Saturday, August 15, 2009

Losing Patients

I got an annoying phone call from AIG yesterday. I'd been in their Hilo office the day before to renew my auto insurance with them. The caller wanted me to rate the service I'd gotten during that visit, on a five point scale from "poor to "excellent," on dozens of different points: Did the person who served me explain my options clearly? Was I greeted promptly? Did she thank me for patronizing AIG at the end of my visit?

All told, the survey took longer than I'd spent at their office. After all the questions about the visit, the surveyor still wasn't done. He had a whole bank of questions about what else they could sell me. Would I be interested in talking to an AIG agent about life insurance? Would I be interested, etc., about homeowner's insurance or renter's Insurance? Health insurance?

I'm afraid that when he reached the question about health insurance, I exploded just a little bit.
"I'd love to talk with someone about health insurance," I almost-shouted, " if they'd offer something I could afford!"

I've been watching the national debate (or yelling match) on health reform with more than a detached journalist's interest. I'm one of those millions of Americans who don't have health insurance.

Fortunately, I live in Hawaii, the only state that offers universal coverage to children, so when my son gets over here, I'll be able to get insurance for him. But that children's insurance program nearly didn't survive the state's budget crunch, too.

So I can understand why tempers run so high on the issue, at least for people like me. I have more difficulty understanding why opponents are so upset. Some of it seems to be emotional reaction to misinformation such as Sarah Palin's "death panel" remarks; some of the heat seems come from legitimate anxieties about what the bill will do to the cost of health care or the already-inflated national debt. And a lot of publicly expressed anxieties seem to be not about the actual details of the bills, but about vague ideals and glittering generalities: I've seen at least two of the town hall ranters in news reports, for instance, saying something like, "The America I know is disappearing!"

America is changing, no doubt about that. Much of the America I grew up in has already largely disappeared, and I'm only 55. The diversified family farm I grew up on, for instance, has been replaced by factory farms, feedlots and corporate food distribution. (See my essay on that subject at The Hawaii Independent Web site. I also highly recommend Food Inc. It just ended its run at the in the Palace Theater in Hilo, but I'm sure it will be showing up on DVD soon.) Most people who've lived any length of time remember places that have been transformed beyond recognition by development and local stores that have been obliterated by corporate behemoths such as Wal-Mart and Target. I can remember when you could make a purchase or cash a check without having your picture taken, and when political conventions weren't choreographed, and when airports weren't police states.

And I remember a time when even a hardscrabble family farmer could get health insurance for himself, his wife and three kids and take them to the doctor of his choice. That world started to die during the Reagan administration, when deregulation allowed both insurance rates and pharmaceutical profits to soar. Its condition deteriorated rapidly after the Clinton Administration's efforts at health reform got torpedoed and HMOs were born instead.

Big abstractions like "The America I knew" can be very dangerous. Wars get started for economic considerations (Even the American Revolution was essentially a dispute over taxes and tariffs), but get fought in the name of "Protecting our Freedom" or "The American Way of Life" or "Manifest Destiny." Bad decisions get made when ideological sacred cows get placed before the realities of daily life.

One of the biggest, most untouchable sacred cows of American life is "capitalism." It's almost impossible for someone to say, in the U.S., that capitalism is not a solution for everything, without the bearer of that news being labeled a "socialist." I am not, repeat, not a socialist, because socialism is not a solution for many things, either. But I'm just the writer of an obscure little blog, so I'm going to say what people with more to lose don't dare say: Capitalism is not the solution to everything. In fact, unbalanced capitalism is often a large part of the problem. And nowhere is that more clear than in the area of health care.

Example: you're a pharmaceutical company, and you're planning your research budget. Which drug is more likely to make you a big profit: a drug that cures a disease, or a drug that alleviates the symptoms but leaves the patient sick, so he'll have to take the drug for the rest of his life?

The answer, obviously, is the latter. I'm on three such drugs myself; they cost me about $130 a month. I'd love to get whatever's causing my high blood pressure and enlarged prostate fixed, but nobody in the medical profession is offering me that option.

If you look at the airwaves (BTW, I remember an America where prescription drug commercials weren't allowed, and companies didn't add millions our medical bills to pay for advertising campaigns) virtually every high-profile pharmaceutical commercial is for such a drug. They lower cholesterol, but only as long as you keep taking them; they cure your erectile dysfunction for twelve hours, but then you have to take another pill--and the pills cost $12 apiece. Why cure cancer, when you can alleviate acid reflux?

