The Promised Land of Health Care

Service and Sermon by Jaco B. ten Hove
Paint Branch UU Church - February 6, 2005

READINGS [Following Hymn #395: Sing and Rejoice]

 

INTRODUCTION:

"Let all things living now sing and rejoice" while they can-because living bodies are complex organisms that break down in complex ways in our complex, dangerous environment. It is a fact of life that no one is immune to the potential of declining health, let alone injury, and thus, a huge healing industry has grown to address those moments when any of us might need medical attention.

How a society organizes its resources toward healing its members says a lot-about what and who matters, about power, about justice. Today, I will examine this provocative, timely and critical subject from those angles, after having closely followed relevant media reports for the past few months. There is no shortage of material to consider, certainly, and much of it is rather distressing.

I suspect there are plenty of you also deeply involved in this issue, perhaps by necessity, who can testify to the demands on us from this often extremely complicated topic. But the bottom line is not very complicated. It's getting steadily better for large corporations and steadily worse for most people who aren't thoroughly insulated by wealth.

Now, lest you think I am falling prey to the fear-mongering doomsayers who are just stirring up trouble, let's get a quick reality check from our first reading this morning, adapted from Time Magazine and a new book by Donald L. Barlett and James B. Steele, called Critical Condition: How Health Care in America Became Big Business-and Bad Medicine. Their summary descriptions are well-documented and irrefutable, if painful.

READING #1:

This is the picture of health care in the United States. We spend more money than anyone else in the world-and yet have less to show for it than other developed countries. That's one reason we don't live as long. We don't adequately cover half the population. We encourage hospitals and doctors to perform unnecessary medical procedures on people who don't need them, while denying procedures to those who do.

We charge the poor far more for medical services than we do the rich. We force senior citizens with modest incomes to board buses to Canada to buy drugs they can't afford in (the U.S.).

We clog our emergency rooms with patients because they can't get in to see their doctors. We spend more money treating disease than preventing it. We are victims of rampant fraud and overbilling. We stand a good chance of dying from a mistake if we are admitted to a hospital, and we kill more people with prescription drugs than with street drugs like cocaine and heroin.

We have an endless choice of health-care plans, but most people have few real choices. We are forced to hold bake sales, car washes and pancake breakfasts to pay the medical bills of family members when a catastrophic illness strikes.

Americans tend to believe they have the best health care system in the world, but in truth it is a second-rate system, destined to get a lot worse and much more expensive.

TRANSITION:

This dubious and deteriorating health care system of ours is based largely on calculated risk, the bread-and-butter of most insurance companies, which seek to profit by insuring a large pool of people. They use actuarial tables-statistics-to improve the odds that more of their clients will hopefully require less attention, which then pays for those who do need attention.

Our second reading wonders if continuing to tweak this dominant method of private health insurance is ultimately appropriate. It raises the possibility of a tumultuous shift to more universal coverage by a single, national operation.

It is adapted from an essay by Stanford University health care system expert, Dr. Victor Fuchs, found in the highly-regarded New England Journal of Medicine of June, 2002, called, "What's Ahead for Health Insurance in the United States?"

READING #2:

Finally, there is the question of values. Should health insurance be organized on the same principles as automobile or homeowner's insurance? When drivers with good safety records or homeowners who install smoke detectors are charged less for their automobile or homeowner's insurance, most people see the system as fair and conducive to socially desirable behavior.

But the actuarial model applied to health care conflicts with a sense of justice and collective responsibility: it attacks a core element of what it means to be a society. In the long run, the extreme actuarial approach will probably be rejected by the people of the United States as an unsatisfactory way of providing basic health care for all.

The timing of such change toward a national insurance model, however, will depend largely on factors external to health care. Historically, major changes in health policy are political acts undertaken for political purposes. For instance, the political nature of such change was apparent when Otto von Bismarck introduced national health insurance to the new German Empire in the late 19th century. It was apparent when England adopted national health insurance after World War II. And it will likewise be apparent here in our time as well.

