Health Care Reform

Dr. John Lantos

Dr. John Lantos is a leader in American bioethics. He has been president at different times of the two leading bioethics organizations in the United States, the American Society of Law, Medicine, and Ethics, and the American Society of Bioethics and the Humanities. He served on President Clinton's health reform panel, and based on that wrote a book called Do We Still Need Doctors? He has taught a course in health policy for 20 years at the University of Chicago. He's appeared, and I'm sure this is most important, on Oprah, Nightline, and Larry King. Five times named as one of Chicago's best pediatricians, he is now starting a pediatric bioethics center at our own Children's Mercy Hospital. There are many more things to say about Dr. Lantos. It's a privilege to introduce him. He will address us on the subject of health care. Dr. John Lanthus.

Dr. John Lantos

Thank you very much. Coming up to the bimah on Yom Kippur reminds me of my bar mitzvah. What I mostly remember is the feeling like I was about to throw up.

Dr. John Lantos

But I want to thank Rabbi Levin for inviting me this morning. I'm new to Kansas City, and it's nice to be welcomed by the Jewish community. Though the more I learn about Congregation Beth Torah, the more I realize that Being invited to this congregation to address the topic of health reform is not necessarily a friendly or hospitable gesture. We're going to discuss some of the ideas that I'm talking about here later this afternoon in a session at 5 o'clock. And it's such a divisive topic that interaction is really the best way to do this. And there's really no way to do that now, except if I say something you really disagree with, what our rabbis say you should do is hold up your prayer book and shout, you lie.

Dr. John Lantos

And

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that would at least keep our dialogue at about the same level as that in Washington.

Dr. John Lantos

So

Dr. John Lantos

let me start not with health reform, but with Sonia Sotomayor's appointment to the Supreme Court. To me, the most remarkable thing about her becoming a justice of the United States Supreme Court was not that she was a woman or that she was Hispanic. Women and Hispanics have always had what it takes to get to the Supreme Court. What was

Dr. John Lantos

most

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remarkable to me was that she had diabetes since she was eight years old. Until this generation, most people who were diagnosed with diabetes in childhood would have developed so many complications, renal failure, coronary artery disease, blindness, peripheral vascular disease, by the time they were 50 that the grueling work of a Supreme Court justice would not have been possible.

Dr. John Lantos

Until the 1920s, diabetes was a rapidly fatal illness, and after the discovery of insulin, it was transformed into a chronic degenerative disease. Diabetes treatment has improved because of new and better forms of insulin and because of new and better ways of monitoring blood sugar, particularly the development of very high-tech microcomputer chips and little insulin pumps that allow better minute-to-minute control of diabetes, which is crucial to preventing long-term complications. Technology and pharmacology are not enough, though. Good outcomes also require excellent primary care. And in one recent study, The best predictor of long-term outcome for people with diabetes is whether on each clinic visit the doctor or nurse takes off their socks to examine their toes for the sign of ulcers. This is a disease for humble practitioners.

Dr. John Lantos

It is remarkable that Ms. Sotomayor could get such care growing up as she did in the public housing projects of New York City. It could only have happened because New York City has one of the best healthcare safety net systems in the country. a network of public hospitals and city clinics which care for everyone regardless of their ability to pay. And thanks to that system, even poor children with type 1 diabetes can grow up to become Supreme Court justices. I was thinking of Ms. Sotomayor and her health story this summer while I was having some health problems of my own. My prostate story is every man's prostate story. I had my PSA checked at a routine physical. It was slightly elevated. A biopsy revealed a low-grade tumor. I was faced with that choice about which experts in the field disagree. Surgery, radiation, watchful waiting. And I was given all the options and was free to choose.

Dr. John Lantos

At the time of my diagnosis, I was about to leave one job and start another. So as I got my diagnosis, I also felt the dread of what it would be like to get such a diagnosis without insurance. Of course, I could have extended my employer insurance for 18 months with COBRA because of federal mandates for this sort of thing, but that would have cost me $700 per month. What if I hadn't found a job, if I'd just been laid off? Then I'd have joined the growing ranks of the uninsured, and with my new diagnosis, the uninsurable. As it was, I got excellent care through my HMO. To this day, I have absolutely no idea what my care cost. I paid a $10 copayment, and that was it. I felt lucky, but I also felt that dread that comes with realizing how much luck you need. Without luck, my outcome and Ms. Sotomayor's might have been very different. We are all one biopsy result and one pink slip away from both life-threatening illness and bankruptcy.

