Health Care and the "Single-Payer" System

Copyright (c) 2008 by Kenny Felder

Ostensibly, this is an essay about the idea of a "single-payer" health care system. But really, this is an excuse for airing my view on politics in general.

What's wrong with a "pay as you go" system?

Hypothetical story: On the planet Blim, going to the doctor is like going to the auto mechanic. Something goes wrong, you get it fixed, you pay for it.
Why isn't health care just like any other commodity, where you just pay for it when you use it? Why do we have insurance companies, HMOs, Medicare, Medicaid, and endless political debate?

Because once in a while—a car accident, say, or a heart attack—health care is really, really expensive. Not "vacation in Paris" expensive: more like "buying a house" expensive, or worse. For one problem that is medically fixed and done with in a few months, you could spend 30 years paying off a second mortgage. Or worse: you can't get the second mortgage, and you just die.

Most of us don't want to live in a world where that one incident could ruin everything. But emergency care really is that expensive, and the money has to come from somewhere. So we all agree to throw a few hundred bucks into a big pot every month. As long as a lot of people pay into the pot, and only a few of them have emergencies, that money provides security for everyone.

That's the basic idea, and it's a good one. But who manages the pot? As far as I know, there are only two possible answers to that question: "private industry," and "the government." There, in a nutshell, is the debate.

From the left: What's wrong with our health care system today?

True story: My mother has a gum infection. The surgery will cost $10,000, not covered by her insurance. She asks what will happen if she can't afford the surgery. "The infection will spread to your brain. Then it will be life-threatening, and the hospital will treat it without charging you."
Our current solution is mostly based on private industry. My employer pays for my health insurance, which in turn pays for my wife's mammograms and my son's broken arm. If you can't afford insurance, a variety of government programs provides the basics. And the hospital is required to treat life-threatening emergencies whether you are insured or not. Sounds like a pretty good compromise, doesn't it?

But only a few employers can afford the top-of-the-line, covers-everything kind of insurance. Most of us have the middle-of-the-line, covers-some-things-but-not-others sort. And millions of us have no insurance at all. (*Many of the uninsured are children. Why does everyone bring up that fact? Because you can't say "Get a job"—children sidestep any argument that "Not having insurance is your fault.") When you have inadequate or no insurance, that means you leave some problems untreated. And this, in turn, leads to two problems.

The first problem is human suffering. Missing or aching teeth, uncomfortable or painful diseases, things that are not deadly but pretty awful, are just unavoidable realities for many people. The cures exist, but they can't afford them.

The second problem is big-picture financial. You have a health problem and you can't afford the treatment. So the problem keeps getting worse until someone else is willing to pay. This is by far the most expensive, inefficient solution: $200 worth of prevention could have prevented $100,000 worth of cure.

This may seem like a detail, but it is not hypothetical, and it is huge. Hospitals are overwhelmed and even shut down by the financial burden of emergency care, much of which could have been prevented by routine checkups and preventative treatments.

The obvious solution to all these problems is a "single-payer system." The single payer is, of course, the government. Rich and poor, employed and unemployed, all get covered by a taxpayer-funded system that pays for all the essentials. Doctors, not insurance companies, decide what checkups and treatments make the most medical sense. You don't have to view health care as a "basic human right" (whatever that means) to see how such a system avoids needless suffering and waste.

Sounds great, doesn't it?

From the right: What's wrong with a single-payer system?

True story: My grandfather calls the hospital: "This bill has a lot of charges for tests and procedures that were never performed." The polite girl on the other end of the phone explains to him: "That isn't a bill, sir, it's an informational statement. Your insurance company pays for the whole thing." She never disputes that the procedures on the bill never happened; she just keeps reassuring him that he doesn't have to worry about it, because it's all covered.
You don't have to be either right-wing or cynical to notice that people pay a lot more attention when their own money is on the line.

Last time you were at an all-you-can-eat buffet, did you figure out which items were the most expensive, and avoid eating too much of them? You probably should: it would save the restaurant a lot of money. If all patrons did the same, the restaurant could lower the cost of the buffet for everyone, including you.

