Friday, June 11, 2010

The Real White Coat Syndrome: Why We Stigmatize the Sick and the Real Case for Single-Payer Healthcare

The two-party system of American politics relies on a nexus of certain polarizing “core issues” with party platforms clearly defining the “black and white” nature of left and right politics. A particular candidate’s party affiliation predictably reflects that candidate’s public views on issues ranging from abortion, to free speech, to immigration, to gun policy and foreign policy. Obviously, there are outspoken “black sheep” from both sides, but these Nancy Pelosis and Ron Pauls are a mostly impotent minority. The vast majority of candidates from both parties must toe the line between observing their prescribed platform and alienating moderate voters. Unfortunately, it is this very pandering that breeds legislative gridlock and blocks real progress and reform. Within the last decade, the epitome of this gridlock is the move towards comprehensive healthcare reform.

By the 2008 presidential election cycle, the economic need for healthcare reform made it one of the most important issues driving debate outside the voting booth. As unnecessary foreign wars and questionable lending practices drained the American economy, candidates were forced to account for why, dollar for dollar, the American healthcare system was (as it remains) among the least fiscally efficient in the developed world—and what exactly they planned on doing about it.

At that time, as now, the system had been very obviously very broken for decades. In 2007 alone, Americans spent 2.3 trillion dollars on healthcare(1)—put in context, this is more than double what has been spent to date on military operations in Iraq and Afghanistan combined since 2001(2). In spite of this, quality healthcare remained a precious commodity with scores of millions of Americans lacking access to even basic primary care—and scores of millions more bankrupted by their need for it(3). The healthcare system had grown into a tangled web of bureaucratic overhead; effectively manufacturing a very artificial shortage of access to quality care.

President Obama’s signing of the Patient Protection and Affordable Care Act on March 23, 2010 and the Healthcare and Education Reconciliation Act of 2010 on March 30, 2010, was intended to represent the first real step towards addressing this artificial healthcare shortage in America—a remarkable step, but by no means a victory for the American people. While the net effect of both bills does ultimately increase healthcare access to productive citizens and promote the general public health, it does not establish healthcare access as a fundamental right and does little to address the expanding healthcare bureaucracy.

Universal healthcare access is commonly attacked in the United States as a “socialist” ideal but it is in fact a fundamental right granted to the people of almost every other developed nation in the world (3)—even in the United States, prison inmates and retirees are entitled to healthcare. Access to quality healthcare is perhaps the only American right routinely granted to convicted murderers and denied of school-aged children. Bearing witness to this, urban streets are flooded with the untreated mentally ill(4) as children in rural Washington are lucky to stay current on their vaccinations(5). Were these disaffected populations ever to get the vote out, the end to legislative gridlock would certainly come quickly and decisively.

The majority of voting Americans are not blind to the disaffected peoples around them—the average American volunteers a remarkable 250 hours per year to community service(6)—but when it comes time to cast a ballot, personal economic incentive invariably outweighs empathy. When dealing with a system as complex as American healthcare, personal economic incentive can be confusing, if not impossible, for the average citizen to objectively determine. Adding to the confusion, political fast-talk regarding the topic has led to the birth an even more complex network of political smoke and mirrors. Put simply, republicans say that healthcare should ultimately be paid for by the recipient in a manner commiserate with the level of care received and democrats say that level of care received should be independent of one’s ability to pay. The Bush deficit aside, both positions are consistent with the established economic stance of their respective parties.

Further cluttering the debate, outspoken and charismatic politicians are guilty of distorting facts and sleight-of-hand wordplay. Sarah Palin’s talk of “death panels” and the Beckism “Obamacare”(7) are born, not out of objective argument—but out of a need to suppress the potential political advances of the rival party. Images reminiscent of cold-war McCarthyism are used by conservatives to quash any budding public support for expanding the role of the federal government in healthcare. Before their final texts had even been decided upon, the radical “tea party” movement had already dismissed both healthcare bills as part of a larger “socialist agenda”(7).

Such foot-dragging put democratic legislators in a rough spot—with most constituents unaware of what the actual wording of the bills entails, voting for a bill touted by conservatives as “providing Viagra for convicted sex offenders”(7) comes at a huge political risk. Coming from the “moral majority”, such rhetoric is neither surprising nor unexpected; unfortunately, the human cost of accommodating this rhetoric far exceeds the value of any perceived moral high ground. Using moral objections to oppose the expansion of healthcare rights is far from a new concept—societies throughout history have attributed a level of social and legal stigma on patients with various conditions.

The most common underlying causes of chronic illness and death in the United States are obesity, an increasingly sedentary lifestyle, and smoking(8). With modern technology, most Americans live free from the infectious diseases that ravaged the populations of their parents and grandparents. Those infectious diseases that do persist tend to have more illicit usual routes of exposure; HIV is most commonly spread through sharing needles and unprotected sex, as is Hepatitis C, and both are far more common among traditionally “disaffected” populations than the American population as a whole(9). Thanks to a sensational media, public fear of these diseases both far outweighs the actual threat and perpetuates the dangerous tradition of ostracizing the sick. Public association of an infectious disease with a particular demographic is dangerous on two counts; first, it can often lead to the arbitrary restriction of the rights of a certain people (e.g. gay men are not allowed to give blood), second, it gives “low-risk” members of the public a sense of false security from a still real biological threat.

