Tuesday, February 14, 2017

Why Healthcare is a Right, and is Consistent with our Founding Principles...

Donald J. Trump has been our President since he was sworn in on January 20th . One of the biggest issues he'll have to deal with is the nation's approach to health care. He has been quite clear that he believes the Affordable Care Act to be a disaster and had promised to repeal it in first week or so in office.

Today, February 14, 2017 marks the twenty-sixth day of his Presidency. He is two days into his fourth full week. The Affordable Care Act has not yet been repealed.

There is no consensus what will happen to the 30 million or so people who have signed up for health insurance via the ACA. Some think a repeal and delay approach would be best where the ACA would carry on for a year or two while its replacement was negotiated, but still give the Trump White House and Congress the ability to look America mostly in the eye and say, "We repealed the Affordable Care Act. Obamacare is no more!"

A smaller number of Conservative voices feel there should be no repeal of the ACA until the "replacement" plan is ready to be transitioned to. Still others have suggested all those currently covered via the ACA could keep their coverage and eventually the "greatness" of the new polices available after "Trumpcare" is introduced will be so appealing, so superior that over time, people will eventually abandon the polices and/or coverage via the ACA marketplace exchanges or the medicaid expansion.

Talk of terminating the main funding streams for the ACA may sound good, but if those streams are ended, while those services are permitted to be still provided is rife with problems. Such an approach will grow the deficit and debt, which combined with Mr. Trump's other campaign promise of a massive infrastructure program that will cost a lot would start the next Administration off on an odd way given all the rhetoric we heard about shrinking government and reducing spending.

Delivering healthcare is a complicated endeavor under the best of circumstances, and we're not remotely delivering healthcare to anyone in the United States under the "best of circumstances." More on that point later on.

A question that often comes up in the debate about what role, if any, should the government play in the delivery of health care to Americans - maybe the fundamental question behind the acrimonious discussion on the matter - is this.

Is health care in the United States of America a right or a privilege?

IN the typical debate about this question, one thing that those who think its a privilege bring up is that the words "healthcare" appear nowhere in our Constitution. The "its a right" crowd usually counter by saying its covered by the general welfare clause. Not really. "General Welfare" really meant that the Government would be able to keep itself healthy and in tact and able to function.

Keep in mind, the Supreme Court ruled the ACA and its "individual mandate" that required most Americans to obtain health insurance to pay a fine, to be essentially a tax, which gave it a different status than many thought it should have.

I think the place to look is in the Declaration of Independence.

Here's the phrase:

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. 


You won't find the phrase "healthcare" here either...

However...

"Men are endowed by their creator with certain unalienable rights." This basically means God has given us certain rights (not privileges,) that no one can take away.

"Among these are life, liberty and the pursuit of happiness." So... God gives us the right to be alive, to have Liberty from birth and to be able to pursue happiness. Let's look at the first of these unalienable rights from God.

Life: We have a right to live. I know we still execute people across the United States for various crimes and we're told those people lost their rights because they broke the law. Those words don't appear in the Constitution either, so it appears there's some negotiable wiggle room. If death can be an exception, can't life? Further, if life is a God given right, and its unalienable - then it can't be taken away. (Yet it is...)

We know African Americans, for example, weren't considered people and were abused terribly. The text of the Constitution doesn't include Blacks or Negroes or anything else.

We know women were denied the right to vote until the 19th Amendment was added in 1920. The Constitution doesn't mention women in its text.

It doesn't say except for crooks or Blacks... it says "men." Not some men or certain men or special men or white men or men who can afford it. It just says "men."

If we want to say we should apply the Constitution literally, then it has to be a 2 way street.

If we're entitled to live, its also implied we're entitled to have access to the basic things one needs to be able to live. Not live like a King, but not expire due to lack of food, heat, water, and yes...health care. 

We decided over fifty years ago that Americans should be able to get help buying food if they met certain financial criteria. Generally speaking, these were the poor people of our society, and while we hear about abuses (which OF COURSE should be addressed) we know that a LOT of people get public assistance. There's also assistance available to qualified people for heat, water, etc.

Next in the usual course of a discussion is the following, "Everyone CAN get healthcare.. all they have to do is go to the emergency room and they can get treated..."

Yes and no...

If a person is in an "emergent condition" the hospital must treat them to the extent that they are stabilized. That may take minutes, hours, days or potentially weeks depending on the circumstances. Emergency room care here in the US is very good, but also very expensive. We lead the world in medical bankruptcies, and this is one of the reasons why. People with no insurance have to pay cash for their medical services and for many - its a catastrophic amount of debt that buries them forever.