But you didn't, did you? If you had been ordering each item individually, you would have chosen much more carefully. There's a world of difference between "This costs the restaurant an extra $5, which gets evenly distributed among all the patrons" and "This is going to cost me an extra $5."

With that in mind, let's take a look at the ideal health care system.

What is the inevitable result? Any time it seems like a certain procedure might possibly be a good idea—might make you more comfortable, or extend your life span, or detect a problem that you almost certainly don't have but who knows?—you go for it, and you go for the best that's available. Hey, my health is on the line. Everyone else is using the system to its full potential, so I might as well too.

This may seem like a detail, but it is not hypothetical, and it is huge. I heard a report on NPR about overwhelming numbers of Frenchmen asking their doctors to prescribe antidepressants. If the doctor refuses, they simply go to a different doctor, until they find one who will. Most of these people have no real medical or psychological issue, but the antidepressants feel good, and financially...why not? The inevitable result is a staggering waste of money.

"How can you possibly talk about money when human lives and suffering are on the line?" Money really does matter, my friend. It takes money to build better schools, feed the hungry, spread Democracy, and finally figure out how to harness solar energy. If all that money is going to fund unnecessarily expensive health care, it isn't going anywhere else. Spiraling health care costs are causing painful ripple effects throughout our society, and it's only getting worse.

From Kenny: What's the point?

Hypothetical story: You are the champion of your particular side of this debate. In future centuries, people will look back on your side the way we look back today on the abolitionists of the early 19th century. "Boy, were they the good guys. The other side was the bad guys."

This story is not true.

Imagine that you are at a party, where everyone is discussing health care.

Table 1 hosts a fierce debate. A group on the left side is screaming about poor uninsured children, financial inequity, and how wonderful things are in Europe or Canada. An equally determined group on the right is screaming about free markets, small government, and American superiority. Both sides are, on one level or another, running my hypothetical story through their heads: "Our side is the abolitionists, and the other side is the slaveowners."

Table 2 hosts the policy wonks. The snatches of conversation you can catch sound...well, frankly...boring.

"If everyone gets the vaccine, the cost is $20 multiplied by the number of babies born every year. If we wait until they're sick, that's $1000 multiplied by the number of people who actually develop symptoms."

"They should have that down to $850 within a year."

"What percentage of people actually develop symptoms?"

"Is there any way to very cheaply determine—say, when you're vaccinating them anyway—which people are most likely to develop symptoms?"

"How is this playing out in other countries who have tried both ways?"

You hear things at this table that you would never hear at the other table: things like "Good point," and "I hadn't thought of that," and even "Oops, I think I was wrong there."

Table 1 represent a moral or idealistic approach, Table 2 a practical or even tactical approach. Which approach is better? Well, it depends on the issue.

Some issues are moral issues. Gay marriage is a hot one right now. No matter which side you're on, it is fundamentally a debate about values. History may well look back at this debate the same way we look back on the abolition debates of the 19th century: "This side was the good guys, and the other side was the bad guys, and thank goodness the good guys won." Which side will be which? Your opinion is just as good as mine.

When you approach a moral question as if it were a practical question, you miss the boat. You can bring up facts and figures showing that homosexuality (is / isn't) tied to genetic factors, that it (is / isn't) cultural, that it (is / isn't) seriously prohibited by the Bible. But you aren't going to change anybody's definition of marriage, because this is about core values, and arguments don't change those.

Other issues are practical issues. My favorite example here is: "Is nuclear power safe?" It's a scientific question, like "Is there enough water on the moon to sustain a human colony?" You don't consider yourself qualified to answer the second question because you read something in "Scientific American." Do you think the first one is so much easier?

When you approach a practical question as if it were a moral question, you miss the boat. No one is arguing that it's OK for the country to be hopelessly dependent on foreign oil; on the other side, no one is arguing that it's OK to irradiate babies. We all agree that both of those are Bad Things. The only way to have the conversation in any meaningful way is to have knowledgeable experts look at the scientific evidence.

