Tuesday, June 18, 2019

The Executive Council of the Episcopal Church Speaks to Vaccination

Most of the world may not have noticed, but the Executive Council of the Episcopal Church met last week. For those who don't know, the Executive Council is charged with carrying forward the decisions and programs of the General Convention between meetings every three years.

And even among those who are aware of the Executive Council, not all are aware that they also pass resolutions. Resolutions of General Convention are the highest-level statements of the positions and programs of the Episcopal Church. However, actions of Executive Council are also important. They address specific actions to carry out General Convention resolutions, and address issues that have come up since General Convention. If you're interested in a summary of all the actions of the most recent Executive Council, you can find them here. And if you're a real Episcopal geek, you can look for actions of Executive Council for the last 40 years or so in the Digital Archives of the Episcopal Church, here. (And thanks to the Episcopal Cafe, where these news stories have been shared.)

One resolve of Council had particular resonance for me, and I reproduce it in full:

Express grave concern and sorrow for the recent rise in easily preventable diseases due to anti-vaccination movements which have harmed thousands of children and adults; condemn the continued and intentional spreading of fraudulent research that suggested vaccines might cause harm; recognize no claim of theological or religious exemption from vaccination for our members and reiterates the spirit of General Convention policies that Episcopalians should seek the counsel of experienced medical professionals, scientific research and epidemiological evidence; call on the Office of Government Relations to advocate to the United States government for stronger vaccination mandates informed by epidemiological evidence and scientific research; urge all religious leaders to support evidence-based measures that ensure the strongest protections for our communities; ask congregations and dioceses to partner with medical professionals to counter false information, and to become educated about programs in their communities that can provide vaccinations and immunizations at reduced or no cost to those in need (MB011).

Some of my readers may know that one of my responsibilities in my last position (happily, one I could share with colleagues), was to review requests for exemption on religious grounds from mandatory flu vaccination. It was an interesting process, and perhaps I'll write more another time.

However, one matter I brought to that process was a request I'd received years earlier. I had a call from a priest, a rector in Virginia. She needed some help. She had a parishioner, a mother, who was terrified because of the misinformation, then already rampant, about vaccinations for children and autism. The parish priest wanted to ask the hospital chaplain whether I knew of any support for exemption in the Episcopal Church. I took some time to look into the Digital Archives myself (I am a geek), and found confirmation of what I already thought. General Convention had not spoken specifically about vaccines, but had a long history of supporting receiving modern medical care. Indeed, I suggested to the priest that, if anything, most would lean on that verse in Ecclesiasticus,"The Lord created medicines out of the earth, and the sensible will not despise them." (38:4) I suggested that the priest accompany the mother and children to the pediatrician to help the mother hear clearly what the doctor had to say, and to support her in her anxiety.

There are a few - a very few - religious traditions that reject vaccinations, even if they don't reject all health care. There are more folks who take a moral position (sometimes expressed in religious language, but often not; and in either case often poorly) against vaccinations as a violation of one's person. In those latter cases, it is always in individualistic choice, rejecting the concept of accepting a vaccine to love neighbor as self, by accepting vaccination to protect those who medically cannot. In taking this position, the Executive Council is certainly standing on sound science. What is more important, though, is that they are standing on sound faith: the expectation that Episcopalians can accept vaccination, not only to protect themselves, but also to protect their neighbors.

Thursday, June 13, 2019

Distributing the Costs of Care, Part 3: It’s Already All of Us

So, I’ve asserted (and I hope folks have agreed) that a thing costs what it costs, whether a strawberry or a medical procedure. I’ve also discussed that what makes those things seem affordable to us (at least, to the extent we do find them affordable; but we’ll come back to that) is that costs aren’t really just costs to us: the costs are distributed across a lot of people in the network of the economy. The clear conclusion (and hardly a new one) is that we’re all in this together.

This always gives me pause when leaders in government and business talk about reducing healthcare costs. If I pay attention, it becomes clear that they’re not talking about reducing what a thing costs. They’re talking about reducing what it costs  in one category or another. And, they’re not always talking about the same category. When the political leader speaks about reducing costs, sometimes he or she talks about reducing what I as an individual pay out of pocket; or sometimes about what I pay in premiums; or sometimes about what I pay (and, sometimes, what we all pay) in taxes. And, sometimes when I listen the leader is talking about what a business pays in the process of being accountable (that’s what regulations do, after all); or what the total is paid through taxes, as opposed to how that affects my pocket.

