Thought on Deferred Maintenance

As with the past few posts, this was first shared on Facebook.

Can we talk for a minute? Of course, I can only speak for myself.

Let’s talk about Texas.

No? Not talk about Texas? Okay, let’s talk about Kansas City, where we used to live.

We moved to Kansas City in 1994. That was a year after one of the worst floods in the city’s history. There were signs everywhere of the water damage. In the Country Club Plaza, an historic and high value shopping district, stores still showed where the Brush Creek had risen to more than three feet in first floor rooms, having completely flooded the basements below.

There were several matters that contributed to the floods, and especially to the Plaza area and also to working class residential neighborhoods downstream. One that was recognized by the time we arrived was that the storm drainage system and the sanitary sewer system were linked. When these were installed in the 1920’s and ‘30’s the idea was that if there were unusually heavy rains the sanitary system would be able to absorb some of the excess.

It’s hard to deny that for decades that had worked, or at least worked well enough. However, after the 1993 floods it was recognized that some important things had changed. Our standards about treating the stuff in our sanitary sewers had changed. Our water quality concerns about our storm runoff and other waters had changed. Most important, there were now tens of thousands, perhaps hundreds of thousands of people living in the Brush Creek drainage, many of them miles upstream of the Country Club Plaza, and quite a number of them across the state line in Kansas. All those roads, driveways, homes, and people were adding to the storm runoff and to the sewage that went into the system. The problem was similar all over Kansas City, although it was especially visible in the Plaza district and downstream.

So, when we moved to Kansas City, the City Council was thinking about how to address the issue. The concern, and for a majority the stopping point, was that it would require an investment of $40 million. (I may be a bit off, but that’s my memory.) So, it was talked about and talked about, and a few small tweaks were accomplished, but the systemic problem was never addressed.

Of course, as it was talked about, you could see one consequence of delay, and I bet you can guess what it was. The cost kept going up. They were still talking about it when we left Kansas City, and over those almost 25 years the cost had grown to $4 billion - 100 times the initial requirement, more or less. Now, I’m sure about the last figure; but even if I’m really wrong about the first figure and it was $400 million, that’s still 10 times the cost. And while the tweaks had helped the Country Club Plaza, there had still been bad storms and significant flooding in the Brush Creek drainage above and below. People still died and people still lost a lot of money to flood damage.

So, there’s a very clear monetary example of the real cost of deferred maintenance - of putting off hard and expensive stuff until “better times.” Too often, though, it doesn’t really seem to be about “better times.” It seems to be about leaders who don’t want responsibility for the hard decisions, especially when those decisions include taxing citizens.

I know, I know: perhaps you thought I was just going to stop with “spending money.” For good and ill, though, the money that governments have to do the jobs we want of them comes from taxes. Now, my wife will tell you that I’ve never seen a tax I didn’t like, which isn’t true; but do understand that paying taxes is one of the responsibilities of having “government... by the people,” alongside voting. Sometimes we find other terms like “user fees” to avoid calling them taxes; or tools like municipal bonds to put off, perhaps for decades, paying the taxes (but, how do you think those bonds are paid off when they become due?) And, yes, we might disagree on how broad the scope should be of what we want government to do. I will tell you I’m really glad when my town can plow my street when the snow is deep. I’m glad my water district has laid mains well below the freeze line and has the resources to respond quickly to a break.

Many, many of us make decisions to tend to matters and avoid deferred maintenance. We keep our cars serviced, and we keep our houses in repair, and we see doctors and dentists regularly. We do those things because we know problems caught early are cheaper than crises caught too late; and that problems prevented are cheaper still. So, why shouldn’t we not only support but expect our leaders to address problems early, including the expectation that we’ll be paying for them?

Of course, I can only speak for myself.

Leadership and Focusing on Facts

This was posted first to Facebook and has been copied here.

 Can we talk? Of course, I can only speak for myself.

