Arizonacare and a Cry in the Wilderness

I don't read a whole lot of Sarah Palin's writings. But I was just looking at this one. What mainly caught my eye was this passage:

The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.

We do have government healthcare already, of course, and lots of it. We have the Federal Employees Health Benefits Program (FEHBP), through which private insurers deliver health benefits to federal employees and retirees under contracts with the Office of Personnel Management (OPM). We have the military's TRICARE system. We have a network of government-run VA hospitals. We have the Medicare system for the elderly and we have Medicaid for low-income people, and the Children's Health Insurance Program (CHIP) that insures children of families with incomes that are low, but too high to qualify for Medicaid.

Medicaid is funded partly by the states and partly by the federal government. The states administer their respective programs and decide what services will be offered and who will be eligible for those services. Medicaid services are offered under various names. In Arizona, the Medicaid program is called the Arizona Health Care Cost Containment System (AHCCCS, pronounced "access"). From what I have read, AHCCCS is considered to be one of the more generous incarnations of Medicaid.

The reason I've been reading up a little on government healthcare in general and AHCCCS in particular is because of a radio program I listened to a couple of days ago. The program discussed how Arizona is cutting back on AHCCCS as part of a more general budget-cutting effort. Specifically, the Arizona legislature voted in March to rescind approval of certain kinds of organ transplants. The bill in question was signed into law by governor Jan Brewer and took effect in October. The legislature and the governor supposedly based their decision on scientific data indicating that the specific transplant types in question are ineffective (a justification that has been rejected by the American Society of Transplant Surgeons (ASTS)). Eliminating AHCCCS coverage of the transplants in question will save an estimated $4.5 million, or about 0.3% of the projected $1.5 billion deficit.

This unfortunately comes at the expense of 98 Arizonans whose organ transplants had been approved by AHCCCS, but have now been cancelled under the terms of the legislation. The aforementioned radio program spent a large part of its hour looking at the plight of one of those people, a guy named Randy Shepherd. At 36, Randy has a wife, a young daughter and a case of cardiomyopathy that has been slowly destroying his heart muscle since he was a teenager, for which reason he was (formerly) approved by AHCCCS for a heart transplant. Randy is an AHCCCS recipient because his inability to work means he has no income, and due to restrictions on pre-existing conditions, it's apparently the only insurance he could get anyway. 

The Arizona legislature is controlled by Republicans (40 of 60 seats in the House, 21 of 30 seats in the Senate). All Democrats in both the House and Senate voted against the bill that cut the transplant funding (HB 2010). All but two Senate Republicans and one House Republican voted for the bill (details here). Republican Governor Brewer signed it into law. While I'm at it, I might as well also note that both US senators and five of eight US representatives from Arizona are Republicans. Not unlike Sarah Palin. The one who warned us about "death panels". The one who predicted that "government health care will not reduce the cost; it will simply refuse to pay the cost." The one who asked, "And who will suffer the most when they ration care?" and answered, "The sick, the elderly, and the disabled, of course." The one who asserted, "Such a system is downright evil." Welcome to Arizona, Sarah.

How's that dyin' of heart failure thing workin' out for ya?

While I'm at it, I might as well mention that one of those Republican US senators from Arizona is John Kyl. You may be aware (as reported here, for example) that Kyl recently complained about Senate majority leader Reid keeping the Senate in session so close to Christmas to debate the New START treaty by saying this was "disrespecting… one of the two holiest of holidays for Christians and the families of all of the Senate, not just the senators themselves but all of the staff". I could spin this tangent a little further by noting that by this logic, we should probably close all hospitals, police stations and fire departments on two days out of every year. But I really just wanted to observe this as one more example of how quick conservative Republicans always seem to be to play the "Christian nation" card when it suits them. Yet I don't see that card being played as the Arizona state government moves to resolve a tiny fraction of its budget problem by withdrawing life-saving treatment from 98 Arizonans. I would think that committed Christians would at some point have stumbled across Matthew 25:31-46 and would want to act accordingly; my mistake.

The Democrats are killing Christmas!

I could stop here and bask in Schadenfreude over such blatant examples of Republican hypocrisy (you will have no doubt divined my own political orientation by now). But that's really not the point I want to make. The point I really want to make is this: When are we, as a nation, finally going to stop acting like a bunch of nine-year-olds shouting "I know you are, but what am I?" (or worse) at each other and have a discussion like grown-ups about healthcare and any number of other pressing issues facing the country (the national debt, crumbling infrastructure, energy issues and spiraling higher education costs, to name a few of those)? When are we going to realize that name-calling is not the same as a program?

