Is the Health Care Debate Missing the Point?

First, I have to apologize to my regular readers (I mean you, Dr. Camosy) for my failure to post anything new over this Lenten season. I was focusing on getting a full draft of my dissertation finished (success!) which kept me from dedicating any brain matter on blogging. So I have some catching up to do.

I would be remiss as an “EverydayThomist” to not post at least something on the health care debate. For those of you who live under a rock or in the 13th century metaphysics section of the library, Congress has passed a health care bill, expanding coverage to millions of uninsured. Historic, monumental, controversial.

Throughout the past months as the health care debate has totally consumed this country, I have been really confused about what the exact issue was. Expanding health insurance, sure, but why? It is not like health insurance is an intrinsic good, nor does there seem to be any clear link between health insurance and the common good. I never could really understand how expanding health insurance coverage made us a better society.

Now, maybe I am missing something. After all, I have been one of those people trapped under a Latin tome in the 13th century metaphysics section of the library (I can tell you more about judgment per modum inclinationis than health care reform, in all likelihood), but it turns out I am not alone in my ponderous state of trying to figure out the exact issue. In this month’s Atlantic Monthly, Megan McArdle questions the assumption about whether people with health insurance are necessarily healthier . . . or if those without health insurance are more likely to die:

Aside from an exchange between Matthew Yglesias of the Center for American Progress and Michael Cannon of the Cato Institute, few people addressed the question that mattered most to those of us who cannot buy an individual insurance policy at any price—the question that was arguably the health-care debate’s most important: . . . If we lost our insurance, would this gargantuan new entitlement really be the only thing standing between us and an early grave?

. . . Even Democratic politicians made curiously little of the plight of the uninsured. Instead, they focused on cost control, so much so that you might have thought that covering the uninsured was a happy side effect of really throttling back the rate of growth in Medicare spending. When progressive politicians or journalists did address the disadvantages of being uninsured, they often fell back on the same data Klein had used: a 2008 report from the Urban Institute that estimated that about 20,000 people were dying every year for lack of health insurance.

But when you probe that claim, its accuracy is open to question. Even a rough approximation of how many people die because of lack of health insurance is hard to reach. Quite possibly, lack of health insurance has no more impact on your health than lack of flood insurance.

McArdle cites a recent study by Helen Levy and David Meltzler on “The Impact of Health Insurance on Health” that finds that “many of the studies claiming to show a causal effect of health insurance on health do not do so convincingly because the observed correlation between insurance and good health may be driven by other, unobservable factors.”

While investigating some of these claims, I have also been watching, with a little bit of shame, Jamie Oliver’s new show Food Revolutions about the British cook’s efforts to make the unhealthiest city in America (“We are Marshall,” WV) a little bit healthier in part by bringing fresh, non-processed foods into the local elementary school menu and by teaching local families how to cook food that is both tasty and good for them.

In the first show, Jamie goes into the home of a family and lays out everything that the family eats on a weekly basis on the kitchen table. It’s pretty disgusting–lots of pizza and fried food, and what isn’t fried is processed. The whole family, including the cute little elementary school aged girl, is obese, which is why nobody is surprised (except for the parents) when Jamie takes them in to get a physical and finds their 14-year old son Justin is basically guaranteed to get diabetes. The doctor explains all the complications Justin is likely to face including the possibility of losing a limb, unless he makes some radical lifestyle changes. It’s a sad story, but Jamie’s point on the show is that it is not uncommon. On the first episode, he claims that this generation of children is likely to be the first generation in a century that does not outlive their parents due to early morbidity caused by diabetes, heart disease, high blood pressure, and other complications linked to obesity.

Why do I bring this up? Because 14-year-old Justin’s problem is not a lack of health insurance (though it is true that those who lack health insurance are more likely to be obese, to smoke, and to drink excessively), but that he is simply unhealthy. We are an unhealthy nation, to be sure, but I still fail to see how expanding coverage is going to make us, on a whole, healthier. As long as our children keep eating pizza and “potato pearls” in their public school cafeterias, and as long as their parents keep feeding them pizza and chicken nuggets for dinner, and as long as our suburban lifestyles become increasingly more sedentary, no amount of health insurance is going to solve our problems, or at least, so it seems to me.

So why focus on insurance? Honestly, I think our legislators’ hearts are in the right spot, but they recognize something implicitly that Jamie Oliver’s show makes very explicit–it is really, really hard to change people’s deeply-ingrained habits. He are in this country habitually unhealthy. We have characters disposed to overeat, to eat junk food, to watch sports rather than play them. And as these habits become stronger, and we suffer more as a consequence, we realize how hard it is to change. There is no legislative quick-fix for bad character, character disposed to make bad choices again and again and again. Such character change would require massive, multi-faceted change–changing stringent USDA regulations so as to allow more fresh food in schools, ending corn subsidies, urban planning projects that encourage walking, extended recess and play periods for children and teens, education, and the list goes on.

Where could Congress even begin? I don’t know, but I do know that it was easier to try and change health care legislation than it was to change people’s habits. And this points to a larger problem with the way we do government in this country–we really don’t craft legislation conducive to national flourishing, legislation designed to make people better people, legislation aimed at increasing virtue, rather than vice. We craft legislation to “fix” problems, without probing to see the foundational issue.

