Monday, August 24, 2009

Socialism, Fascism and Health Care

I have a child who is uninsurable. As with so many millions of Americans, she has a "pre-existing condition." Simply translated: "known to actually use medical services and therefore predictably too expensive." Recently I learned my job is in jeopardy, and like millions of parents with children with disabilities, did the only thing I could. I panicked. 

Socialism is flung about as a dirty word by those opposed to changes in the flow of money through the healthcare industry. According to the Encyclopedia Britannica, socialism is based on the ideals of democratic, “non-coercive communities working non-competitively for the spiritual and physical well-being of all.” That does not sound so bad. Almost like church. 

On the other hand, Fascism includes a “…militaristic nationalism, contempt for political and cultural liberalism, a belief in natural social hierarch and the rule of elites and a desire to create… a community in which individual interests would be subordinated to the good of the nation.” That sounds familiar in a not-so-nice way. 

Competition has its place. In a well functioning market we see contained costs, customer driven prices, availability, and productivity. But competition implies losers. Who wants to lose in the health care race? Who wants to even chose who should lose?

The thing is, insurance is not the same thing as medical care. Medical Insurance is a profit driven, competitive business that makes money by charging more for medical services than they actually cost. Insurance companies would have us believe that we Americans have the best medical services in the world. That is a half truth. Some Americans have excellent medical care. But millions of Americans have none at all. Most Americans who have medical insurance are healthy, able-bodied and inexpensive to insure. 

Here are case studies from my family (where everyone is actually insured):

My permanently disabled eight-year-old daughter waited three years for a commode (that is a grown up potty seat). For three years she was unable to use the toilet and had to soil herself. Five years to get a speech generating device (still not approved) and six months for a wheelchair. Physical therapy? Denied for the third year in a row. Her illness is progressive, but she is likely to survive for decades. As hard as it is to say as a mother, she probably will not get better. Her disease is being studied by private foundations and a small grant through the orphan diseases project recently begun at NIH. Insurance companies and government agencies all have layers of bureaucracy to screen her expenses and deny what they can. 

By way of contrast, my father developed small cell lung cancer at age 65 (he was a smoker). He received top of the line cancer care. The research for this disease was initiated by Nixon, who started the "war on cancer" that continues today through private and public funding. That prolonged his life several months at a cost of $75,000 per chemo treatment (dozens) and several ICU stays. Following his treatment, he received emergency surgery for an aortic aneurism, a surgery that has fifty percent chance of leaving healthy patients gravely disabled. If they survive. The average survival rate is 6 months and the average cost is 2.5 million dollars. Typically, he faired poorly and spent the remaining several months in ICU. Thankfully, he had excellent care and never wanted for anything. While on the floor he had 24 hour nursing care, a respiratory and physical therapist, cardiologist, pulmonologist and intensivist a commode a wheelchair and a walker. The most likely outcome from the beginning (as hard as it is to say as a daughter) was that he would not survive more than five years from his first diagnosis.  

Why was it so easy to get top of the line care for my father, but not my daughter? Even when they had the same insurance companies, it was always harder to get care for her. Layers of bureaucracy  lay between her and the simplest of procedures while he had a liaison in hospital who provided case management. In essence, they both needed similar care: physical therapy, feeding, changing and medication management. 

The answer is simple, but cynical. He was profitable. She is not. Insurance companies are not there to provide care, they are there to make money. In a free market system, his care made money, her care continues to lose money. He needed that level of care for a couple years after needing little for a long time. She will need a lot of care for a long time. 

In the real America, Main Street America, you get medical care if, on balance, you don't cost too much. That is fascism. It used to be a dirty word.

I think, on balance, I may prefer a single payer system. Call it socialism if you want. I will call it providing for the physical and emotional and spiritual well-being of the nation. I will call it family values. You might too, if someone you love actually needs medical care, not just insurance.