So, you know I’m a preacher, right? When I was in seminary, we talked about a big change in how we do things (in Western culture) that took place in the 13th Century. With the teachings of Albertus Magnus and of Thomas Aquinas, European culture made the change from seeing the world based on the teachings of Plato to seeing the world based on the teachings of Aristotle. Without getting too deep in the weeds (but, please do invite me! I love the weeds!), the difference was about what you could know and how you could know it (and what follows is a clearly Christian way of using these categories). For followers of Plato, the truest truth was in the mind of God, and if you thought long and hard enough you could intuit the truth as God saw it, or as close as you could get. For Aristotle, you couldn’t know God’s mind directly but you could see what God had done in the world; and by carefully observing you could see that and from that deduce the truest truth, or as close as you could get.

My professor of Christian Thought and Systematic Theology (same professor, different classes) had a clear understanding of why Aristotle’s position quickly became dominant in Europe: “it built a better cannon.” It was by observing, trying, and adjusting that you improved useful and effective things were, and in those days better siege weapons were considered really important. Sure, cannon would not come to western Europe until the 14th Century, but in those days that was “quickly.” Still, they were clear that observing, trying, adjusting, and observing facts was more effective than simply imagining in making things work better.

We’ve come a long way with those principles, even if we don’t always use those terms. One shorthand we have for that approach is the scientific method. In keeping with our European cultural heritage, we’ve used it to make better bombs. We’ve also used it to make better medicines. The scientific method was critical with getting us to new vaccines for coronavirus that are going to help bring us out of this pandemic (along with mask wearing and social distancing, also supported by scientific method). 

We’ve used them in our industries. Whether we’ve heard of it as performance improvement or continuous quality improvement (CQI) or total quality management (TMQ), we’ve seen how it reformed the Japanese auto industry and then the American auto industry, and many other industries besides. They stopped just imagining what might work and started finding and focusing on facts of how things worked, and used those facts to make things work better.

With all that demonstration of the value of using facts for decisions, perhaps we should expect the same things of our leaders.  If our leaders focus on facts rather than simply on theories and principles, they should be able to offer better programs, better government. If we focus on facts rather than simply principles, or worse, rumors, we should be able to select better leaders who will then offer better programs, better government. Principles have a place because they can help us think about how to use facts. I am after all a Christian and that certainly informs how I might want to respond to the facts in front of me. But I can best apply my principles if I start with observing and testing facts.

Of course, I can only speak for myself.

Accountability, Unity, and Voting

This was posted first on my Facebook stream and has been copied here. 

Can we talk? Of course, I can only speak for myself.

I am thinking about unity and accountability. Actually, I’m thinking at the moment about unity and accountability and voting.

In most of these United States, at some points convicted felons receive again the right to vote. We heard a lot about that this past year in light of changes (before 2020) in Florida. Felons there could regain the right to vote, but only after completion of sentence, completion of any probation, and payment of any outstanding restitution and fees. Now, some think the requirements are too great, and that the system can be set up to make it practically impossible even it it’s theoretically possible. What I think we can agree on, though, is that this is unity that is possible, but only after accountability.

Unity after accountability is really pervasive in our culture. Kid misbehaves? Send said kid to bedroom or sit said kid in the corner, and only after that accountability can that child return to the community, to friends, to chosen activities. I was (rarely but occasionally) spanked as a child; and once I had endured that I was returned to my own (hopefully) better choices and behavior.

It makes sense, too, in so much that has shaped our culture. Since I’m a preacher, I can think particularly of our religious texts. All those sacrificial laws in the Hebrew Scriptures were about unity after accountability. I’m among those who has preached about atonement as “at-one-ment,” to emphasize that it was through accountability, and not without it, that one could return to right status in the community. Jesus in Matthew 18 gives a format for reconciliation when one member of the congregation sins against another. In that format, reconciliation requires accountability, even if there’s no punishment per se. The sinner has to own the sin - to be accountable - to be reconciled.

So, I think many of us would agree that there can be unity, but there has to be accountability first. Felons in Florida, and in most other states, can regain the right to vote after sentence is completed - accountability and then unity.

Which brings us to last Wednesday. After last Wednesday’s assault on elected leaders and a completed election, there are some who want to talk about unity. Well and good; and in our tradition, that should also require accountability. And if unity after accountability should apply to the drug user and also to the drug dealer, it should apply to the ones who stormed the Capital and also to any person whose rhetoric helped them think that was an acceptable thing to do. 

Of course, I can only speak for myself.

