A Radical Idea for Health Care: Patient Approval.
Unless the Patient Signs Off, No One Gets Paid. Put the focus on the patient, where it belongs, by giving them the power to deny payment. And four other ways to make health care better.
In 1977, when I was 8, and my father was 44, he was diagnosed with stomach cancer. We lived in Winnipeg, Manitoba, and an initial surgery showed it was worse than they thought. They sent the results to the Mayo Clinic, in Rochester Minnesota, which sent a telegram to my mother with their regrets that the best case scenario, even if a surgery and follow-up treatment were a success, that we would have a year to live. My mother faced being a widow with four children 12 and under.
Dr. Jim McGoey was the surgeon who operated on my father at the St Boniface Hospital in Winnipeg, under Canada’s single-payer health care system. McGoey told my mother to throw away the telegram, because the surgery had gone well. McGoey was right: my father lived for another 21 years, not just one, when the cancer returned. My father was able to get treatment again, and though he died, my mother had no medical debt and didn’t have to worry about losing a house.
Canada’s health care system saved my father, and kept treating him when private insurance wouldn’t have covered him. He got to see me grow up. I got to have a dad. The Canadian system has lots of problems, but it has saved the lives and limbs of huge numbers of people who went on to live full lives.
Knowing what other systems are like, I am grateful for that.
The murder of a U.S. health insurance executives has rocked the US and sent shockwaves around the world. At the scene, the shell casings had the words “delay” “deny” and “depose” - a reference to how U.S. health insurance companies deny claims in order to increase profits.
The shooting was a shock, as it happened on the street in New York City, as Brian Thompson was walking to an annual meeting. Luigi Mangione, a young man in his 20s from a well-to-do family that actually owned and ran long-term health care facilities, apparently suffered from disabling back pain. The real shock was the reaction to the CEO’s shooting, where the shooter was treated by many as a folk hero, with people being positively giddy in their admiration.
If this is a shock, it should not be a surprise, and there are attempts to paint the reaction as being partisan, and widespread defenses of the health insurance industry somehow not being to blame.
“When nobody’s right, then everybody’s wrong.” The reality is that you can condemn murder and condemn business practices that lead to preventable deaths through the denial of payment for care. In fact, it’s the appropriate moral reaction to an industry whose business model is your money or your life.
Articles in the Economist, Vox, the Atlantic, the Washington Post and a variety of others have generally defended the industry as necessary while trying to shame people for not being adequately appalled (or not at all appalled) by a shooting.
This is the kind of argument that is based on a belief that people who have been immoral deserve punishment, including death, I happen to believe that that is inhumane and no guarantee of justice, because we should be able to agree that no one involved deserved to suffer as they did.
What is being ignored is the much larger reaction, which has been an outpouring of horror stories by patients and doctors alike.
It has to be said, that whatever complaints a highly divided American public might have about the real and perceieved corruption of their political opponents, they can, and have, come together in recognizing that the U.S. health system is monumentally morally corrupt, because people’s lives are ruined through bankruptcy or ended through denial of affordable care.
It is not an exaggerration to say that Americans have been tormented, physically and even psychologically tortured by their health care system, and the numbers are huge.
Bankruptcy was still common despite “Obamacare” or (the Affordable Care Act). “Myriad anecdotes—of a Nobel laureate who sold his medal to pay medical bills, or the more than 250 000 GoFundMe medical campaigns last year—attest to the financial toll of illness on American families. National surveys confirm that medical bills frequently cause financial hardship, and the US Consumer Financial Protection Bureau reported that they were by far the most common cause of unpaid bills sent to collection agencies in 2014, accounting for more than half of all such debts.”
15% of Americans - 1 in 6 Americans - had medical debt in collections.
There are people who continually refuse to believe that economic circumstance can play that much of a role in politics and elections - after all, the numbers always seem to show that everything is fine. That is because the 1970s neoliberal economic formulas are such a crude model of the economy they don’t include debt.
As a consequence, the mainstream economists and the people they advise in all parties don’t see the actual economic forces at work, and try to explain everything through “values” and “messaging” instead of dealing with reality.
In 2016, the political scientist Mark Blyth talked about “Global Trumpism”. Blyth predicted Brexit, and predicted Trump would win.
