



You're receiving this email because at some point in the past two years you signed up for my tinyletter. I didn't know what I wanted to do with it then, and still don't, so I reckon why don't I post about healthcare a bit. I hate writing like I hate the thought of yanking out my own teeth, and I'd like practice writing good.



If you have a healthcare question you'd like me to see if I can answer, you can use this:



Right now it's mostly people asking me about Thin Lizzy's "The Boys Are Back In Town." It's slightly less fun to answer 1200 questions about "The Boys Are Back In Town" but I made my bed and I'm prepared to sleep in it.



Here are three things I'd like to talk about, briefly:



0) Medicaid cuts



1) Physicians and single-payer



2) Risk adjustment







~~



0) Medicaid cuts



Trump's budget came out, and it includes an $800b tax cut for--surprise!--wealthy people. This is funded by cutting Medicaid by $800b--the same idea we saw in the AHCA when it passed the House.



Forgive me for repeating myself: This is a full-frontal assault on the poor and an unprecedented challenge to federal entitlement programs. In a less enlightened time, such unrelenting barbarism from a nation's government might prompt the fear the guillotine--me, though, I just wish someone would corral the authors and give them Hepatatis C.



Much of the rhetoric surrounding Medicaid cuts comes from the paranoia that the poor are somehow "getting away" with something--in this case, arbitrarily restricted healthcare access. Unchallenged, triumphant capitalism has convinced us that nothing good or ambitious is possible; liberalism insists with each groaning bleat that ours is a purely meritocratic society; if our individual lives must be so horrid with no hope of improvement, why should we extend any compassion to those below us? Fuck it.



This idea appears in a pillar of the "consumer-driven"/neoliberal healthcare model--the idea of "moral hazard." Moral hazard means, in short: when people have access to healthcare, they might use it. When people use healthcare, it costs money. So if we give people access to healthcare, they might use it irresponsibly, and then we'll be on the hook for a jillion dollars in care costs. Thus, a necessary component of any Big Government healthcare model is preventing unbridled utilization; a system for restricting access to care--the "death panels".



This is, of course, absurd. Healthcare is not a "normal good" and people don't pursue it the same way they pursue bubblegum or beer. Duh! Nobody gets recreational heart surgery. Fuck off. There are some exceptions--high-cost, low-utility services--but they're small potatoes and can be regulated with enough imagination.



And we already have a process for restricting access to care in America--cost, and the inaccessibilty of care to those without the money to pay for it. Wealth is the arbiter of who has access to essential medical care, not a rigorous cost-benefit population analysis. The federal government is the only actor who bears both the costs of providing care (the literal cost of treatment) and the cost of not providing care (mass death; declining workforce; general "bad vibes")--the argument for making it the centerpiece of healthcare payment is obvious. To quote Zsa Zsa, "It's Simple, Darling."



1) Physicians and single-payer



I gave a talk at SUNY-Downstate a couple of weeks ago to a bunch of med sudents. It kicked ass. Some students told me they receive no policy education at all in school; that there's an idea that delivering care is entirely independent of politics. I understand this in the abstract, but is clearly inaccurate in practice. In fact, I'd argue that physicians have the greatest leverage in the healthcare debate, but it's unrealized, so dickheads like the AMA fill the vacuum and claim to speak for them while advocating heinous bullshit.



In fact, one of the clearest, most compelling documents calling for single-payer comes from a group of physicians (led by Adam Gaffney up at Harvard, who rules and who has been on this beat forever):



For that talk at SUNY I put together a small argument for why doctors can and should demand single-payer. It looks like this:



Thesis: The consumer-driven healthcare model coerces doctors to make choices that ultimately harm their patients.