The Collapse of Western Civilization Seems Closer....

Fourteen years go I wrote a post on my blog call Collapse of Western Civilization. It was built around this quote from Margaret Thatcher when she was Prime Minister of the UK:

"I think we've been through a period where too many people have been given to understand that if they have a problem, it's the government's job to cope with it. 'I have a problem, I'll get a grant.' 'I'm homeless, the government must house me.' They're casting their problem on society. And you know, there is no such thing as society. There are individual men and women, and there are families. And no government can do anything except through people, and people must look to themselves first. It's our duty to look after ourselves and then, also, to look after our neighbour." (From "Statecraft" by Margaret Thatcher. Although this quotation is from her book, I believe she also used it in public addresses.)

I've highlighted two of her comments. Hers is the attitude we've heard from conservative leadership (small "c," as it's not just her party in UK or the Republican party in the US) for a long time. It certainly wasn't new when I wrote about it then.

And now we're seeing the results in the midst of the pandemic. "Me and mine first; and no society to which to be responsible." She may have complained about some who wanted (and arguable needed) more support from government than she wanted government to give. However, there are times (and we are in such times now) when it simply can't be just about me and mine. My impact on my neighbor is so much less in my control than I think. My need can be so much greater than I can manage. It is these circumstances that show not only that society does exist, but that it must exist. To be civilized - to live in a civilization - establishes those responsibilities beyond me and mine. If we don't want to lose that, we have to challenge such an attitude as the late Lady Thatcher and her current adherents. For there is an alternative to civilization. As the philosopher Thomas Hobbes wrote, "No arts; no letters; no society; and which is worst of all, continual fear, and danger of violent death: and the life of man, solitary, poor, nasty, brutish and short." (Leviathan, chapter 12)

Reflections for the Times 2

When I was a child in the Knoxville City Schools, I was required to read Christy by Catherine Marshall. While not the only reason it was required (I can only imagine that the explicit Christian context didn’t hurt), a central reason was that the book described Appalachian community life in the late 19th and early 20th Centuries. Catherine Marshall’s mother was a teacher in a small community in Virginia, and the town in the novel was based on a town in Tennessee, not far from where I grew up.

I will be honest that I don’t remember much about the book. However, one chapter has stayed with me over the years. One of the central characters is the preacher, David. Like Christy, David is an outsider in the community, but thoroughly committed to his people. In one chapter a member of the community needs to clear a field to be plowed. This becomes a work of the whole community. The men gather, and each takes a portion of the field to clear with scythes and axes. David steps up to do so, too. This comes as a surprise to the community. He’s not a farmer, used to the tools, or even to the hard physical work it entailed. And, then, too, he’s the preacher! He insists; and even though it takes him much longer to finish, he gets his part done.

What has long stayed with me about this is David’s determination to give of himself, at, really, great expense, for the good of one family, and to model serving the whole community. 

But, then, the whole chapter was an example of a community coming together to serve one another. Once upon a time, that was a common example of American values. Perhaps from recent movies we attribute it especially to Amish communities; but it was once a more general idea. One of the major scenes in the musical, Seven Brides for Seven Brothers, takes place at a barn raising. Communities gathered to help because there were things to accomplish that no one person could do. 

There is, in American public life, that countervailing theme of the individual - commonly called in arts and letters “the rugged individual.” It’s been pitched at us especially since the Reagan Administration as the model of American freedom. But, American freedom, and American history, has also involved individuals sharing common purpose, working as communities to accomplish things no individual alone could do - like building a barn; or flattening the Coronavirus curve.

Reflections for the Times 1

First published on Facebook.

I am a citizen of the United States. There are many folks these days that want to remind me that as a citizen I have rights, some guaranteed in the Constitution, some set by laws, and some determined by how various courts have defined those laws in light of the Constitution.

And, as a citizen of the United States, I also have responsibilities. For this point, I have responsibilities to my fellow citizens - to *all* my fellow citizens. That includes my neighbors here in rural Tennessee, and the neighbors of my children in California and the neighbors of my niece in New York (just to give as broad a range as possible).