National health insurance will probably come to the United States after a major shift in the political climate-the kind of change that often accompanies a war, a depression, or large-scale civil unrest. Until then, the chief effect of smaller innovations, such as new medical savings plans, will be to make young and healthy workers better off at the expense of their older, sicker colleagues.

SERMON: The Promised Land of Health Care

I recently decided to take the plunge and send in my $12.50 a year to join AARP-the American Association of Retired Partiers. I avoided it for a few years after becoming eligible, but it was like fighting the Borg in Star Trek: "Resistance is futile."

So now I'm part of a huge lobbying group for the increasingly huge sector of our population that is aging more or less gracefully. Yessiree, day by day we Baby Boomers are adding our demographic weight to the already significant political power of the AARP. As we have throughout the life journey of our collective bulge, we are a force to be reckoned with, especially once we actually start retiring.

But what, to make of predictions like "young and healthy workers (will be) better off at the expense of their older, sicker colleagues"? This doesn't seem right, given the political influence a booming elder generation should have. However, I've investigated the prediction and it holds up under scrutiny, the key word being "workers." As more and more healthy (read: younger) employees move out of comprehensive medical insurance and into various "remedies" like Health Savings Accounts, which may be to their advantage, it does shrink the pool that insurance companies depend on to spread the risk.

And for those who have to remain in comprehensive plans, usually because of ongoing medical concerns (read: older workers), the premiums will continue to go way up and the coverage way down, severely compromising the older worker's health security. But this allows the insurance companies to still turn a profit, which is, after all, their business. The cost of medical care and pharmaceuticals is skyrocketing, along with malpractice insurance, and of course these expenses get passed along to consumers.

It's called our health care "system" for good reason; everything's connected. We may envision a grand American "Promised Land" of effective, inclusive health care, but there are plenty of shortcomings to go around, with fingers pointing every which way, and I shall add my share this morning. But I do this from a religious commitment to community, near and far.

Religion has, in various ways throughout history, provided a setting where morals and values are held up and hopefully lived out. Religions all teach how we should care for one another. Islam, for example, requires its adherents to give to the poor and not gather up too much wealth for themselves. Christianity reminds its believers to love their neighbors as themselves. These beliefs certainly should influence how people respond to those nearby who are sick or injured.

In Unitarian Universalism, we affirm "justice, equity and compassion in human relations" as one of our core principles. All three of these values relate directly to the current crisis in American health care, and those plus our first UU Principle, "the inherent worth and dignity of every person," were cited when this congregation voted last June to select Health Care as its social action focus for the year. It is indeed time for people of faith to bring our hearts minds and spirits to bear and find a better way to manage this interdependent system, a better way than the status quo, a more just, equitable, and compassionate way.

As most preachers try to do, I'll first portray my sense of the issues, which in this case are rather outrageous, literally, and then I'll close on a hopefully hopeful note. I'm trying to include both specifics and big picture angles that have helped me understand some of the forces at work in our current dilemma. And if you don't consider it a social dilemma or don't feel some outrage yourself, let me gently suggest that your may either be numb or not paying attention, or both.

But then, some of the forces as work here have become quite adept at distracting us, or hiding the true nature of changes so that the odds are improved we won't notice. One critic of the American health care system (Dr. David Himmelstein, professor at Harvard University and a founder of Physicians for a National Health Program, quoted in Public Citizen Health Letter, Oct., 2004, pg. 5) invoked a time-honored and graphic image. If you put a frog in very hot water, it will jump right out. But if you start out with cold water and gradually raise the heat, the seduced creature will stay in it and get boiled alive.

Individual consumers might not notice the increasing heat these days until they stumble into a health crisis and find out just how much coverage they really have-or really don't have-from their insurance policies. And the changes taking shape in recent years are clearly going to support well off, healthier Americans and mercilessly boil our struggling, less healthy neighbors.

