and forget about trying to force a secular, God-ignoring government to do God's will.

Byron, you seem like a nice guy and you've put up with my rantings so I thank you for that. But let me leave you with this: whenever someone starts talking about reviving the SGM in one form or another, it makes me wonder if they care more about marching to Washington (or Canberra) for the sake of the gospel, than they do about marching across the street to share the gospel with their neighbor.

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byron smith said...

The drugs don't work: drug trials, big pharma and the corruption of medical science.