I have a responsibility to consider the welfare of my fellow citizens - the ones who live with me in my retirement community and the ones I encounter in church and the ones I encounter at Walmart. I have a responsibility as a citizen (without even going to how I understand my responsibilities as a Christian) to consider the health of my fellow citizens.

So, I wear a mask when I go into town; I stay six feet from folks I encounter walking my neighborhood; and I stay home. I pay attention to medical information. I recognize that we’re far from knowing just how prevalent the current corona virus actually is in my own county, much less anywhere else. Sure, I haven’t had the identified symptoms; but “absence of evidence is not evidence of absence.” I may have a right to be out and about, but I have a responsibility to my fellow citizens to limit myself to protect the health of others, whether I know them or not.

When I was a boy, I was taught, “My rights end at your nose.” These days there seem to be a lot of folks asserting “*Your* rights end at *my* nose.” This is a difference that makes a difference.

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.

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 polítical 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.

Distributing the Costs of Care, Part Two: More Than Just Me

A thing costs what it costs. That’s as true for a medical procedure as it is for a strawberry.

I started with a new primary care provider recently. That start involved meeting with a new professional provider, and a set of lab studies and tests - nothing exciting, but part of the process.

Now, I will have certain expenses out of pocket for that, but how those charges are determined is, again, a reflection of a slew of costs. There is the cost of the professional’s time; and, trust me: these days any health care business has some idea what to charge by the hour, even if that’s not how the charge is reported on the bill. And then, going into that cost is the cost of educating that professional, which may or may not include education loan debt. There is the cost of the computer system used to keep the records, the software it runs on, and the hardware that holds it. There’s the cost of the malpractice insurance that any professional will have; for after all, a suit can be filed before anybody actually determines whether the facts support it. And of course there are the costs of the facility - rent, utilities, insurance. There are also costs of getting paid: paying someone to issue the bills, to report to the insurance company, to know relevant law and regulation. And, there are the costs of not getting paid. Medical debt has been an important cause of bankruptcy for individuals, even if that’s been reduced under the Affordable Care Act. Sometimes people can’t, or won’t pay.

And that’s a simple new patient visit. Had I needed a procedure, then there would have been more costs: the required equipment, and amortization of that; the costs of nurses and other technicians, including their professional education and expenses; and, again, losses to charity care or refusal to pay. That’s kind of like the dropped box of strawberries: costs are raised and/or shifted to that the institution can cover here what is lost there. The big difference in healthcare of course, is that it’s not a $4.00 box of strawberries, but a $50,000 hospital stay.

All of this affects, but isn’t shown in the bill I will receive. What the bill will show, though, is something about the ways that my out of pocket costs are reduced by the distribution of charges. There are, of course, all the other patients in my new professional’s practice. More important, though, is insurance. Insurance, really, is the ultimate distribution of charges. I’m one of a large group that pays into the insurance company, and so far I’ve hardly ever had to use as much in one year as I paid - or, since so far my insurance is been provided by employer, as much as was paid in on my behalf. The insurance company distributes the costs of any current claim across the premiums paid by all the covered members. Then, again, my employer distributes the costs. The employer negotiates with the insurance company based on a pool of covered employees, figuring that the expenses for any individual employee will be lower. (I’ve written before that the currency of that negotiation is not dollars but “covered lives” - you and me and our family members.)

A medical procedure costs what it costs. For good and ill, though, I won’t see that cost. What I will see is what I pay out of pocket, and also what the insurance company paid on my behalf. Oh, and I may also see the results of the negotiation between hospital and insurance company as a discount or reduction. Of course, that’s what I see. Another patient with another insurer or another employer (or a person not having either) will see different numbers. That’s because there’s a different negotiation with each different company. Oh, and because for any given procedure with any given patient the insurer may renegotiate and pay less - which almost inevitably ends up with you or me paying more out of pocket.

We hear about that a lot now in efforts for “price transparency” for medical procedures. Everybody agrees it would be a nice idea. However, it’s hard in practice. There are differences in negotiations between each institution and each insurer. There are differences in negotiations between each medical practice (and most medical practices are still small businesses). Newer equipment costs more, and takes more procedures to amortize out that older. And, of course, large research and educational health care centers in urban settings take both higher risk patients, who need more resources; and more patients who can’t pay. A procedure costs what it costs; but the various inputs into those costs can vary a lot from setting to setting, as can the various ways to distribute costs as widely as possible. A procedure costs what it costs; and it may well cost more in one place than another.