But, note that, as the current system is running (employer based insurance for most, Government-based insurance for the elder and the poorer), those changes are mutually exclusive. To reduce what I pay out of pocket, I end up paying more in premiums; or, conceivably, I could end up paying more in taxes. A thing costs what it costs, and the difference is in how those costs are distributed.

Also concerning to me are those polĂ­tical leaders (and, I will say I don’t hear this from healthcare providers or from supply industries) who seem to want to reduce how much I pay for the benefit of someone else (and, really, usually someone elder or poorer or both). Now, as an Episcopal priest I will assert that such an argument is immoral - broadly un-Biblical, and definitely un-Christlike. However, I also want to look back at our discussion so far and suggest that it’s simply unworkable.

A thing costs what it costs. If costs are redistributed, they appear to change, but that’s deceptive. They will still come back to me, but in a different form - and sometimes one that is destructive.

For example, there are ongoing efforts to reduce Government expenditures for Medicaid, both federal and state. The visible consequence as of those are pretty hard. Look at the number of rural and regional hospitals that have closed over the past few years. People lose care. Communities lose jobs. But also, people end up getting care that costs more, traveling farther, needing more intense and expensive care, and dying. Since hospitals cannot by law refuse emergency care (and that is the law), they make up elsewhere what they lose on those patients. Their basic costs structures go up; their negotiations with insurers go up; and my bills go up. The analogy of squeezing the balloon is apt: it may appear to reduce my taxes, and look good for the political leader, but it will still hit me somewhere else.

What can most effectively reduce my personal expenses? To most widely distribute the costs across the most people. Which leads us to Medicare for All.

It wouldn’t surprise anyone who knows me that I think we would all benefit most from a system offering universal access and requiring universal participation. That is, everyone can get care, because this most widely distributes the amortization of costs of equipment and paying for professionals. And, everyone pays something, in some way that is progressive related to economic capacity (considering both income and wealth), because this most widely distributes, and most justly distributes, financial resources in the system.

Now, at this point no one knows what a Medicare for All plan would do, except perhaps these two points; mostly because there is more than one plan proposed under that heading, and they don’t all agree. However, I do want to note that in some ways we already have something for all in Medicare.  

We normally just think of the insurance for folks over 65 and folks with significant disabilities paid for by Medicare. However, that also means Medicare is perhaps the biggest insurer, and so has a great deal of influence in how widely costs are distributed. I’m not on Medicare, but my insurer knows what Medicare is willing to pay, and wants to negotiate my rates accordingly.

Another aspect in which Medicare serves all is that most if not all medical education is paid for in full by Medicare. This certainly applies to the vast majority of medical residency positions. For most medical residents, hospitals are reimbursed in full for the cost of salaries and perhaps for benefits. In addition, Medicare pays in part for many other kinds of clinical education. This includes nurses, therapists of various kinds, and even chaplains. If you get care from a physician who is in or has completed a residency, your physician was provided to you in part by Medicare. For teaching hospitals, this means that a good deal of the budget that allows them to take care of the poor and allows them to keep their equipment current is relieved by Medicare.

Finally, we can’t undervalue how Medicare has kept many, many seniors out of poverty. Some of us may remember commercials on television before Medicare was in acted, identifying the elderly in urban settings as particularly and acutely poor. Now that I am retired and up on the Plateau, I see that level of financial concern in the rural poor almost every day. Medicare by itself has raised many folks out of poverty and bankruptcy for the two generations we’ve had it.

These are ways in which Medicare currently serves all of us. These are also examples of the value of seeing our healthcare as a social good, and not just as an individual good.

A thing costs what it costs, whether a strawberry or a medical procedure. We are concerned about paying for the healthcare of others, but in fact we are already doing that. We can decide whether that continues to be something that happens outside our view, or if we want to be deliberate and public and all involved in those decisions. To do that, we need to distribute those funds and those costs as widely as possible; and in these United States as widely as possible means all citizens and all residents.

The thing costs what it costs, and we are all always  already sharing those costs, whether we are aware of it or not. Maybe it’s time to recognize that social connection and to see healthcare as a social good, and not just a retail product.