Which kind of issue is health care? Like almost all issues, it's a mix of both. But—again, like almost all issues—much more practical than moral.

The liberals are correct when they say that our current system leads to needless suffering and waste. The conservatives are correct when they say that a complete separation between those who decide and those who pay is inherently inefficient if not completely unworkable. Neither one of these claims contradicts the other in any way. So instead of deciding which one makes sense, we need to think hard and plan carefully and innovate ingeniously within all those constraints. It's like writing the research paper from hell.

The big problem is, practical is a lot less fun. I don't wanna write a research paper. I just want to vote for the good guy!

That last paragraph may seem glib, but it is not hypothetical, and it is huge. Almost all the political conversations I hear are dominated by high-sounding rhetoric that is visionary, combative, and largely pointless. It's much too rare in my life that I hear a conversation that is intelligent, cooperative, factual, and seems designed to find a solution to anything. I have discovered that those kinds of conversations can be just as lively and a lot more interesting than the first kind, but I'm just as likely as anyone to go into a moral rant when I get going.

And it isn't just how we talk: it's how we vote. Imagine a politician who was frequently heard to say "I will need more facts before I can form an opinion about that issue." He would get his butt kicked by his opponent, mindlessly repeating "Better jobs at better wages" or "Where would this country be without this great land of ours?" So we talk empty, we vote empty, we elect empty leaders, and then we wonder why we don't seem to be getting anywhere. The whole cycle isn't—if you'll pardon the expression—very healthy.

After I wrote this, I looked back and realized I had written something else on very much the same theme—shorter and punchier—seven years earlier as a radio commentary. It's called The Abortion Debate.


From: Michelle Williams
July 22, 2008

Thought germinated while reading this: We need a system of checks and balances. But not cripplingly slow like the one our government is built on. Or, another way to think of it, folks game the system—any system. Insurance companies don't have your best interest at heart—they're privately held companies for whom the bottom line is key—so they're going to want to deny all claims. Companies with short-sighted leadership in particular will not pay for preventative measures. Doctors don't necessarily have your best interest at heart—join my study; I get a kickback if I prescribe this drug to you; my personal belief is that you should stop smoking and I'm going to focus on that even though it's unlikely to be part of this particular problem—so they may run a ton of tests, Rx drugs you don't need, or not based on themselves, not on you and your symptoms. (Most doctors are smart and good-hearted but even they can get trapped. In managed care programs, doctors often don't get paid for charting and other paperwork—they only get paid when they're with a patient. So they want to maximize how many patients they see in a day and minimize how much time they spend thinking about patients outside of visiting hours.) We don't even have our own best interests at heart or there wouldn't be so many of us obese or such. Da Vinci Systems paid for my gym membership for a while. I went twice, I think, during my year of subsidized membership. So the system needs to be set up such that gaming it gives the desired results. What system would that be? I dunno. Thinking...

P.S. I'm sure I'm not the first to realize this. What, to me, is a profound insight probably has dozens of books and articles written with arguments framed just that way. But today was my day to groc it. :P

From: Gary Felder
August 24, 2008

I think you are a bit too facile in the distinction between "moral issues" and "practical issues." For some people the gay marriage debate is about core values that have nothing to do with data or arguments, but many of the issues that sway people to one side or another of this debate are related to complex, arguable issues. To say that facts about the genetic basis of homosexuality won't actually sway many people just makes the point that people tend to treat most issues they care about as completely "moral issues." On the other hand, for many people the abortion debate is fundamentally about the God-given soul that you acquire at conception and any data is therefore irrelevant. In general I think the distinction you are making is important but it's nowhere near as clear-cut as you seem to suggest.

As for the nuclear energy question, there's another issue there. If you ask whether dinosaurs were ancestors of birds I pretty well trust that the experts are busy looking at the data and scientifically moving us towards a reasonable consensus. If you ask whether nuclear power is safe, however, I think it's far more likely that the scientists working on the issue are deeply biased in one way or another. If I found out that decisions on nuclear safety were being made entirely on the basis of studies funded by the nuclear energy companies that would raise concern for me, even though I haven't reviewed the scientific data myself and probably don't have the background to understand it if I did. There are a number of reasons why scientists funded by companies tend to find results favorable to those companies. The most obvious is the desire for more funding. Even more blatantly, I've heard news stories of companies making deals with universities to endow large research funds on the condition that the company vet any research results and decide whether they can be published or not.