There are of course people who voted for Brexit, or Trump, and plenty of other nationalist parties because they are nationalists. There is lots of psychologizing and sociologizing about people in a way that treats them like animals, or punchlines.
The irony of all of the psychoanalysis is that it is, in itself results in a dehumanizing, reductionist othering and name-calling, which has a real political effect: everyone just gets angrier and more divided.
Blyth points out that if it’s all about racism and psychology, it doesn’t actually say much economics being any use.
So when they look into the data, “Trumpette” support in Europe correlates incredibly strongly with
“areas that have been exposed to Chinese import competition.” Areas that are exposed to competition from China in trade or services have very, very high support.”
"health inequalities. If you are poor and unhealthy you are more likely to vote for a right wing party - and a left-wing party.”
“Job insecurity - it’s not just the fact that you are being paid less and less, it’s that you have no control.”
This last is important - because in the UK, a category of people surveyed who felt that they had a “good deal of control over their jobs” had dropped from 30% to 9%. There are also, as Blyth notes, plenty of stories about how awful it is to work at an Amazon warehouse, or be a driver for UPS, both of which involve being tracked every minute of the day.
Blyth describes it as “an astonishing feeling of being disempowered and out of control.”
It has to be said, the numbers are simply too large for this to be a bipartisan issue.
Over the last quarter century, millions of people around the world have endured events that are profoundly traumatic and agonizing. Everything from attacks and wars in which many people died, and many came home wounded in mind and body, to financial crashes where people lost their homes, their health insurance.
Manufacturing workers in the U.S. lost thousands of dollars in income a year, and millions of jobs in the US were lost after China was granted favoured trading nation status around 2000. But it has happened everywhere: manufacturing disappeared from Canada, Mexico, Europe, and all around the world.
There are winners and losers in trade. This is known, and accepted in economics but the result is what one commenter called the “free market economist (FME) two-step”.
FME: Trade policy X will make us richer on aggregate
Other: What about winners and losers?
FME: Policy can be created to compensate the loser.
O: Sounds good, heres a policy we could use?
FME: Redistribution is distortionary, this cannot be allowed!
Politicians often ignore it and promise more jobs, which are not actually predicted by trade. What trade usually promises is that some people will lose their jobs, but the losses will be offset by gains for someone else, or in another sector. The gains may, in fact, go entirely to people at the top.
It is possible to shut down your factory in North America and ship the whole thing to another country, while keeping the executive suite in town, and massively increasing profits - but also keeping them offshore and not paying taxes on them.
With all of those job losses, people also lost their insurance. The opioid crisis, which resulted in addiction and deadly overdoses that have been killing 100,000 people a year.
For many Americans, their addiction started when they were prescribed Oxycontin, which they were told was not addictive, when the company knew it was. When people experienced withdrawal from the drug, they would seek out illicit sources.
For many people, clearly, this violation of trust is profound.
Scrolling through social media, I stumbled upon a woman talking about how appalling health insurance was and that the reason she had voted for Trump, was because she believed in RFK’s health plan.
I was surprised, but it occurred to me part of the appeal of RFKs message was that he is talking about solutions to health would appeal to people who have no access to affordable care. RFKs role in attracting voters has been nearly totally ignored.
Many of his statements are completely divorced from reality, and are frankly dangerous. People are anxious, and he is offering reassurance - false reassurance, yes, but reassurance just the same, when it isn’t to be found elsewhere.
So, in a very basic sense of how people are treated as human beings, the “scientific” health care system has made people feel worse - more anxious, disrespected and uncared for - while the wellness influencers who are frequently selling folk remedies, make people feel better because they are reassuring, even though the reassurance may be dangerously wrong.
Why the current market models for health care are so wrong
Matt Stoller wrote about the blame game for high costs in health care, as well as bipartisan efforts by Elizabeth Warren and Josh Hawley to try to break up “Big Medicine.” It’s a great and worthwhile read, and it brought my attention to an economic argument that explains why health care is so bad.
Stoller writes that “In 2020, one study showed that 34% of American expenditures on health care was spent on administration, about $2497 per capita, versus $551 in Canada.”
However, the real problem is the theory that the reason that health care costs are high is because of “overconsumption” - that patients are generating waste in the system with the health-care equivalent of nuisance calls.