One of the really cool things about Jamie Oliver’s show is that he realizes that to get kids who are habituated to eat horrible processed foods to start eating healthy, he actually has to teach them how to eat. This requires lots of steps–teaching them how to use a knife and fork to cut chicken rather than picking up chicken fingers with their own sauce-covered fingers, teaching them the names of vegetables and which of their favorite foods come from those veggies (surprised that none of the kids filmed knew that french fries came from potatoes and ketchup from tomatoes?), teaching them how to cook and helping them to realize that cooking your own food is fun, and most importantly, giving them time to eat and encouragement to eat the right things. In a crowded lunch room where none of the first graders are eating his homemade burritos and salad, Jamie begs the administrator to give the kids more time to finish, then he painstakingly goes through the room, encouraging each child, helping them to realize the food in front of them was good, and rewarding “clean plates” with stickers and applause. He ends up fairly successful, but look how much time, energy, and effort this takes. And these kids need such encouragement everyday for the next few years to reverse all the negative habituation they have had since birth to think that processed finger foods are good. These are not the things that government is good at doing. Sadly, it is what needs to be done.

And so now more people have health insurance, and I guess we will have to wait and see if we become a healthier nation as a result. I, for one, am not holding my breath.

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4 comments so far

  1. Micah on

    Hey Beth, really interesting stuff. I am certainly no expert and have not followed the healthcare debate very closely, but to me it seems that the issue is an economic one. Maybe lack of insurance won’t get me killed any faster, but it does make financial progress much harder. I just got insurance through working at Starbucks, so things are going well at the moment, but had my wife gotten pregnant before that we would have been looking at 8-10 thousand dollars of medical bills for doctors’ and hospital fees. I have no idea if this bill is actually a good way addressing the issue but I’d sure love to see a way for people with big medical problems to not get financially sunk by their medical bills.

  2. Michael Rubin on

    Beth,

    I have the easiest answer to your essay. In it, you ask, “We are an unhealthy nation, to be sure, but I still fail to see how expanding coverage is going to make us, on a whole, healthier.”

    Health insurance is not just about who eats right and who avoids obesity. It is also about….. detecting and treating diseases.

    Keith Olbermann (yes that liberal guy from MSNBC) helped raise money for several free clinics in which thousands of people showed up to without health insurance to get checked by doctors. Some of them had not seen a doctor in years. A number of them were diagnosed with diabetes. They would then have to start checking their bloodsugar.

    I think at the free clinics they may have detected some people to already have Cancer. Let’s face it, the earlier people find out that they have Cancer, the more likely it can be treated. Many Cancer patients may not noticed something is wrong until it’s too late. But without health insurance, people are less likely to get preventative checks to avoid diseases, no matter how healthy they may look.

    This is not just an issue about eating healthy and exercising. Having health insurance and going to see a doctor regularly can actually prevent diseases from killing people. It’s that simple.

    Michael

    • everydaythomist on

      Hey Micah,
      Thanks for commenting. I do think that it is better, in our society, to have health insurance for exactly the reason you mentioned–when something comes up, you may get treated, but without insurance, you are in for a load of debt down the road to pay for things like pregnancies, appendectomies, stitches, and broken bones. So now the government requires you to buy insurance rather than letting you choose to go without, and subsidizes the cost for those at a specific percentage above the poverty line. I assume that you would be one of the ones to benefit from such subsidies prior to your Starbucks job?

      Michael,
      You are right that detection and prevention are important tools in health care. However, I want to raise a couple of questions for you.

      First, early detection is actually not always in a patient’s benefit. A NYTimes article yesterday revealed that CT scans to screen patients for colon cancer put patients at unnecessary risk of radiation poisoning. A frightening stat in that article was that as many as 14,000 people die every year from radiation-induced cancers that result as part of the screening process. The risks involved with early detection have received particular attention involving PSA screening for prostate cancer. PSA screenings have led to the overdiagnosis of prostate cancer, putting patients at unnecessary risks involved in the surgical and chemical treatment of what turns out to be benign abnormalities in the prostate (an October episode of This American Life entitled “Less is More” originally brought this to my attention). So frequent screening and early detection is not actually always better.

      Second, my husband has health insurance and basically never goes to the doctor to get screened for anything. This is a more common problem than you might think. A lot of screening and detection failures are not due to a lack of financial means, but a lack of awareness, and perhaps more importantly, intention. People who feel healthy simply do not go to the doctor, regardless of whether they have health insurance or not. I fail to see how the health care bill is going to change that. How often do you go to the doctor?

      Last, I am a big fan of free clinics, which are often staffed by highly motivated people who do a lot of good on a small scale. Because the clinics have limited resources, they are usually very small and community-specific, that is, able to provide for the specific needs of a given community. I wonder how these free clinics are going to fair as we move more towards large-scale distribution of medical goods through hospitals. Do you think we will still have highly motivated people staffing these clinics if their patrons can simply go to the hospital and get what they need? Maybe, since illegal immigrants aren’t covered, the free clinics will turn their attention to the health needs of the immigrant population.

  3. Charles on

    I think it really is an economic issue. Atul Gawande writes in this week’s New Yorker:

    “In 1965, health care consumed just six per cent of U.S. economic output; today, the figure is eighteen per cent. Nearly all the gains that wage earners made over the past three decades have gone to paying for health care. Its costs are curtailing all other investments in the economy, and, if they continue to rise as they have been doing — twice as fast as inflation — the reform’s subsidies, not to mention America’s prosperity, will indeed prove unsustainable.”

    Do I think health care is a human right? Nope.

    Do I think the current reform will improve the nation’s healthcare? Nope.

    Do I think the reform act will cause Americans to start taking more responsibility and making more informed choices about their health? Nope.

    Do I think government-run or private enterprise health care delivery systems bring the same level of dedication to its clients that free clinics do? Nope.

    Do I think what we’ve been doing will bankrupt us if we don’t change it? Yup.

    Do I think the reform act will improve health care delivery? Yup.

    Do I think the reform act will save some individuals and families from bankruptcy-by-health-care-bills? Yup.

    Is this a bad thing? Nope.


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