Of course, we may also be willing to pay those costs. If I need a procedure, I may be willing to pay more for the professionals and the institution that have more experience - literally, that have offered that procedure more times to more patients. Professionals and institutions with more experience get better results. Or, I may be high risk myself for one reason or another. So, I may well be willing to pay for an institution with more resources. I don’t know I’ll need them; but if I do need them I don’t want to have to go somewhere else.

Then, of course, there is emergency care. If it’s really an emergency, I’m not about to start haggling over prices. I want to be where the right people and the right equipment are available for a good outcome, not a lower bill. And, I want those resources available 24 hours a day, whether I’m using them right now or not. “Just in time” may work well enough in having the right parts at the car plant for assembly, but I don’t want to trust “just in time” staffing for my emergency room. “Just in time” staffing may not be just in time to save me.

But, still, the biggest issue with price transparency, and one of the biggest things shaping what I pay out of pocket, is the sheer number of different insurance companies negotiating with the number of different health systems and institutions, and professional practices; and that includes the two biggest insurers, Medicare and Medicaid.

Once again, that sheer number is also part of the distribution of costs. My out of pocket expense feels small because the insurer distributes all my expenses across the premiums of all of us who are members; and because my providers, professional and institution alike, distribute my expenses across all the patients cared for using that expertise and equipment. A thing costs what it costs, whether a strawberry or a medical procedure. It can just feel less expensive to me because of how a lot of other people participate in paying those actual costs; and that will be the starting place for part Three.

This Week’s Challenge on Informed Consent

In this week’s news, this article from the New York Times caught my eye:

Louisiana Tests Unapproved Anti-Addiction Implant on Inmates. Now, there have been a number of references to the fact that these devices haven’t had FDA review. However, that lack of review only highlights the more basic problem: the problem of informed consent.

I actually learned in detail about research ethics in healthcare before I learned about clinical ethics - the difference between ethics in research and ethics in actual treatment. Our concept of Informed Consent is actually rooted in professional and political reaction to abusive research, and only then applied to abusive care. Reflecting such research horrors as the Tuskegee Syphilis Experiment and the atrocities that came to light in the Nuremberg trials, we developed the standard that human subjects participating in research have the right to informed consent: to decide freely whether to participate, based on thorough information about risks, benefits, and procedures.

In that light, then, we developed the concept of “protected classes,” subjects to have special protection because they could not participate in informed consent. While the categories defining protection could be complicated, they largely fell into two broad categories: those who needed protection because they couldn’t or wouldn’t be informed (think children, or adults of limited capacity); or those who needed protection because their capacity to consent wasn’t free.

Among those “protected classes” are prisoners.They are not free in their daily life, and their freedom to consent it assumed to be limited until proven otherwise. That isn’t about the capacity to understand. It’s because being in prison limits freedom of action, and makes one potentially subject to coercion or to inducement that wouldn’t have the same power outside the walls.

The story as reported in The Advocate provides a more thorough discussion of the situation. For example, it lays out how this happened - apparent largesse from the decide manufacturer (who will, perhaps, benefit greatly) - and how the prisoners involved might benefit. The device provides a steady dose of a medication proven effective for some in curbing opioid addiction. However, it also highlights the issues of prisoners and informed consent. In that light, it only highlights the concerns that the device hasn’t had FDA review: part of informed consent has to do with knowing the risks, and FDA review is usually how most of us learn about risks.

It doesn’t explain, though, other aspects of research. For example, in most situations there is a review committee, commonly referred to as an Institutional Review Board or IRB, that reviews risks and benefits on behalf of the institution or company overseeing the research. While the company in this may have one, there’s no reference to it. The company, too, is funding this internally, so we don’t know about conflicts of interest, etc.

All in all, this is a questionable and concerning event. I’m not opposed to these few prisoners benefitting. However, if this becomes a more common practice for bypassing the FDA, it becomes a practice that should concern us all.

Distributing the Costs of Care, Part One

Can we begin with a simple premise, that a thing costs what it costs?