As Rooke-Ley describes, when the Democrats took over in 2008, they would embrace the theory of managed care, but they would implement it differently, and call it by a new name: value-based care. And that gets to why Obamacare, aka the “Affordable Care Act,” was designed the way it was. The “overconsumption” thesis was put forward in one of the most influential articles in American health care history, Atul Gawande‘s 2009 piece in The New Yorker titled “The Cost Conundrum” that articulated the rationale behind the ACA. In it, Gawande argued that Americans spend too much on health care because doctors over-order it. “The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen,” he wrote. It is the “accumulation of individual decisions doctors make” that drive health care costs. “And, as a rule, hospital executives don’t own the pen caps. Doctors do.”
The obvious way to fix this dynamic would be to publicly ration care. Another way to do this would be to expand the existing system of private rationing through insurance companies, ie standard managed care. But policymakers were wary of the backlash to managed care and burned from the 1990s-era battles over so-called HillaryCare, which effectively sought to put everyone in a managed care HMO and have these insurers compete through “managed competition.” They needed a different way of private rationing of utilization. So they needed to hide the rationing. And that’s what they did. In 2009, for instance, economist Doug Elmendorf, a major player in policy debates, testified to Congress as to the reason health care costs were so overwhelming in America. He said it explicitly.
Given the central role of medical technology in the growth of health care spending, reducing or slowing that spending over the long term will probably require decreasing the pace of adopting new treatments and procedures or limiting the breadth of their application. Such changes need not involve explicit rationing but could occur as a result of market mechanisms or policy changes that affect the incentives to develop and adopt more costly treatments.
When I read this, I was surprised, because this policy of “managed care” that blames high costs on patients is also used in Canada. I have spent years arguing against it, both as an advisor to politicians, and in the five years I spent as an elected offician in Manitoba.
There are many reasons that rationining care is a terrible idea, when there is resource capacity in the system. However, in the province where I live, there are quotas for the number of hip replacements and knee operations that could be performed, even when there were surgeons, support teams and facilities available. In the last two months, there have been at least two outright disasters in two hospitals. In one, a patient had the wrong leg amputated. and in another, the patient faces losing a leg because there was no hospital bed to deal with a post-op infection. This is a direct consequence of austerity in health care blamed on overconsumption.
While people should be cautious, and allow for the possibility that natural healing may have better results than a medical intervention, for certain ailments, early detection, intervention and properly managed care all reduce long-term costs, as well as preventing a much more invasive and costly medical intervention later.
Rationing and postponing care, or increasing deductibles, shifts the costs and risks onto patients in ways that means that care will be denied not because it was unnecessary, but because it of abilty to pay, or profitability.
This is because of a view of the market that is not based in reality. It is the same, fundamentally neoclassical / neoliberal junk economics which blames everything on the either the government or customers.
How can anyone keep a straight face while they argue that the private sector and health insurance are keeping costs down, and are necessary to efficiently allocate scare resources, when the U.S. has the most costly and wasteful system in the world. Money is not scarce. Executives are being paid multi-million dollar salaries. It is 20% of GDP when many other countries get better results in systems that cost less, people are healthier and everyone is covered.
The entire debate is both intellectually and morally bankrupt because it doesn't begin to deal with all the ways that trying to use market principles can't possibly work where the stakes are life and death. What kind of bargaining power do you have with someone who can choose whether you live or die? How rational are you going to be when you are in agony and desperately want to be better, or not to die?
That's the problem with both doctors and insurance.
Add to that that there is no greater gulf in knowledge between patient and doctor in terms along the range of correct diagnosis, treatment options or costs. Patient, not client.
That is an absolute recipe for predation, and for moral catastrophe, which it is.
I will add that the reason these apologists are able to make these ludicrous arguments is that their economics treats everything strictly as a matter of supply and demand, without considering power imbalances created by these self-evident assymmetries.
Five Solutions for Better Health Care Everywhere
1: Patient Approval: The Patient Signs off on Payment
First, if people want to address the issue of cost, lets talk about the fundamental breakdown that is preventing all of this from working.
First, we have to recognize that new technology and developments create new political and ecnomic dilemmas. Since 1850, we have basically invented all of modern medicine, from pain relief and total cures. It has extended people’s lives.
Anyone can get sick, and not everyone can pay for it. This creates new moral and political dilemmas when a life saving treatment or cure is only available to a select few.