Ironically, the deadliest and most visible stigmatized condition is not infectious at all; addiction is, perhaps, the single most common and least understood chronic condition in the world. Whether directed at alcohol, food, sex, or controlled substances, addiction imposes a higher social and economic cost on American society than all infectious diseases combined(10). Neurobiologically speaking, all addictive processes seem to share a common molecular etiology; genetics is known to play a significant role, but the true disease mechanism likely stems from a complex combination of genetic predisposition with novel environmental factors(11). In spite its known biological basis, addicts are treated like criminals. Public resources available for the treatment of addiction are sparse at best—the majority of addicts who fall out of the system ultimately find themselves on the streets or in prison. The cost of prosecuting the “war on drugs” alone was an astronomical 40 billion dollars in 2000(12)—with the vast majority of drug shipments evading capture to be readily distributed to addicts from every background(12).

In addition to addiction, untreated mental illness is endemic among the American homeless population(4). For many of these people, their individual diagnoses would be manageable with the proper level treatment and support—properly managed, many could probably go on to live otherwise productive lives. The resources exist to treat many (if not most) of these people who would otherwise fall out of the system; it is only access to these resources that is limited. A universal healthcare program that extends access to mental health and addiction treatment services could render these people into productive tax-paying citizens. Therefore, spending taxpayer dollars on such programs would be far from a wasteful handout, it would be an investment made by taxpayers into producing more taxpayers—many of whom would pay, in taxes, for their own treatment within years.

The paradigm of government run healthcare as a vehicle through which a society can invest in itself is not new either; it is one of the more profound economic arguments favoring such a system. However when healthcare is viewed as a consumer commodity, this argument makes little personal economic sense. Simply put, American voters do not want to pay for services that they themselves are not consuming. This potentially represents a strong argument against a single-payer government run system; until the true cost of indigent care under the current system is considered.

Emergency rooms are required by law to provide care to every patient who presents regardless of that individual patient’s ability to pay. At major public teaching hospitals, this requirement to provide care extends to everything from lengthy ICU stays to the management of chronic illnesses. In the average American emergency department, only one patient in every three pays their bill. The two out of three patients who were treated “for free” had their tab picked up in the form of higher costs assessed to the patient who did actually pay(13). These savvy “healthcare consumers” are blissfully unaware of the fact that the majority of their healthcare costs already go towards covering indigent care. Furthermore, most indigent patients requiring long-term residential care are covered by Medicare and already reflected in the tax-rates paid by the general population(14). A universal single-payer system is nothing but a more honest way of doing business; furthermore, because such a system could be funded from income tax dollars, it would be a way of ensuring that everybody with the means to contribute something to the system actually does.

The administrative streamlining allowed by such a system—by standardizing reimbursement protocols and short-circuiting the bureaucracy of the current system—would mean fewer middle men between patient and service. A service that costs a dollar in the clinic requires a dollar to reach the clinic. Under the current system, this dollar usually passes through at least three sets of sticky hands between the patient and the provider—a single-payer system run by the (obviously not-for-profit) federal government literally requires fewer hands and maximizes the value of every dollar.

Medicare is a fine example of this; as the model for a potential American single-payer system, Medicare is perhaps the single most efficiently run insurance provider in the country. Dollar for dollar, Medicare is able to cover the costs of more care than any private insurer. It is also worth noting that Medicare funds a significant portion of post-graduate medical training in the United States—thereby covering an even greater distributed healthcare cost than most private insurers(15). What is even more remarkable is that Medicare was molded around the existing tangle that is privatized healthcare—an integrated Medicare-like system that provides care for every citizen has the potential to be even more efficiently administered.

Making Medicare eligibility universal has been suggested before. First introduced in 2003, HR 676 aims to do just that—provide universal healthcare by expanding the already existing American single-payer system(16). The bill has been resubmitted every year, most recently in 2009, but has never reached the house floor for debate or a vote. Perhaps more disturbingly, at the congressional hearings that eventually gave rise to the bills signed in March by the president, not a single lobbyist supporting single-payer healthcare was invited to speak (see video). Perhaps because of vehement opposition from the far right, Americans will still have to wait for truly universal single-payer care.

The bills that did pass are still woefully inadequate and politicized. Imposing harsher regulations on insurers and providing subsidies to the poor only adds another layer of complexity to the American healthcare landscape. It is entirely likely that insurers will increase rates across the board to compensate for the additional strain placed on the system. Even after all of the reforms outlined in the bills take effect, there will still be uninsured Americans and there will still be a shortage of access to quality primary care. As much as the public conversation over healthcare reform has ceased since the passage of these bills—it would be to the detriment of the greater good to assume that the debate is over.

Works Cited
1. WHO. “World Health Statistics 2009.” 2009
2. (accessed 7/6/2010)
3. Anderson GF, Reinhardt UE, Hussey PS, and Petrosyan V. “It’s the prices, stupid: why the United States is so different from other countries.” Health Affairs (2003) 22:1:89-106.
4. Fazel S, Khosla V, Doll H, Geddes J. “The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis.” PLoS Medicine (2008) 5:12:1670-1680.
5. (accessed 7/6/2010)
6. Corporation for National and Community Service. “Volunteering in America 2010 Issue Brief.” (2010)
7. (accessed, regrettably, 7/6/2010)
8. (accessed, 7/6/2010)
9. (accessed 7/6/2010)
10. (accessed 7/6/2010)
11. Feltenstein MW, See RE. “The neurocircuitry of addiction: an overview.” British Journal of Pharmacology (2008) 154:261-274
12. (accessed 7/6/2010)
13. American College of Emergency Physicians. “Release: the uninsured: access to medical care” (20110)
14. (accessed 7/6/2010)
15. (accessed 7/6/2010)
16. Conyers. “HR 676.” 111th Congress 1st session (2009).

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