So as a policy maker considering a proposed nuclear power plant, I'm forced to do my own meta-analysis of the research results that are presented to me, even though I'm not an expert. Hopefully I have expert advisors, but quite possibly I need to have one on each side of the issue and finally make my own best judgment.

I couldn't agree more with the point you are making in "Abortion" and "Health Care," but you don't touch the much harder question of why our political debates are like that and whether anything could change them. I can agree with you in principle, but it seems pretty clear to me that any politician who said "That's a good point that I hadn't thought of" during a debate would be demolished.

From: Kenny Felder
September 1, 2008

I agree completely with your last point, but let me ask a question about the prior one. How much data, or meta-data, would you have to collect before you felt that you could make an informed decision? Or, to put it the opposite way, is there a threshhold below which you would consider someone's opinion to be relatively meaningless?

From: Zach
September 28, 2008

I wanted to expand on Gary's point that you make too facile a distinction between "moral" and "practical" issues agree that health care is extremely complicated and that well-meaning people can have good faith disagreements about what's the fairest and most efficient way of delivering health care. But most complicated public policy questions have significant moral elements that ultimately come down to how much you are willing to put the interests of your fellow citizens ahead of your own interests.

Ultimately you cannot resolve the health care question without first deciding how much individual taxpayers should pay to ensure that everyone has adequate health care. To me, this is a classic moral question: How much do I sacrifice (as a taxpayer) so that my fellow citizens can have health care? Do you put yourself first or sacrifice your money for the common good?

My point here is NOT that the morally correct position is always higher taxes, or that there aren't good reasons to control the amount that taxpayers must contribute to health care. But I do believe that at some point, taxpayers have to decide how much they as individuals should pay for everyone to have health care. And if one's attitude is "I have health care, and poor people who don't are not my problem," then I have more than an honest disagreement with such a person. I have problems with that person's morals.

Just one more footnote: your grandfather's story is probably true but there could be another dimension to it. It's easy to cry "fraud" when you see hospitals billing for procedures that weren't performed, but given the environment they work in I can't blame them. Health care providers are constantly fighting against insurance companies that want to second-guess the decisions of doctors in favor of the insurers' own biased conclusions about what the patients really need. For every illegitimate claim you might find 15 legitimate claims that insurance companies unjustifiably deny. My point here is not that two rights make a wrong, but that the hospitals/doctors are often doing the best they can to stay in business in what is undeniably and ugly and unfair system. If the doctors/hospitals didn't play this game, they wouldn't be able to care for anyone.

From: Kenny Felder
September 28, 2008

Although I'm sure there are people out there who have the attitude "I'm covered and poor people aren't my problem," I haven't met them. I've spoken to a lot of small-government conservative types, and they wanted basically the same things I want, although they disagreed about how to get there.

From: Zach
September 29, 2008

I think this (like most moral failings) is more a question of impure motives than diabolical intentions. I have no doubt that 95% of free market absolutists have all sorts of complicated theories explaining why everyone acting only for themselves is really in the public good. But if someone's idea of the public good also means lower taxes for himself, I think it's fair to give extra scrutiny to that person's true intentions.

From: Kenny Felder
September 29, 2008

Fair enough, but be very careful: it's also very easy to wind up assuming that all the people who agree with me are "good" and the other guys are "bad." A big percentage of the time, energy, and (yes) money that gets donated to the poor in this country comes from right-wing church-goers. If someone is spending his Sundays working with the homeless, he has every right to point to me and say "You're just trying to appease your conscience by voting to give everyone else's money away."

From: Zach
September 29, 2008

Yes, that's true (although given my tax bracket and lack of kids or mortgage deduction, I'm voting to give away plenty of my own money). A fairer assumption is that we're all imperfect, probably more selfish than unselfish, regarding of political affiliation.