For instance, just this past week, a new study announced that "illness and medical bills caused half (50.4 percent) of all (1,458,000) personal bankruptcies in 2001." And most of those people had health insurance at the start of the bankrupting illness. The lead author of the study (the same Dr. David Himmelstein, quoted immediately above) commented, barely exaggerating: "Unless you're Bill Gates, you're just one serious illness away from bankruptcy. Most of the medically bankrupt were average Americans who happened to get sick." ("Illness and Injury as Contributors to Bankruptcy," Himmelstein et al, Health Affairs Web Exclusive, February 2, 2005. Copies of the paper are available on-line at www.pnhp.org/bankruptcy, with the password "uninsured.") And that was way back in 2001. Take a wild guess which way the medical bankruptcy statistics have headed since then.

As has generally been the case over the past four years, the business world seems to get primary consideration in whatever changes are proposed. The latest tweakings of our health care system, for instance, are certainly going to help employers, who now can force employees to take on more and more of the burden of health insurance, again seeking to maintain a healthy profit margin.

In fact, there is reasonable concern that the job "benefit" of health insurance will soon all but disappear. According to one Human Resources executive (Neil Trautwein, National Association of Manufacturers, quoted in Public Citizen Health Letter, Oct., 2004, pg. 3), "We see the wheels coming off employer-based health care."

We've come a long way from the halcyon days of medical insurance for employees, which first emerged as a side-effect of wage and price controls during World War II. Labor was scarce then, but businesses weren't allowed to compete by raising salaries, so they increased benefits, such as paying the cost of health insurance. (From a booklet by Ken Frisof, MD, "Affordable Health Care for All: Turning a Dream into a Reality," published by the Democratic Socialists of America, 2004.) That was seen as an acceptable cost of doing business in those days, as well as adding value to society, encouraging healthier workers, who were then more able to contribute productively to the "common-wealth."

We're in an entirely different ballgame today, when the barely disguised effort of a business/government partnership is to dismantle many of those kind of improvements for individuals in favor of corporate profits, which then go clinkety-clink into re-election coffers. This feeds a disastrously insatiable cycle-disastrous for everyone except those who profit from it, of course. For instance, thanks to the recent shift in political climate, the profit margin for all Health Maintenance Organizations, which was zero in 1999, has grown by leaps and bounds in each of the past four years. (Source: Weiss Ratings, Inc., as reported in the Frisof booklet immediately above.)

Meanwhile, you may have heard that the number of uninsured Americans has also grown by leaps and bounds each of the past four years, what a coincidence! It now stands at 45 million-including almost 2 million veterans, which seems like it should be a crime! The percentage of children included in this swelling figure is also scandalous.

The astonishing number of uninsured people in the US is probably the biggest reason we have "a second-rate system, destined to get a lot worse and much more expensive." It is why we are ranked 37th in health care efficiency, according to the World Health Organization. We do indeed top the world chart in health care spending, both per capita and in percentage of Gross Domestic Product, but we are no better than 10th in both Infant Mortality Rates and Healthy Life Expectancy. (All figures from WHO, The World Health Report, 2004 - Changing History, as reported in Frisof booklet above.)

Another reason we are so regressive about health in these United States is our collective attitude and philosophy about medical care, which we treat as a commodity, much like car insurance and homeowners insurance. And our system is designed to use market forces to regulate it. You know, good old capitalism.

But in a true market, if you can't afford something, you don't get it. Can't afford car insurance or homeowners insurance? Well, you figure out how to get by without a car or your own home. But this is not true with health care. Most of those 45 million uninsured people do, eventually, get their medical needs addressed-usually through very expensive Emergency Rooms, and often so much later than they should that treatment is also more demanding and expensive.

And the only way for "The Market" to accommodate that extreme expense is by socking it to those who are paying. Hospitals and health plans pass those costs on to consumers because, after all, this is just a commodity and corporations have to make their profit, so someone has to pay.

The attitude in many other cultures is decidedly different. The three dozen countries that rank ahead of us in health care system efficiency, for instance, all have one thing in common: they make sure every citizen has access to comprehensive care (Frisof, pg. 5). They may or may not imagine it as a "Promised Land" of health care, and they accomplish it in many different ways, but their national commitments are to provide care for all. Compare that with the US, where medical insurance is a market-driven commodity providing huge profits to a few while 45 million have to go to the Emergency Room for any care at all.