Dr. John Lantos

Now in most other countries, most industrialized countries, such arbitrariness, such bizarre lotteries for medical care, such fear of being excluded from the system have become things of the past. In those countries, health care is just there. The way clean water or police protection or electricity are just there. After the surgery, in my month off, I went to Monhegan Island, a beautiful dot of land ten miles off the coast of Maine. It is a place of stunning natural beauty. Waves crash against stark granite cliffs, and the waves seem powerless, the rocks immovable and permanent. But we know that those persistent waves can wear away even granite cliffs with persistence Even things that seem unchangeable can be shaped and altered. Monhegan Island was a good place to heal and to ponder the intractable problems of our healthcare system.

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I thought about my two brothers,

Dr. John Lantos

who also have prostate problems. My older brother, Jeff, like me, had an elevated PSA. He had a biopsy and his too, unfortunately, was positive. He had surgery and was cured. He's a school teacher in the LA public school system. with health insurance through his job. He paid his $2,500 deductible, much more than my $10 copay, and the rest of his care was covered by insurance. He took his sick leave and had no lost income during his illness. My brother Tom also had an elevated PSA. His biopsy luckily was negative, but 24 hours after the biopsy he developed septicemia and was admitted to the ICU and nearly died. He was in the ICU for a week. He's a psychiatrist in private practice and buys his own health insurance, and because he was previously healthy, chose a policy with a high deductible. So he paid $10,000 for his care. He had to pay out of pocket. So we three brothers all got the same diagnosis at about the same age. We all had different insurance. I paid $10, Jeff paid $2,500, and Tom paid $10,000.

Dr. John Lantos

And he wasn't even sick until the biopsy made him sick. I'm sure every family has stories like this, curious little parables about the ways that our health care system treats people differently.

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We are in

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the midst of the great Obama health reform debate. periodic national conversations about the healthcare system. Such conversations have become almost a ritual of American life. We elect a Democrat to the White House and debates begin anew, as ritualistic and predictable as a kabuki play. Each time reform seems urgent, each time our highest hopes and our darkest fears are both engaged, each time we are treated to the dire statistics of the utter unsustainability of our present system. Harry Truman in 1948 famously predicted that if health expenditures in the United States ever went above 4% of the gross domestic product, the economy would implode. They are now at 17% of a much larger gross domestic product, and Harry was wrong. Health expenditures seem to be one of the few things that is sustaining the economy during this recession. And then each time, so far, in these great debates, we chicken out of comprehensive reform and opt for another patch, another crutch to keep our old nag of a healthcare system hobbling along. Roosevelt settled for social security. Truman funded the construction of hundreds of hospitals, mostly in rural areas throughout the US. Johnson got Medicare and

Dr. John Lantos

Medicaid. It's not just the Democrats.

Dr. John Lantos

Nixon proposed a national health insurance plan and also passed the bill that created HMOs. Reagan implemented a radically new way of paying hospitals for medical care, the diagnosis-related group. George W. Bush passed the Medicare prescription drug benefit and also increased funding for community health centers. Each new piecemeal program adds to the astounding complexity, the enormous bureaucratic inefficiency and the bizarre irrationality of our health care system. The stories of me and my brothers illustrate what I see as the major problem of this crazy system. It is not that it is unjust in the way that usually bothers liberals. That is, it is not a system in which only those with money and power get good health care, or in which the poor, the minorities, and the disempowered suffer systematic deprivations. When you look at those without insurance, they are not, for the most part, the poorest people in the country. The poorest people qualify for Medicaid, a $400 billion federal program. The elderly get Medicare at a price tag of another $500 billion. The sickest or the chronically ill or the disabled qualify for Medicaid, Social Security, and something called SSI.

Dr. John Lantos

So who are the uninsured? About 40% of the uninsured, 20 million people, live in families with annual incomes over $50,000. They are the small business owners or the employees of small businesses, entrepreneurs. They are young people right out of college.