From: Julia Ziobro
August 16, 2009

Kenny, there is a way to make this work that you are ignoring. And there's a part of the financial picture that you're ignoring too. First, the way to make it work... the care we have now is based on "what the patient wants" and "screw the insurance company (or at least make sure the doctor gets the most money they can"). Both of these methods of determining treament completely ignore the medical outcome...whether people live or die, how many more months of comfortable life they had (both for big medical issues) and for smaller medical issues, whether the treatment was effective with the fewest possible side effects, and even, did the treatment work? In order to make sense of outcomes, medicine needs to be much more EVIDENCE-BASED, gathering data—probably through computerized anonymous statistic gathering—and making wise use of the data to recommend treatment protocols to doctors. Doctors should then be compensated for the number of patients who are meeting treatment goals...

For instance, diabetics who have acceptable A1c levels over time, high blood pressure patients who have good readings, asthmatics who maintain good control with their medications and don't require ER visits, and so forth. Doctors are not punished for having sicker patients in their practice as long as those illnesses are also treated correctly and successfully. If you think this sounds nuts, I can tell you that it's already working in the NHS, and doctors there are becoming GPs in greater numbers again since there's actually incentive (financial!) for doctors to spend the time with patients that those people need and to get and keep them healthy. (I have an ex-sister-in-law who is a GP and we've talked extensively about how successful this program has been for the NHS...people are healthier and happier with their doctors, and the NHS is SAVING money!)

As for the financials, this makes me a bit angry. Even intelligent people who say "I have good insurance and the hell with everyone else—I don't want to pay for their care" are completely missing the boat. They ARE already paying for the care of others, and they are paying DEARLY. Remember the poor person who had to forgo the $100 preventative treatment because they couldn't afford it, but waited until it was a complete crisis and then had a $3000 ER visit? Who pays for that "charity care"? WE DO. We pay through higher insurance premiums, we pay through taxes which support emergency room construction and operation (there would be many fewer ER patients overall if ER visits were for REAL emergencies only), and we pay for Medicare.

It would be MUCH cheaper to cover everyone directly, especially if doctors were rewarded for keeping people healthy (now the $100 preventative care becomes the gold standard protocol!) and we can stop constructing new ERs at such a frantic pace. Folks who argue against this seem to forget about the "universal" healthcare that our government officials get, and that provided by our government for militray people and their families—the VHA. The VHA is not perfect, but it works quite well, and many people in that system are very happy with it. Our congresscritters certainly don't seem unhappy with their coverage. Perhaps they should have to buy their insurance on the open market like the rest of us? Then they might sing a different tune.

Finally, there is another giant inefficiency that costs us all tons of money and perhaps years of comfortable life...the medical billing people and other paperwork administrators. If you go to your doctor's office and ask around/pay attention, you will find that only 1/2 to 2/3 of the staff there are directly involved in patient care—doctors, nurses, maybe a phlebotomist. The rest are paperwork shufflers...chart creation and maintenance, medical billing experts, insurance processors. Because insurance companies are concerned with the bottom line, they have to reject every claim they can get away with, and your doctor has to spend a lot of money fighting back to get their dollars. Imagine instead computer-based charts (some places already have them) where your doctor enters things during your visit on a Tablet PC. Those records are immediately available to any other doctor you see in the practice and they are not subject to illegible-scrawl errors and the like....

In a single-payer system. the doctor submits reports with procedures performed, number and length of visits, and the vital stats of people being treated for various conditions. Perhaps one person in the office addresses the rare concerns or oversights brought up when the information is reviewed. All those expensive insurance-fighting people are unnecessary. What a huge relief, financial and stress, for the doctor! Medications are the same usage by millions of people reveals side-effect trends, drug interaction concerns, and other subtleties not revealed in limited clinical trials. So doctors can choose a medication that will give the most result for the lowest cost and everyone (except the overcharging drug company) wins.