I know that sounds trivially true, but in fact most of the time, most of us don’t think that way. That is, we note what we pay out of pocket for an item, but don’t think about all the costs that went into what we pay.

I bought some strawberries yesterday morning. What that box of strawberries costs is the result of a whole slew of expenses. What did the farmer pay for the land, and what is the measurable (if tiny) incremental cost of one strawberry in light of those and other costs of production - water, fertilizer, labor, etc? What is the cost of processing and shipping that strawberry; of warehousing it for the wholesaler; of having it in my local market? Just because we don’t think about that strawberry’s contribution to paying the electric bill of the grocery story doesn’t mean that it isn’t there and fixed. When we remember that a thing costs what it costs, we can look beyond just what we pay out of pocket.

And, of course, we can remember that those costs are shared with others. If my box of strawberries were priced so that my purchase would sustain the market, I wouldn’t be able to afford them. If I alone were paying the fuel charges of the trucker and the labor charges of the wholesaler, that box of strawberries would be far out of reach. I can only afford those strawberries because a whole host of folks participate in distributing the costs of those expenses. That’s the difference between the economy of a large society and -  well, really, any society. Once upon a time, perhaps, there was an individual working an individual plot of land and providing only for himself, and so paying personally all the costs of having a strawberry; but once folks started living in communities and sharing resources and exchanging (even in barter), costs started getting distributed.

That’s particularly true when we find a “bargain.” If I find my box of strawberries on sale, it might be that the farmer somehow produced for less, or that diesel was temporarily down. Or, it might be that these strawberries are getting close to the end of their shelf life, and the store loses less by selling them at a reduced price than by letting them get old and not selling them at all. And, after all, the store can take that decision, not out of the goodness of anyone’s heart, but because the store can adjust prices somewhere else, and so better distribute those costs. Someone else paying a dime more for apples allows me to pay a dime less for strawberries. It costs less out of my pocket, but it didn’t cost less in the real costs of production. J, at each stage of production, one of the costs that gets distributed is losses. If one field fails, that’s going to raise the price (not the cost) of the strawberries from fields that succeed. If someone drops a box in the store and all those berries are ruined, you can be sure that the store has some calculation of how that loss can be made up elsewhere. In a market economy, those losses get covered, or the person at that level can no longer produce or provide.

A thing costs what it costs, with all those costs of production figured in, and with all those distributions of costs worked out. What it costs out of pocket is a combination of all those costs, and how all those costs are distributed.  It’s true of a strawberry; and it’s true of a medical procedure. And that’s a thought that I will explore in Part Two.

An Interesting Comment on Christian Moral Teaching

I was pointed to a new article from La Civilta Cattolica, a Jesuit publication based in the Vatican. Notably, the Wikipedia article about it states, "It is the only [publication] to be directly revised by the Secretariat of State of the Holy See and to receive its approval before being published." The article, published in English, is titled "Evangelical Fundamentalism and Catholic Integralism in the USA: A Surprising Ecumenism." (And thanks to IT at the Friends of Jake blog for pointing to it.)

The article raises very interesting questions about the political alignment between (political) Conservative Evangelicals and (political) Conservative Roman Catholics. While I would encourage my readers to read it in detail (and, it isn't either so long or so complicated as to make that difficult), I can point to the one theme I think important. The article points to the model of Pope Francis in trying to embrace the full breadth of Roman Catholic social teaching. That is, the Catholic Church is equally concerned about abortion, poverty, and stewardship of the earth. It has teachings on providing medical care to all, on serving the most needy, and on pursuing peace, as well as on human sexuality.

The point is not that the Catholic Church has changed any of the teachings that progressives might find difficult. It is, rather, also to embrace those teachings that progressives might agree with, and to challenge the pursuit of political power as a form of enforcing moral authority.