The law that compels the hospitals to treat such acutely ill or injured people doesn't afford much protections to those not yet in a emergent condition. You can't walk into an ER and ask for nutritional advice. You can't ask them to review your medications. You can't stroll in to an ER and ask for a treadmill test because you think you need one. You can't pop in and ask for a cup of dialysis. You can't ask for anything really.

Folks in that situation were typically turned away, and they were welcome to return when they were in a bad way. Then and only then would the Emergency Room staff be happy to help them. Hopefully, things wouldn't be too hard to repair or fix and there would be a happy ending. Too often, it wasn't a happy ending.

Emergency room care isn't health care. Its emergency medicine. Its not the sort of preventative health care one would receive from their primary care doctor. It's not screenings. It's not education. It's not routine checkups, blood work, urine tests, etc. It's not contraception. It's not nutritional guidance. It's not learning how to walk again or write again or speak again after something took those skills away. It's not an discussion on the options for end of life care that's occurring while a patient is in the middle of a crisis that may end their life.

In other words, its not the kind of health care that could help a person stay healthy or address a small issue on their own under the guidance of a primary care physician before it becomes an emergent condition which may be life threatening. 


Maybe they were kidding about life being unalienable?


So, allowing people to not have access to affordable health care creates a perverted dynamic. We, the people of this fine country won't help you to access the cheaper but vital healthcare that might in fact, keep you out of the very, very, very expensive emergency room where the care is great but where people still die in every hour of every day.

This also makes financial sense...

To which the General Welfare clause makes a a return visit to this discussion. The Congress is compelled to secure the general well-being of our government's fiscal health. GDP issues due to health care costs pose a major threat....

A look at thirty four other industrialized countries healthcare spending as a percent of their GDP:





From the managed care of the 1980's to the Affordable Care Act of 2010, the United States pays a higher percent of our GDP than any other country on earth. That's bad...

Another thing to note. Those other countries on the chart have universal coverage. They are able to provide health insurance to all of its citizens, while spending less as a percent of their GDP.

Pick your poison in terms whether you prefer Conservative or Liberal, Republican or Democratic style plans and approaches to address health care delivery in the US. Its inefficient and consuming more of our dollars than any other country in the world.

The so-called "greatest healthcare system in the world" also has major issues with its delivery and outcomes when compared to other industrialized countries around the world who offer universal coverage.

Consider...

*The United States has fewer physicians per 1000 (2.6) than the median OECD Country in 2013 (3.2)...

*Data from this decade shows Americans see their doctor on average fewer times (4/yr. ) than the median OECD country (6.5 visits per year.) Canadians saw their doctor on average 7.7 times a year. In Japan, the average number of visits is 12.9 per year.

*The US also has fewer hospital beds per thousand people (2.5) compared to the average median OECD (2.9), Germany has twice the number of beds as we do and Japan has over three times the number of beds we do.

*In terms of outcomes...

US life expectancy - 78.8 years
OECD Median  - 81.2 years

US Infant Mortality - 6.1 deaths among 1000 live births (highest among 11 countries studied)
OECD Median IM - 3.5 deaths

Chronic disease prevelance in the US (2 or more chronic conditions) = 68% of adults >65 yrs. old
Other countries in study, figures range from 33% in the UK to 56% in Canada

Obesity in the US is the worst in OECD countries...  35.3% of the US population is considered obese. Higher than any other country in the study.

While we do well with treating cancers, we don't compare well to other countries in treating diabetes, amputations due to diabetes, ischemic heart disease...

See the entire study from the Commonwealth Group here...

So...

We cover fewer people, in many cases our outcomes are less than steller to say the least and we pay significantly more for this level of "...effectiveness."

Bottom line:

Our approach to health care delivery in the United States since the 1980's through today is expensive, inefficient, unavailable to many and consuming far more of our GDP than any other industrialized country in the world.

If you have money or a job that provides you the access to health insurance you still have to deal with the terribly flawed, segmented and inefficient US health care system. If you're poor or don't have a job that provides health insurance benefits, depeneding on where you live - you may be with out access to even Medicaid, the public safety net program for poor people. Medicaid is administered by the States, and many have refused to participate in the Medicaid Expansion within the ACA. Currently, 32 States and DC have adopted the expansion, while 19 have rejected it. 

Without access to affordable health care and health insurance, people have a impediment to life, liberty and a pursuit of happiness afforded them by our Declaration of Independence. This issue hurts both individuals as well as the welfare of the United States.

The above reasons are the foundation of my position as to why healthcare is a right and not a privilege.





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