Finally, I think the "death panels" are a good thing, when applied correctly. Evidence-based medicine requires the acknowledgment that we can't treat EVERY condition for EVERY person, and it doesn't make sense to do so. Insurance companies are already forcing this on us willy-nilly, based on expense, NOT outcome. It would be much more humane to base such a system on ethical, humane considerations like improvement to health, maintenance of comfort, and so on. I don't think people should be left in pain, but it seems insane to do quadruple bypass surgeries on 83-year old smokers while 3-year olds with leukemia are denied effective treatment by their insurance companies (and yes, I know of first-hand examples of each). It seems insane to let 26-year olds with super morbid obesity die for lack of an insurance company's approval for $25,000 proven-effective surgery when covering millions of dollars of lung cancer treatment for 58-year old smokers....

People who want gold-standard, no questions asked, no proof of efficacy required treament should be able to get it—if they pay for it. The UK has a thriving secondary insurance market for those who want on-demand c-sections, cosmetic dental implants, liposuction, and all sorts of other treatments that don't meet the criteria for medically necessary and affective treatments. That kind of pay to play insurance seems fair to patients, and fair to doctors. But children, the poor, the elderly, all get the basic care they need without risking bankruptcy.

Kenny, I have to admit, I do think it's interesting that you never address the facts about how our country spends the most money per capita, and has the highest healthcare spending as percentage of GDP in the world, while ranking quite low on infant mortality, maternal mortality, and life expectancy, all considered good measures of the success of a health care system. Why do you think people—U.S. citizens—are so convinced we have the "best health care in the world" when it costs us so much and doesn't even work? I personally think Canadian, French, and UK citizens are all better served...they are healthier, pay less of thier own money, and live longer lives than we do. How can you ignore those facts when you talk about this issue? That's a major oversight, I think.

Sorry for any typos... I typed all these comments without my glasses which makes it hard to re-read and revise before sending them along.

Looking forward to your further thoughts...

From: Mike Carter
August 16, 2009

I enjoyed the analysis of the framework (moral/practical) and the follow up comments seeking more granularity on the specific issue. One thing I didn't see was an exploration of how single payer would impact the incentive to invest in further medical R&D. I agree that the current model is broken and has inefficiencies and inequities, but the past 30 years have brought a lot of advancements that were largely due to capitalism. I am assuming that the government would not put as much capital at risk as Private Industry and that R&D for new drugs and medical devices would slow with the reduced likelihood for dramatic payback under single payer. Do we hurt long-term outlook for quality of care if we insulate health care from corporate greed?

Also, following this same economic line of thinking, would capacity not be impacted if we turn off the pricing filter that limits volume. Take heart surgery for example, if every person that could benefit from bypass surgery were booked for an OR, what would incent the buildout of this capacity, both infrastructure and staffing? If each proceedure yielded a lower fixed payment to the surgeon and the facility, what would motivate building more capacity? From an economic perspective, it seems like enabling more demand without incenting more supply will create backlog and the potential for long wait time. In UK, Canada, etc. these longer lines motivated a full-price tier of service as Julia describes above...only not just for elective procedures, but also for more timely service on needed procedures.

From: Julia Ziobro
August 16, 2009

Mike, when do we build new libraries? Firehouses? Schools? Not going to be much different with hospitals and ORs, and I think that's how it should be. The drug market is still a global one. Compete!

From: Mike Carter
August 16, 2009

I'm trying to stay practical and not get into a moral question of how it "should be." I guess I just want my hospitals to be managed more effectively than my local schools are being run. If you standardize wages and skillsets across your government's employees, you get what you pay for. In a world where librarians, principals and brain surgeons are all homogenized into civil servants, I hope I don't need surgery.

From: Anshin Xanthine
August 17, 2009

"Some issues are moral issues. Gay marriage is a hot one right now. No matter which side you're on, it is fundamentally a debate about values."

I very strongly disagree with this. I don't like Chinese people so I, and large organizations that I support decided to make sure they can't marry. Making sure they miss out on things like tax incentives and being able to accompany someone they have been with for 50 years in an ambulance even though it may be the last time they could have ever spent together.