Example #2: Insurance is essentially legalized gambling: the company is betting you won't get sick and you're betting that you will. Like any gambling, the odds have to favor the house, or the casino goes broke. But what if the rules allow the house to drop you like a hot potato if you do get sick? Then it's a rigged game, and the profits get much, much higher....

My ex and my son are already relying on socialized medicine, and I'm very grateful that it's available. She was a lawyer with an independent law office; when she got cancer, her insurance policy skyrocketed beyond what she could afford. The insurance company lost its bet, but it still got to keep all the money she'd paid in until she got sick. Then she had to close her law office and go on disability; now the government is paying for her chemo and my son's ADHD maintenance drugs.

Sarah Palin is worried about government death panels. What about the private ones: the insurance company rule-makers who cut cancer patients off from treatment?

My ex's case is hardly the only one. My heart goes out to the family of Kimberly Reyes, the 51-year old Waimea mother who died on July 27 after being denied a liver transplant because trace amounts of marijuana were found in her blood.

That's what happens when the goal is to maximize profits: you find ways to minimize your payouts and maximize your pay-ins. The health-care crisis, in a nutshell: too many people--doctors, nurses, medical technicians, hospital companies, pharmaceutical companies, insurance companies, tort lawyers, medical supply distributors, medical machine manufacturers, advertising agencies, unions -- are demanding the right to maximize their profit margins on our misery, and we patients have too little leverage to bargain with them.

Some things are just too important to leave to market forces alone. Health care is one of them.

Tuesday, August 11, 2009

A Correction, and an In-Tents Discussion

Some follow-ups on my last post:

First, a correction. In the first draft of the previous post, I mistakenly said that Brenda Ford was chairing the Hawaii County Council's Planning Committee; actually, she was chairing Public Works. I later fixed that, but not before a fan e-mailed the uncorrected version out to a few hundred other people. My apologies.

A couple of other observations about that day at the Council:

I was actually very impressed with Brenda Ford as the day went on. Yes, she's not the smoothest reader in the world, but that's more than outweighed by her thoughtfulness, especially on fiscal matters. Time after time, when other councilors were routinely going along with the administration's requests, Ford was asking good,specific, well-researched questions about budgetary procedures and cost effectiveness. In many ways, she's begun to take Curtis Tyler's place as the council's conscience, voting against things that she didn't think quite right, even if that meant she was the sole vote in opposition.

It's not surprising that Ford and Emily Naeole sometimes clash. Naeole seems intuitive and impulsive, following her gut; Ford comes across as just the opposite, critical and careful , sometimes almost nit-picky.

There was one point during the day, however, when Naeole actually thanked Ford. Naeole's bill to allow residents to camp on their land while building a permanent home was up for a re-vote. Ford offered an amendment that would make the bill temporary and experimental and would limit the tent exemptions to Puna. Naeole accepted the amendment as friendly and thanked Ford for her help in moving the bill forward.

In this case, though, I wonder if Ford was right. In offering her amendment, Ford cited an online poll in which the majority of Puna residents supported the tent bill, but an overwhelming number of respondents from Ford's district opposed it. Dominic Yagong, supporting Ford's amendment, cited similar results in his district.

That's troubling. It could be another sign of the way this island has been ghettoized. Ford's district certainly has a large number of upscale subdivisions in it: places where people who are struggling for a home can't afford to build, and people who have forked over huge piles of cash for their homes are more worried about maintaining their property values than about helping poorer families to move in next to them: prime NIMBY country. Yagong's Hamakua Coast is rapidly becoming a combination of old plantation towns and new upscale subdivisions. But Puna, thanks to the lack of foresight of certain land speculators, is riddled with substandard subdivisions that the developers originally thought they were going to sell to unsuspecting mainlanders who would never build there, because nobody would actually build on land in a high-risk lava zone if they understood what that meant. But the developers didn't count on thousands of poor and middle-class families who were just desperate enough to play the odds of a lava inundation in order to have a home.

Kelly Greenwell raised the issue of economic discrimination, if the bill was limited to Puna. Years ago, planning advocate Bonnie Goodell and others had talked of filing an economic discrimination case on behalf of district's residents because of the deprivation of basic services and infrastructure they were suffering, especially compared to the level of services and infrastructure in Hilo. I wonder if it's time to re-explore that issue in a full-fledged article: are the people of Puna being discriminated against? Is funneling the middle and lower classes of Hawaii into a single district, and setting up separate rules to encourage that economic segregation, legal and ethical?