In this arrangement, while treatment of patients is supposed to be the purpose that justifies the existence of the whole system, the patient has the least control and negotiating power.
Instead, you have a system where people get paid whether the patient dies or not, and worse, where denying claims and increasing illness and death is more profitable. To say this is a “perverse incentive” is the kind of understatement around economics that is no different than military euphemisms like calling torture “enhanced interrogation techniques” or carelessly killing civilians and allied soldiers as “collateral damage.”
The solution I propose is to move to a system of “Patient Approval”.
The funds for treatment are not released until the individual patient, or a patient representative agrees to it. The patient has the authority to withhold or dispute charges, or refuse to sign when treatment is unacceptable. It’s got to be in good faith, as the rest of the system should be, too.
What this does is provide very clear feedback to the system about what exactly is not working.
Naturally, this proposal will be met by shock and opposition, by individuals who will claim that patients don’t have the knowledge to challenge charges - which, by regulation, should be very clearly laid out.
That illustrates the entire problem with a system where there is a power and knowledge imbalance between patients and caregivers.
If they don’t have that capacity, how can overdemand be the problem?
People will also ask whether this is going after people in health care.
This is a way of creating a patient-focused system by establishing a mechanicsm by which patients, who face the greatest risks of all in the system - the risk that they could die, and the opportunity to be healed.
The idea here is to decouple incentives that are immoral, and align incentives that are moral, because they are in the best interests of the person who faces the greatest risk and costs in the system. Risk in terms of their life and health, costs in terms of whether they remain solvent or not.
If people are presented with itemized bills of their stay, they can certainly ask why a single tablet of an over-the-counter painkiller would cost $150, and how much of their bill is going to bonuses that year.
The idea is that if the care is good, as far as the patient is concerned, you get paid. That’s the way it should work. If it doesn’t, the people doing a bad job pay the price, not the patient.
This could also work in single-payer systems, for the purpose of holding service providers and bureaucracies accountable, and providing continual and meaningful performance feedback.
2. More Affordable Medications
In the U.S. under George W. Bush, the government agreed that they would not bargain for better prices with pharmaceutical companies. In addition, trade deals and domestic intellectual property
Pharmaceutical companies have been extraordinarily profitable, and have continually sought and won extended patent and intellectual property protections that keep prices higher than are justified.
In Canada, a patent medicine review board that is arm’s length from government negotiates reasonable prices that are still affordable, Until the 1990s, Canada had no patent protections for pharmaceuticals at all. They were introduced by the PC Government of Brian Mulroney. Prior to that, Canadian companies could make generic medications based on the chemical formula of other medications. Once patents took hold in Canada, there were times where the fastest rising costs in health care were drug prices.
Allowing governments to bargain and get economies of scale when purchasing medications are an obvious, positive and common-sense reform for the U.S., which currently allows companies to set the price. This is legalized price-fixing for drug companies.
The routine response when this is raised is to issue a fearmongering threat: that unless drug companies can to charge exorbitant profits while enjoying a patent-enforced monopoly, they won’t bother to do the R & D and we’ll lose the benefits of new cures.
This is the same false argument that if you raise capital gains that investors won’t put money in in the first place.
More specifically however, pharmaceutical companies in the U.S. spend more on marketing than R & D, and just as important, as Marianna Mazzucatto has shown much of the fundamental research and breakthroughs are done at public, not private expense.
(This is true of information technology as well as pharmaceuticals.)
There’s also no doubt that the pursuit of profits has led to corruption, which has led to a disastrous loss of trust when there truly have been innovations that are nothing less than miracle cures.
There are millions of healthy people who are alive today because of innovations and medications and treatments that are incredibly effective and that could barely have been imagined within living memory.
Organ transplants, cancer treatments, joint replacements, insulin, and all sorts of treatments for physical and mental disorders that used to be certain death.
Once again, this creates a situation where drug manufacturers are in a position to say to the patients who need their medication to live, “your money or your life.”
The success of these medications has also led to hugely profitable companies, and that money involved has led to corruption in two important and profoundly negative ways.