And on this last, it is especially pointed. Francis is leading in this, but he is not the model. As the last paragraph states,

This is why Francis is carrying forward a systematic counter-narration with respect to the narrative of fear. There is a need to fight against the manipulation of this season of anxiety and insecurity. Again, Francis is courageous here and gives no theological-political legitimacy to terrorists, avoiding any reduction of Islam to Islamic terrorism. Nor does he give it to those who postulate and want a “holy war” or to build barrier-fences crowned with barbed wire. The only crown that counts for the Christian is the one with thorns that Christ wore on high. (emphasis mine)

Thinking About Who Pays

So, I have been aware today of the case before the Supreme Court of the owners of the Hobby Lobby retail chain resisting a provision of the Affordable Care Act intended to insure access for women to all forms of birth control by requiring that employers either include that in company-sponsored health insurance plans or pay a penalty that would allow then allow women to pursue in the insurance exchanges health insurance plans that would cover birth control. There have been many reports about it; and regular readers will know that I listened to the report this morning on NPR.

 

I wasn’t paying too much attention, largely because I wasn’t hearing much new. After all, this has been a topic of discussion for a while. Then I heard this:

　

"The Hobby Lobby corporation and its owners counter that the simple answer to these arguments is to have the government pay for contraception.

The government replies that is no answer. Otherwise, the government would end up paying for everything. A decision is expected by summer."

　

I found myself wondering something more profound in this idea that if the government wanted to mandate health care, the government should pay for it – something I doubt the Greens or their attorneys thought about when they made that statement (if they made it as reported). That is, if this applies to birth control then it should also apply to therapeutic abortion.

　

First, let me take on directly what I mean by "therapeutic abortion." There are cases (and perhaps not so rare) when terminating a pregnancy is medically appropriate. Think, for example, of the woman a few years ago in Phoenix. She was diagnosed with pulmonary hypertension in the eleventh week of pregnancy. While the case was reported because it was complicated for religious reasons (she was a patient in a Roman Catholic hospital), under court decisions and state laws terminating the pregnancy was appropriate because it was literally to save the life of the mother. In fact even the hospital saw it that way, and terminated the pregnancy. The controversy and news coverage came because of the reaction after the fact of the local Roman Catholic bishop, not because the woman didn’t get the care.

 

So, I’m not talking about "abortion on demand." I do think that terminating a pregnancy ought to be a decision a women makes with her doctor; that there ought to be a supportive family and community for that woman; and that the procedure needs to be available and safe. But, for this post I’m only talking about situations that are clearly medically indicated. The one I cited above was rare and rather spectacular. More common are situations like loss of amniotic fluid mid-pregnancy that doom the fetus and put the woman at severe risk. Sure, these aren’t common, but they do happen. And women die. According to the Centers for Disease Control, in 2009 the rate of pregnancy-related deaths was almost 18 per 100,000 live births. That comes to about 650 women each year; and while that may not sound like many over all, say that to the families of those 650 women.

So, by the logic stated above, the government ought to pay for therapeutic abortions. Of course, that brings us up against the other perspective: those who say "no government money" for abortion, including Medicaid dollars. And then, of course, there’s this problem with the logic: those who would refuse to support birth control in the insurance plans offered by the companies they own would then be supporting birth control in the tax-supported insurance plans and/or direct purchases – because to say "let the government support it" is to say, "let all the taxpayers support it – including us."

My guess is that the Greens’ attorneys have a much more sophisticated way of stating that idea that the news report may not do justice. However, the principle as stated caught my attention. It has possible consequences that seem directly contrary to the results the Greens want to see. Call it another of those unforeseen, but perhaps predictable, medical outcomes.

Conformed Consent

Yesterday in a conversation about ethics a turn of phrase occurred to me, and the more I've thought about it the more sense it's made. Let me make it in context.


The specifics of the conversation had to do with informed consent and the decisions of patients and/or families - perhaps especially families when the patient can't participate - regarding goals of care and possible treatments. Now, there have been many discussions on what "informed" consent might mean, and whether we can really and accurately inform patients and families. Those discussions are important, but I was struck in the conversation by another point. Even when we try hard and do our best to provide information that is accurate, and try to provide it in a form comprehensible by the person in front of us (usually someone who would not comprehend the word "comprehensible"), people make decisions or ask further questions that seem to us as professionals as if the person didn't understand. With some further conversation the person might completely and accurately recount back to us the information provided, and then still ask for information or, more importantly, for an intervention that seems to us unhelpful. Once again, we wonder whether the information has really been comprehended (understood more deeply than simply the level of definitions and concepts).