Let's go back to healthcare in general and the AHCCCS situation in particular. If I step back from polemics for a minute, I have to ask this question: "It's horrible that 98 people were taken off the transplant program; so what should we cut instead? School lunch programs? Education? Infrastructure maintenance?" I'm sure there are a lot of non-essential and downright frivolous things that could be eliminated, but let's be realistic and recognize that even that can only be taken so far, and that what may sound like a frivolous waste as a soundbite on CNN may actually be pretty important. For instance, I read a suggestion somewhere that nearly half of the $4.5 million for the eliminated transplant program could be restored by instead cutting a $2 million program to "study algae". When you paint it in those terms, it seems like a no-brainer to get rid of something as dumb-sounding as that. But when I looked a little more closely, I learned that this funding is for R&D on algae as a source of biofuel, which could spawn programs that will help address the country's energy problems and also bring a lot of revenue to Arizona, which doesn't sound so dumb. Maybe that really is more important than the lives of 98 Arizonans; maybe it's not. Maybe both things are needed and the solution is to collect the additional taxes needed to pay for them. This is a critical policy decision that needs to be debated by looking at the substance of the issues involved and not by seeing who can generate the cleverest slogans.

I'm pretty happy about the healthcare reforms that were signed into law this year. They are going to help millions of Americans. But let's also concede that they come at a cost. For instance, getting rid of coverage denials for pre-existing conditions is a very humane thing to do, but I don't think you have to be an actuary to conclude that adding people who by definition are high-risk individuals to the insurance pool has to raise the overall cost of covering that pool—that's basic statistics (an expected value calculation, to be specific). In the medium to long term some of that cost will be offset by savings through things like administering affordable preventive treatment through regular doctors to those individuals who are currently uncovered and therefore wait until they have a really serious condition and then show up for really expensive treatment given "for free" in the emergency room (with the real cost absorbed by the hospital and then indirectly passed on to you and me anyway). But at least in the short to medium term I expect to see my own premium costs go up for a given level of care as a result of these changes.

But my bigger concern is this: All we are really doing with this recent reform is tinkering with an existing system that is phenomenally inefficient. A few minutes of Google searching on terms such as "US healthcare per capita spending" will turn up lots of studies and reports showing that compared to the other industrialized countries, we have the highest per-person spending on healthcare but get significantly poorer results. Extending coverage to people who couldn't previously qualify for it is laudable but it's not going to address such fundamental flaws in the system as the crazy patchwork of different health insurance plans that drives up doctors' administrative costs, or provider compensation schemes that reward volume more than outcomes. We have not had a serious discussion about actually replacing the system with something better, and we have not had a serious discussion about alternatives that are practiced elsewhere in the industrialized world.

We don't have to choose between the current US model and something like the Canadian or British systems that conservative Republicans love to bash. In between the extremes of national single-payer systems (e.g. Canada or Great Britain) and completely unregulated, market-driven systems there is a whole range of possible solutions to consider, e.g. the German system, my personal favorite after having lived there for many years and having had only positive experiences, even though I know that it, too, has its imperfections. For a more in-depth discussion of healthcare systems in other countries, and their respective upsides and downsides, than I can offer here, I would suggest the book The Healing of America by T. R. Reid; for now, here is a short article in which Reid discusses some of the key ideas presented in his book.

The closest that we have come to a discussion about real change in healthcare is with the brief dust-up over the "public option". But we did not have a serious debate about that. And we most certainly did not have an adult discussion about the fundamental issue of whether healthcare is a fundamental human right to be guaranteed by the government, or a service that will be sold in whatever manner generates the most profits for those who provide it, or something in between. The broad American middle did not say to the right, "I want to hear what your program is; I don't want to hear a bunch of blather about about death panels and socialism," and to the left, "I want a credible accounting of how much this will cost and how it will be paid for." Nor did it say to itself, "I accept that I may have to change my whole way of looking at this problem and that in any case I can't get something for nothing." We just settled for people yelling at each other on TV "news" shows. We also didn't demand that anyone who said "no" to the proposals on the table propose an alternative, or at least publicly acknowledge that the benefits to those who would be helped by those proposals are, in his or her opinion, simply not worth the money.

In summary: we need solutions, but we seem to be satisfied to settle for slogans. Wake up, America. But more importantly, grow up.