One is the corruption of the norms and practice of science and medicine, because of conflicts of interest and conflicts of loyalty. The entire association of the bundled MMR (Measles, Mumps, Rubella) vaccine with autism was driven by a doctor in the UK who had the rights to alternate vaccines that were not bundled together, from which he would have personally financially benefited if MMR was scrapped and his vaccines were used instead. He succeeded in placing a bogus study in The Lancet.
This has been a serious problem, as pharmaceutical companies are the ones providing funding for research, where impartial research is not being funded.
The other is that some newly developed medications that are subject to patent protections, offering years of monopoly high prices, are not as effective as established medications. For example, “old-fashioned” diuretics that relieve high blood pressure are highly effective and low cost - which means they have much lower profit.
This creates yet another perverse incentive, which is that companies market the newly developed, less effective pill because it is the one that will generate more revenue, instead of a lower cost, more effective solution.
This requires regulation and effective oversight.
How this will actually play out in the U.S. when RFK Jr’s incoherent plans for reform run up against the Trump cabinet’s incoherent plans for deregulation, and how the affected corporations might respond.
3. Wraparound Primary Care
The U.S. has fewer doctors than many other systems, and there are shortages of doctors in Canada and the U.S. because the responsible authorities in both countries have been throttling the number of medical graduates for two decades, even as coming shortages were being predicted.
Aside from increasing training spots and residencies, a focus on primary care centres where a doctor works with a team of other medical professionals has been demonstrated to provide better care at lower cost through early detection and intervention.
Known as the “NUKA” model in Alaska, clinics greet patients and immediately take relevant diagnostic tests, including taking blood and urine samples on site, instead of giving patients orders to go to a lab elsewhere and report back, which can cause delays or break the chain of care.
The team may include a physician, a nurse practitioner who can prescribe medication, a mental health expert. Effective primary care is lower cost than crisis intensive care, and prevention of the complications of diabetes, which include blindness, amputation, heart attack, stroke and sudden death.
A similar clinic in Northern Manitoba saw better results and significant and immediate reductions in Emergency Room visits, hospitalizations and emergency travel, all of which have far greater costs.
The problem is the perverse incentives of the health care market - and of the market generally, which is that a crisis is more profitable.
4. Abolish Medical Debt
While Occupy Wall Street and the “Occupy” movement sputtered out, they did have one important legacy, which was what they called the “Rolling Jubilee” a successful scheme to buy and forgive people’s outstanding and distressed medical debt.
Using crowdfunded donations, the Rolling Jubilee abolished more than $32 million of medical, student, payday loan, and probation debt. We then collaborated with the New Economy Project to ensure that 120,000 judgement debts — worth $800 million — were forfeited and retired as part of a legal case.
When people in the U.S. cannot pay their medical debt, the initial holder of the debt gets fed up and sells it to someone else to collect - often for pennies on the dollar to a collection agency, which, having paid pennies, then tries to collect dollars again.
The Rolling Jubilee took donations and would use it to buy up that medical debt. I donated US$50, and was informed it was used successfully to clear $1,000 of someone’s medical debt.
To the free market enthusiasts who want to argue that prices are whatever the market says they are, the sale of distressed debt is a clear signal of what that debt is worth - next to nothing.
Canadians also have medical debts because many treatments and medications aren’t covered under different provincial plans.
5. Forever Chemicals
So called “forever chemicals” - PFAs - are now a widespread and widely knownhealth hazard. They are “endocrine disruptors” which means they mess with the hormones and development of humans as well as animals.
They are stain- oil and water resistant. They are found in some widely used agricultural chemicals as well as in consumer goods - Gortex clothing, scotchgard treatment for furniture.
What Are the Health Effects of PFAS?
PFAS from foods or drinks build up in your body and stay there for a long time. Some studies suggest that high levels of PFAS can lead to things like:
Changes to cholesterol and higher cholesterol levels
Developmental effects or delays in fetuses and children
Low birth weight
Early puberty
Changes in the bones of children
Childhood obesity
Decreased fertility
Changes in the body’s hormones
Changes to your immune system, making it harder to fight infections and reducing how effective vaccines may be
Thyroid problems and thyroid disease
A higher chance of kidney, prostate, or testicular cancer
Changes in blood pressure during pregnancy
Liver damage
Ulcerative colitis”
Here again, these are chemicals that are widely allowed and approved because they are a matter of corporate convenience and profit.