Most of the time over the years I have noted and pointed out to colleagues that this is one consequence of the principle of autonomy, and especially of how in our American context (by which I mean specifically the United States, and not including Canada or Mexico) autonomy has become the overwhelming principle applied in making health care decisions. If we allow folks to make the decisions, we need to be prepared for them to make decisions we find foolish. As I have often said after a difficult family conference, "It's not that they don't "get it." The problem is that they don't want it."

It occurred to me, though, that this reaction doesn't do justice to the families of patients, because it doesn't claim our part in our own frustration. It occurred to me that we expect that informed consent will in fact be conformed consent - that is, that the information that we find compelling will also be found compelling by the other party.We have been persuaded by our own information and logical reflection, and we expect it to be persuasive to any other rational person. Ergo, if it isn't persuasive the other person must not be rational.

And that is our sin. That dishonors the other persons' values and frames of reference. It is also as much a cause of our frustration as the other persons' responses. It's the unclaimed, usually unrecognized prejudice - literally, our pre-judging of what constitutes reasonableness, if not of the person specifically - through which we set ourselves up to be disappointed.

In that light I'm humbled by how often we aren't disappointed or frustrated - that it doesn't happen more often than it does. That is, in fact there is enough of a shared social frame of reference that much of the time the "best medical advice" that we offer is persuasive for those who listen. Let me be clear: it is also part of that, and a part that we need to be self-aware about, that some of that social frame of reference has to do with the status of the expert and of the physician (in these instances combined in one), so that it is not the information or the logic that is persuasive but instead the perceived authority of the physician. Still, even recognizing that caveat, it is a fact (one that we don't appreciate often enough) that there is enough shared sense in our culture of what constitutes "reasonable" that we don't have more moments than we do when we project that the patient and/or family are "unreasonable."

Nonetheless, these encounters happen more than we like, and perhaps should happen more often than they do. That is, we are too hasty to present our information and our reason from our context without taking the time to step into the other person's. We think what we find compelling must surely be compelling for others. We expect an informed consent process to result in conformed consent, and get frustrated when it doesn't work out that way. Unfortunately (and this is not really news), our expectations are as much an issue as another's lack of understanding or unreasonableness; and our frustration with the situation and with them is in no small part our own fault.

Context Is Everything - or At Least an Awful Lot!

An ongoing problem in health care is the use of Emergency Rooms as primary care providers. With that in mind, I was interested to see the story, How Oregon Is Getting 'Frequent Fliers' Out Of The ER by Kristian Foden-Vencil on the NPR web site.

The article describes efforts to address the social needs and issues that keep patients out of primary care, and so in the Emergency Room. It looks at one patient as an example, and speaks to the needs he has for housing, clothing, dependable food - all those things that make for stability. With stability, he has been able to avoid expensive ER care and instead see a primary care physician, get necessary medications, and stay on them. Without stability, he has hardly any choice.

This is a well known problem; and, really, this is not a new solution. However, it's not always the first to come to mind. There is some expense in meeting his social needs and in following through with him so that he uses resources effectively. However, as the article notes, those are only a fraction of the expenses generated with avoidable visits to the ER and avoidable admissions to hospitals.

On the other hand, this is very different from our more common use of resources in health care. It involves spending money on folks who aren't at the time in crisis (leaving aside for the moment that social crises that is defined by the social needs). Our current insurance structure (including Medicare and Medicaid), built as it is on paying for procedures and interventions, isn't oriented this way. Some efforts have been made in the past toward that - think HMO's and "capitated care" (providing so much reimbursement per person) - but they were still oriented toward the traditional categories and the traditional venues of health care: medical and nursing and pharmacy care provided in medical and nursing and pharmacy settings. 

This answer is different, if not original. It is investment, really, in the life and situation of a person to provide the resources that prevent crises and so prevent crisis-level health care expenses. 

There are aspects of how health care is changing under our feet that might better coordinate the traditional aspects of health care. The important buzz words are medical home and accountable care organization. These are new to most of us, but there are good ideas behind these words. That said, they are still focused on how we provide and pay for the traditional categories of health care. It remains the case that for so many without the resources that provide social stability those good ideas won't accomplish all we hope.