This market mentality feeds a three-headed beast that is undermining our health care system: high prices, wasteful practices and fragmentation of care, which all persist for one main reason: vested interests influence any attempts to significantly change the status quo. This has long been the case, I suppose, but lately we are seeing the even more profound effect of large-scale government collaboration with those vested interests.

It is not a reach to suggest that there is a "radical reordering" of our entire federal culture underway under our noses. The title of a recent Washington Post (1/31/05) op-ed piece by commentator William Raspberry says it all: "Cutting Out the Poor." Because of a huge fiscal crisis-created largely by "an unnecessary tax break abetted by an optional war"-our government is making immoral budget choices that will eviscerate programs for people who struggle to get by in the lower third of our economy. Is it a coincidence that these voters have little, if any lobbying presence?

And so it goes in 21st century America: the influential rich get richer and the voiceless poor get poorer. The insulation between these classes is so thick that our leaders can't even hear the clanking echo of their euphemisms. We didn't swallow "privatization" very well, so now it's "personalization" of social security and health insurance that is supposedly so good for us. This basically means, "You're on your own, folks. Figure it all out for yourselves and enjoy the market ride." So much for justice, equity and compassion.

 

But (and here's where I finally shift into what hope I can find), there are other, increasingly loud voices clamoring for a major redesign of our health care system (versus just another round of tinkering). And unless one has a vested interest in the status quo, it's not hard to see why. The American health care machine, assembled in a mish-mash of pieces over the past century, is clunky and unmanageable, and for more and more of us it just doesn't fly. Tweaking it is making things worse, not to mention more inequitable. We need an overhaul.

Even though there are problems with Medicare, especially with drug costs soaring and a suddenly tenuous connection to Social Security, it is the closest thing we have toward a "Promised Land" of health care. At least some people still have a safety net left under them. So a few renegade politicians are touting it as a model for a national health insurance system that would cover all the people. And Capitol Hill yawns.

But a growing chorus of other voices are also clamoring for this kind of a large move. Groups like Physicians for a National Health Program are quite vocal, with significant credibility. In our state, there's the Maryland Citizens Health Initiative (www.healthcareforall.com) and a local, two-county group called Coalition for Universal Health Care (CUHC, Bob Rochlin, chair, bobrnjan@erols.com). Virginia Richardson, a leader from the Health Care Task Force of River Road Unitarian Church in Bethesda, is here today and will join the discussion afterwards

 

There are lots of proposals worth considering, but nothing makes more sense than looking seriously at a national health plan that's already working, even if only for those over age 65. Perhaps the most dramatic comparison between government-run Medicare and private insurance plans is in administrative costs, which are estimated at 2% for Medicare, and 10-15% for managed care plans (Wash. Post Health Section, 10/26/04: "Medicare's a Solution, Not The Problem" by Abigail Trafford). What are we who are not yet 65 getting for five times the administrative expense? Squeezed.

And for more and more of us, getting squeezed is forcing our dander up, which is probably what it will take to have any effect on this entrenched system. Unfortunately, the way things happen in our world is that only when there's enough pain, spread around into enough lives, is there incentive enough to force change. The powers-that-be clearly aren't feeling enough pain; they're effectively insulated from the effects of their policies, so they're just tinkering, carefully turning up the heat in small increments, hoping the people don't notice their lack of leadership. I predict things will continue to get worse until, as our reading earlier suggested, "large-scale civil unrest" or some other kind of societal trauma boils over.

If you think about it, those who decide health care policy in our land are probably well off enough that they can afford whatever kind of health insurance they want. To my mind, it's not unlike the way old people sit far from the action pushing buttons that send young people off to die in war. As long as politicians stay disconnected from the real stories of real people caught in the machinery they've set in motion, they're not likely to advocate for change.

So I'm encouraged by productions like the short video the River Road Health Care Task Force put together, called "Faces of Maryland's Health Care Crisis." Also, the UUA Washington Office's Health Care Campaign (contact Amelia Rose at arose@uua.org or 202- 296-4672 x21) is working with Families USA (http://www.familiesusa.org) to collect vivid stories of vulnerable households in America, in an effort to humanize the related crisis in Medicaid funding. Showing the all-too-human impact of their action or inaction is one way to impact those hardened politicians, who mouth platitudes and then distance themselves from change for the common good.