Here again, the incoherent policies of RFK Jr. to scrap dangerous chemicals will butt up against the incoherent Trump Cabinet policies of deregulation, all of which will be challenged by the companies that manufacture or use these chemicals.
These are non-partisan solutions for sometimes agonizing choices
There are other changes that could be enacted. I’ve focused on these because they are practical, achievable and aren’t ideological. It would be an improvement for the vast majority of any population.
The faith in the virtues of the free market stumbles on the reality that in health care, patients are in no position to bargain, and are faced instead with being supplicants and beggars, pleading for their lives.
The hardest part of all of this is that it deals with the most bitter reality of human existence, which is dying. Sometimes there is no cure. Sometimes the treatment involves profound discomfort or suffering.
Sometimes there are bottlenecks and scarce resources in the system that mean that only some people can get care.
These are real-life “lifeboat” situations, where we have to come up with ways of making these difficult moral and ethical choices. It’s similar to being in lifeboat on the verge of sinking, with limited water and food, and you have to choose who will die. These are not imaginary thought experiments - there really were such cases.
In his phenomenal book on ethical challenges of the criminal law, Bad Acts and Guilty Minds, Leo Katz talks about legal cases around real lifeboat situations.
Katz says we use four ways to allocate scarce resources. His insights are revealing as to why we choose them, and why some are more appealing than others .
1. The Committee — selecting people from a group of applicants
In the U.S. in the 1960s, kidney dialysis machines were in short supply, and could only handle one person at a time. LIFE magazine ran a profile on a the deliberations of a hospital committee tasked with deciding who, among a large number of candidates, would get treatment.
It came to be known as “The Seattle God Committee,” and it took a huge number of variables into account when choosing the patients who would receive treatment, going beyond their likelihood of survival to the number of children they might leave behind, their career, and more. Committee members agonized over each decision, since the choice meant that one person would live while another died.
The benefit of the committee, as Katz argues, is that it:
Preserves our sense of control and fairness because we get to make a case.
It discriminates by picking and choosing the best candidates — a poor righteous man with many children might be selected over a wealthy dilettante whose kidney damage is the result of a lifetime of binge drinking.
Its deficiency, says Katz, is that it humiliates the loser by pronouncing them inferior, because the decisions are made based on whether people are seen as deserving : “He is not just left wanting,” Katz writes, “he is found wanting.”
2. The Lottery — picking people randomly from a select group
A lottery might seem like a particularly outdated or unfair way of delivering health care, but it is being used today. When U.S. states resisted the expansion of the U.S. Medicaid program under the Affordable Care Act, Tennessee, did so by adopting a lottery. A single phone number was provided and only the first 2500 callers would receive care.
Katz argues that selecting people by lottery has the advantage that:
It doesn’t discriminate, because every person is treated equally — each person has the same chance of receiving treatment.
Its pitfall, Katz argues, is that it highlights and is open about our “social stinginess”: it makes it clear that we don’t have enough resources for everyone, and
Strips us of any sense of control. There is no appeal or argument to be made.
3. The Market — competing for price
Katz sees that there are a number of reasons we like the market approach.
It discriminates in two ways:
Patients can pay a premium for better service or faster access, but
Service providers will also shift their practices towards patients or specializations that generate more revenue.
Because we can earn or borrow funds to get treatment, it “preserves our sense of control, doesn’t publicly humiliate, and expresses no open preferences.”
The market solution creates the illusion that anyone can get access: the only issue is money. The reality, of course is that the cost of medical treatment is such that most people will be unable to afford care without either private or public insurance.
“No wonder,” writes Katz, the market “is so often used or recommended for making tragic choices.”
In the 1970s Arthur Okun wrote a book called “The Big Trade-Off: Efficiency and Equality”. It was a liberal challenge to the incoming “neoliberal” and neoclassical economics that were about to take over the U.S. and the developed world.
Okun had been in the interesting position of having been on President Nixon’s economic council, and also having been named on Nixon’s enemies list.
He wrote then that “The cliché should at last be validated: the market should not be able to legislate life and death.”
It says everything about the sea change in economic and political morality that no one today would recognize this as a cliché - in the U.S. - and creeping elsewhere - it’s that only the market should legislate life and death.
It’s a cliché that’s worth reviving. That, and “First, do no harm.”
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DFL