I do not consider bigotry to be an issue of values.

Also I think the large issue here with healthcare is people somehow believing one political doctrine has the answer to every problem in every situation. (Of course all the others are evil) I believe social constructs like communism, socialism, democracy, and republics all have something to teach us.

The important part, I believe, is making sure a socialist system of medicine does not preclude the possibility of private doctors and hospitals that operate outside of that system. This way the people that chose not to take part in the system relieve some of the stress on the system, yet children don't have to forgo medical treatment because they are unfortunate to be born in the wrong family.

As someone that almost died, suffered brain damage that resulted in years of psychosis, and large amounts of damage to my lungs [it still feels like I have the lung capacity of a child, and I have large white spots from scarring in my lungs that show up in X-Rays] because my parents where worried about the costs of taking me to the doctor. I find it abhorrent that anyone acts like the American helthcare system's problems will eventually become fixed operating in a purely capitalist manner.

A true test of any society is how well it takes care of the people that can not take care of themselves. America is failing that test on many fronts.

Which is a large part why I no longer live there, and do not have plans of going back.

Actually when looking up the word values, I now think you correctly used the word as per it's actual definition. It's just it's common usage culturally has a positive connotation, which kinda threw me off a bit, as I've not heard anyone other they you really use the word to describe traits that might be considered positive or negative.

From: Kenny Felder
August 18, 2009

I think my point about "values" may not have been clear, because the issue for me is not whether it is used in a positive or negative way. Look at what you wrote about gay marriage. You told about how you feel Chinese people should be treated, and you made it clear that you feel the same standard should apply to gay people. You didn't offer any facts or figures, because there aren't any. You just told us your values. If you want to win someone over to your side, you're going to have to win him over to your values. The gay marriage debate is (and must be) all like that, and my point is, I don't think the health care debate is (or should be) like that at all.

From: Anshin Xanthine
August 18, 2009

It is a fact that gay couples do not get to accompany each other in ambulances, because since they are not directly related and can not get married in most states. They do not have the option of having any say if their significant other is unconscious in an hospital like a straight couple.

Heath care plans also can not extend to their partner, the way plans extend to your partner if your married. If your partner dies unexpectedly withount a will, being married there is little debate over who gets what. Since that's not an option for gay people, their partners' family can make a case that they are entitled to the deceased person's belongings. Life insurance plans will pay off for your spouse, but not if someone is say just your boyfriend. One year me and Zoe (after we had planned already on spending the rest of our lives together) ran the #s and figured out we would get 700 back in taxes if we filed separately, but if we filed jointly we got 3000.

A husband/wife relationship is a privileged (confidential) relationship just like doctor/patient, so you can say you don't want to testify against your spouse...

Taken from Virginia Code 19.2-271.2. Testimony of husband and wife in criminal cases.

"In criminal cases husband and wife shall be allowed, and, subject to the rules of evidence governing other witnesses, may be compelled to testify in behalf of each other, but neither shall be compelled to be called as a witness against the other."

Gay couples are not afforded these rights, even though...

"Article I. All men are born free and equal, and have certain natural, essential, and unalienable rights; among which may be reckoned the right of enjoying and defending their lives and liberties; that of acquiring, possessing, and protecting property; in fine, that of seeking and obtaining their safety and happiness."

The Equal Protection Clause of the 14th amendment says you can't have separate rules for gay people then for straight. This has been held up in the supreme court....

In Lawrence v. Texas (2003), the Court struck down a Texas statute prohibiting homosexual sodomy on substantive due process grounds. In Justice Sandra Day O'Connor's opinion concurring in the judgment, however, she argued that by prohibiting only homosexual sodomy, and not heterosexual sodomy as well, Texas's statute did not meet rational-basis review under the Equal Protection Clause; her opinion prominently cited City of Cleburne.

So, gay couples are not entitled to the same emotional, legal, and monetary benefits that straight couples are granted by not just society, but the important part.....the government.