Almost 150 years ago (1857), Frederick Douglass provided an insight that remains stunningly true: "Power concedes nothing without a demand; it never has and it never will." These days it seems that as there's less accessible health care for more and more people, there's also less accessible politicians with more and more excuses for resisting opportunities to do the right thing.

Some kind of national health plan is the right thing, affirming the inherent worth and dignity of every person, in whatever degree of health. The UUA General Assembly voted a resolution to that effect in 1998 (see addendum). Universal coverage will require an organizational revolution, to be sure, but without it, many Americans are very likely to get slowly but steadily boiled. Such change faces an uphill battle, and even when there's finally some agreement, the actual conversion will be a huge job. But it is rapidly becoming clear that taking the risk to steer the course of our collective future toward some kind of national health care system is much preferable to the status quo, which is a dead end-indeed "a second-rate system, destined to get a lot worse and much more expensive."

I want to believe that momentum is beginning to shift. There's already enough pain to go around and we can certainly tell that the water's heating up around us. I believe that we will create a "Promised Land" of health care worthy of this great country's vision and resources. We can have a more just health care system, with comprehensive coverage accessible to all and costs spread fairly. But we're going to have to demand it of our policy-makers, because they will have to go up against powerful vested interests, which they're just not going to do without a strong mandate from constituents.

So I urge you to add your voice to this clamor, wherever you can. Don't get mad at the embodiment of an unjust system, however, such as the workers you encounter at clinics and hospitals. Get after their bosses and the policy-makers, who must feel the pain, too. Tell them health care is a human right not a commodity. Tell them that the Universal Declaration of Human Rights articulates this in Article 25:

"Everyone has the right to a standard of living adequate for the health and well-being of self and family, including food, clothing, housing, necessary social services, and medical care."

Tell your stories and join the growing ranks of coalitions across the country that will carry the day, I do believe. We want to be able to tell the policy-makers, "Resistance is futile."

We do this because it is the moral thing to do, because our religious values urge us toward the common good, because we know we can do better as a civilized society. We know there is more love, more hope, more peace, more joy somewhere, and we're going to keep on 'til we find it

[Sing Hymn #95: There is More Love.]

 

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HEALTH INSURANCE

UUA Resolution of Immediate Witness

June 1998

WHEREAS millions of Americans are presently denied medical insurance and, in effect, denied the right to basic health care because the United States government, employers, and the insurance industry have been unable to implement a national health insurance program; and

WHEREAS this has been brought home to our Association by the June 1998 action of the Blue Cross Blue Shield of Massachusetts, which has notified the Unitarian Universalist Association that its group medical plans will not be renewed on September 1, 1998, so that our Association, along with several other religious groups in the United States, is being forced to discontinue medical insurance for its clergy and staff because of costs; and over 70 clergy, their families and/or partners, are in danger of not being able to obtain replacement health insurance with affordable premiums, if at all;

 

THEREFORE BE IT RESOLVED that the 1998 General Assembly of the Unitarian Universalist Association:

  1. decries a system where the values of the medical and insurance marketplace and the pursuit of profits in the guise of managed care conspire to deprive United States citizens of basic health care;
  2. urges individual Unitarian Universalists and member societies to study the inequities of the present health insurance situation in the United States and take assertive public positions to seek remedies at the state and federal level;
  3. calls on Unitarian Universalist congregations and individual Unitarian Universalists in the United States to urge members of Congress and the Administration to proceed toward the creation of a comprehensive health care system which will guarantee affordable medical, hospital, and mental health care (both inpatient and outpatient) to all persons regardless of age, place of employment, or personal financial circumstances; and
  4. urges the staff and volunteer leadership of the Unitarian Universalist Association to assist all persons in the Unitarian Universalist Association Group Insurance Plan who may lose coverage to find replacement health insurance with premiums which can be afforded by their employer-congregations.

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