Dr. John Lantos

10 million are not US citizens, though most are legal immigrants and pay taxes. Many of the rest of the uninsured qualify for one of the existing programs but either don't know that they are eligible or don't know how to enroll. Almost all live in major metropolitan areas where most of the safety net providers are. Twenty million Americans get care at one of 1,200 federally funded community health centers, places like Swope or Rogers in Kansas City. And their care will be either free or billed on a sliding scale according to the patient's income. Safety net hospitals like Truman or Children's Mercy get money from the federal government based on the amount of uncompensated care they provide for the poor. And these disparate elements of our public safety net system cost as much per capita as most countries' total expenditures on health care. That is about 9% of our GDP, or about a trillion dollars a year. But because we have both this private and a public system, our administrative costs and our inefficiencies multiply. The complexities of the two systems trying to work together make it difficult for people in either system to figure out how to get the medical care to which they are entitled. Are there people who fall through this safety net? Sure, but this is crucial. They are not, for the most part, the neediest people in society. Lack of insurance or under-insurance is much more random than that. So our problem is not the cartoony sort of injustice that liberals endlessly decry and conservatives haughtily deny. It is not primarily a lack of justice. It is a lack of fairness. Justice would require attention to these power differentials and income differentials. Fairness requires only a universal set of rules. And making rules is what our crazy government does best. We create agencies that make and enforce rules. This levels the playing field and makes market competition possible. The SEC, the FAA, OSHA, EPA, they all make rules. And the health care system needs some equivalent, a rule book and a referee.

Dr. John Lantos

As it is, we're playing with hundreds of sets of rules. Each state has its own regulations. Each insurance company has its own policy rules. Each employer makes deals with insurers and employees. And the costs are hidden. Everyone tries to game the system and get their hands on some of that $2.4 trillion that flows through our health care system each year. Insurance companies have strong incentives to deny expensive care. Each doctor and hospital has strong incentive to preferentially treat patients who have the best insurance and shun patients who have the worst. No wonder we have more specialists and fewer primary care docs than any other country. And no wonder those specialists provide care that is expensive, high-tech, and lucrative, even though it often leads to outcomes that are no better than the outcomes in countries with different incentives. or the type of care that's offered looks very different. Examining the feet of diabetic patients is not one of the big money makers, all the more reason why Ms. Sotomayor's life is so remarkable and why, without reform, it may be harder for a child with diabetes today to do as well as she did than it was in the 1950s.

Dr. John Lantos

We could change all this. by starting with one simple rule. People should not be denied health insurance because they are sick. Now, like all good rules, even, say, the golden rule, this is not as simple as it sounds. To implement this rule, the very nature of health insurance would have to change. In all other domains of insurance, if you have an insurable event, your rates go up. You crash your car, your car insurance costs more of it. Healthcare is different. We're not insuring against random and unpredictable events. We are insuring against the inevitable. We all get sick. We're all going to die. Changing eligibility requirements then, saying nobody could be denied, would change the amounts that people would have to pay. It would also require that everyone buy health insurance, or else the rational thing would be for everyone to wait until they got sick. and then buy health insurance, which would not work as

Dr. John Lantos

well.

Dr. John Lantos

So if everybody bought health insurance, it would have ripple effects on Medicare, Medicaid, medical schools, and hospitals, as well as, of course, on doctors. In the insurance company, the system is like a spider's web in which a disturbance at any point disturbs the whole, or perhaps a better analogy is a Rubik's Cube. You fix one side, you screw up the other. So inevitably we end up with 1300 page bills in Congress, aggressive lobbying about the details and fears about who will win and who will lose. A change to make the system fair would be complex, but that doesn't mean it's impossible. After all, the status quo is pretty complex and we've learned to live with that. A change would cost money. But the status quo is going to cost money too. Healthcare expenditures have gone up at twice the rate of inflation for the last 25 years. So when people talk about a trillion dollar price tag for change, the comparison is not what we have now, but where we'd be without the change.

Dr. John Lantos

Amidst all this complexity, it's wrong, it is wrong for liberals to insist that only government solutions can work. and for conservatives to insist that only markets can work. Especially because liberals in America are not really leading-heart socialists. They like markets as much as anyone. And because conservatives are not really heartless capitalists, they also believe in charity and safety nets. We have much more in common than it seems. We really should be able to talk about these issues, these problems, and possible solutions without shouting or carrying weapons or invoking Nazis or demonizing capitalists or insurance companies. None of us is pure, none of us is perfect, and we are all in this together. Yom Kippur is a time to think not just about matters of life and death, and health reform is a matter of life and death, but also to think about our sins and transgressions, both personal and political. We recite these long lists of sins not because we individually necessarily committed each and every one of them, though some might have, but instead to remind ourselves of the ones we have forgotten and to take responsibility of the ones that may have been committed by other Jews, by other members of our sacred community, and thus in our name and in the name of God.

Dr. John Lantos

So for the sins we have committed by tolerating the unfairness of our health care system, the sins we have committed by our complacency in the face of other people's suffering, and for the sins we have committed by selfish partisanship and destructive divisiveness at a time when we need to come together as a community to solve one of our most important communal problems, for all these, God, forgive us, pardon us. Grant us atonement. Shana tovah.