Hello to you,You're receiving this email because at some point in the past two years you signed up for my tinyletter. I didn't know what I wanted to do with it then, and still don't, so I reckon why don't I post about healthcare a bit. I hate writing like I hate the thought of yanking out my own teeth, and I'd like practice writing good.If you have a healthcare question you'd like me to see if I can answer, you can use this: https://curiouscat.me/crulge . There are so many things I don't know, but it'd be fun to learn what people who don't read health policy for fun are curious about.Right now it's mostly people asking me about Thin Lizzy's "The Boys Are Back In Town." It's slightly less fun to answer 1200 questions about "The Boys Are Back In Town" but I made my bed and I'm prepared to sleep in it.Here are three things I'd like to talk about, briefly:0) Medicaid cuts1) Physicians and single-payer2) Risk adjustment~~Trump's budget came out, and it includes an $800b tax cut for--surprise!--wealthy people. This is funded by cutting Medicaid by $800b--the same idea we saw in the AHCA when it passed the House.Forgive me for repeating myself: This is a full-frontal assault on the poor and an unprecedented challenge to federal entitlement programs. In a less enlightened time, such unrelenting barbarism from a nation's government might prompt the fear the guillotine--me, though, I just wish someone would corral the authors and give them Hepatatis C.Much of the rhetoric surrounding Medicaid cuts comes from the paranoia that the poor are somehow "getting away" with something--in this case, arbitrarily restricted healthcare access. Unchallenged, triumphant capitalism has convinced us that nothing good or ambitious is possible; liberalism insists with each groaning bleat that ours is a purely meritocratic society; if our individual lives must be so horrid with no hope of improvement, why should we extend any compassion to those below us? Fuck it.This idea appears in a pillar of the "consumer-driven"/neoliberal healthcare model--the idea of "moral hazard." Moral hazard means, in short: when people have access to healthcare, they might use it. When people use healthcare, it costs money. So if we give people access to healthcare, they might use it irresponsibly, and then we'll be on the hook for a jillion dollars in care costs. Thus, a necessary component of any Big Government healthcare model is preventing unbridled utilization; a system for restricting access to care--the "death panels".This is, of course, absurd. Healthcare is not a "normal good" and people don't pursue it the same way they pursue bubblegum or beer. Duh! Nobody gets recreational heart surgery. Fuck off. There are some exceptions--high-cost, low-utility services--but they're small potatoes and can be regulated with enough imagination.And we already have a process for restricting access to care in America--cost, and the inaccessibilty of care to those without the money to pay for it. Wealth is the arbiter of who has access to essential medical care, not a rigorous cost-benefit population analysis. The federal government is the only actor who bears both the costs of providing care (the literal cost of treatment) and the cost of not providing care (mass death; declining workforce; general "bad vibes")--the argument for making it the centerpiece of healthcare payment is obvious. To quote Zsa Zsa, "It's Simple, Darling."I gave a talk at SUNY-Downstate a couple of weeks ago to a bunch of med sudents. It kicked ass. Some students told me they receive no policy education at all in school; that there's an idea that delivering care is entirely independent of politics. I understand this in the abstract, but is clearly inaccurate in practice. In fact, I'd argue that physicians have the greatest leverage in the healthcare debate, but it's unrealized, so dickheads like the AMA fill the vacuum and claim to speak for them while advocating heinous bullshit.In fact, one of the clearest, most compelling documents calling for single-payer comes from a group of physicians (led by Adam Gaffney up at Harvard, who rules and who has been on this beat forever): http://www.pnhp.org/beyond_aca/Physicians_Proposal.pdf For that talk at SUNY I put together a small argument for why doctors can and should demand single-payer. It looks like this:: The consumer-driven healthcare model coerces doctors to make choices that ultimately harm their patients.

0) Medical costs have been rising since we’ve been tracking them. Since the 1930s we’ve invented different ways to mitigate them, and lurking in the background has been an ideology positing that healthcare is a regular, normal commodity. Most recently, that ideology has taken the name “consumer-driven healthcare,” and it posits that making patients bear a higher share of medical costs will bring costs down; that a ‘rational patient’ exists who shops for healthcare the way you or I might shop for beer or apartments; that they’ll shop around and only seek necessary care.



1) It is false (and has been since it first surfaced in the 1900s). Patients are uninformed, or carry a lifetime of medical mythology to the room. Their decisions are made under duress—fear, anxiety, pain. So they do what they should, and seek the advice of experts—their doctors. But the resulting choices come with financial costs. Thus, the doctor's medical advice is laden with financial repercussion—this is unfair to the doctor and harmful to the patient.



2) I am interested in the theory of Zack Buck (a law professor at UT Austin), who posits "financial toxicity" — that debt is very, very bad for health. A doctor seeking to "do no harm" avoids courses of treatment causing life-threatening side effects—and medical-cost-related poverty should be considered as such. Putting a patient into eternal debt is doing that patient harm.



Any system which coerces doctors to harm their patients is one which is fundamentally incompatible with the doctor-patient relationship. Thus, doctors are compelled to advocate for change—not as a matter of politics, but as something essential to their practice.