I'm not trying to tell anyone how they should believe, their outlook on relationships, marriage, sex, religion.. I am saying that government has created (by not allowing gays to marry, and though the defense of marriage act) a separate set of legal rules and tax privileges for homosexual couples as apposed to straight ones, and that this is in direct conflict with its highest laws and doctrines.

P.S. I hope it's clear that I was using Chinese people as an example, and that is not actually how I believe Chinese people should be treated... I believe it was, but text is limiting in certain ways, so I would like to clear up any ambiguity.

From: Felicia Bridges
August 18, 2009

Kenny, as always, your writing is so insightful! You did a great job of distilling the essence of the debate and I think you're entirely correct that we must find a practical solution that reduces the problems you identified for both extremes. One aspect that you didn't mention that I believe is critical to our success is tort reform. We must find a way to ensure that those who are truly victimized through malpractice are taken care of while eliminating frivolous lawsuits that reward anyone willing to call 1-800-sue-m-now! So often these suits have no merit, but the malpractice insurers and hospitals will settle rather than spending the money to go to court...and we end up paying for all of it through increased health care costs. Even outside of the health care field, businesses are being ruined by this 'play the lottery' mentality that suggests I can get rich by filing a lawsuit and then taking a settlement before I have to actually prove anything.

From: Cheenu Tiwari
November 12, 2011

I got around to your essays again this long weekend and decided to read the Health Care Essay. You definitely put a lot of authentic points about health care and how people go about solving it. I definitely agree with the empty words, empty leaders, and empty voting idea that you mentioned. I see that all the time when it comes to politics and media stars (ex. Kristen Stewart liking Robert Pattinson all because of Twilight, which is totally false). Most of these empty actions are for publicity and self-promotion anyway.

I also agree with the moral debate and practical discussion part of the essay. That got me thinking: What does the health care controversy fall under? I feel that the health care is a mix of both types. I am sure that people on both sides use statistics (practical) and moral values to make their point(s) about health care.

I agree that life-threatening emergencies should be treated free of cost for those who can't afford. If those emergencies aren't treated, it becomes a matter of affording to live! That to me is just dumb. I also agree that treating life emergencies creates loss overall. Also, I agree with your point about the French people finding a doctor to give them antidepressants. The question is: How does this all get solved?

This is probably going to sound very radical indeed, so bear with me. I feel that medical treatment costs (normal checkups, medicines, etc.) should be based on income instead of just a flat cost for everyone. That way, life-threatening emergencies are prevented, reducing loss, and everyone can afford health benefits. I'm not sure, but Medicare and other government institutions are probably covering my ideas. Feel free to criticize this idea and point out weaknesses, because that way I can learn from that. This could also apply to insurance as well, but in this case insurance will be for everything (optical, orthodontic, dentist, pediatrician, etc.) unlike Medicare and other government institutions.

From: Meg Crenshaw
July 8, 2017

I was having a conversation with a family member who is against "socialized medicine" (although I think we called it universal health care), and it became clear that she's against it because she really wants the best medicine possible if she is close to dying. That makes a lot of sense.

But somewhere between "I need to get my insulin or I will die" and "I need to have 1000 surgeries done to maybe be able to survive," (BTW, when you talk to doctors who work with old people who are about to die, they say they would absolutely never want those operations done on themselves.), there's some line that gets crossed. I think the way death is handled in most of the U.S. (Judaism might provide an exception here) is frightening, and it makes the conversation about health care all the more frightful, fascinating, futile(?). I don't have any evidence—only a gut feeling. I'll try to parse it a bit more: If you are always terrified of death and also believe it can't happen now, it's absolutely essential that you get the best care when you're close to dying. But the very very expensive emergency care must be paid for in some way! And so here we are. And like I said, I don't quite know when that line is crossed between the obviously-we-should-get-you-insulin and the maybe-we-could-try-these-1000-surgeries-and-see (if I knew more about medicine, I would replace the insulin side of the spectrum with something in the "emergency medicine" side that is equally obvious/successful as insulin), but it becomes hard to find any line between them when we can't even talk about dying.

 Kenny Felder's Essays and Commentaries

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