[Dialogue] Thoughts While Listening to America's Health Care Debate

Thu Mar 20 19:34:32 PDT 2014

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Thoughts While Listening to America's Health Care Debate
We had one of our closest personal friends to dinner recently. He is a stock analyst, a very successful and wealthy man with a passion for understanding the economy. In the course of the evening’s conversation, he listed among the threats to America’s economic prosperity the costs that will be associated with the “Patient Protection and Affordable Care Act,” which he called by its popular name “Obamacare.” It was and is a legitimate concern and it is regularly cited by those who oppose the Affordable Care Act.
What does not get spoken in this political debate, however, is any estimate of what the cost of health care would have been had this nation’s lawmakers not passed the Affordable Care Act. One of the factors that built political pressure for the adoption of this act was the spiraling health care costs, which were leaping at the rate of about 25% a year, far beyond the normal cost of living increases. No one either in the private or the public sector seemed able to rein them in. Health care is no longer considered a luxury available only to those who can afford it, but a necessity that is the right of every citizen. This nation either had to control these costs or watch it entire economy be wrecked. Since in the United States we have followed the unique and even peculiar method of linking health insurance to one’s job as a perk of employment, these rising costs were falling heavily on American businesses, large and small. In most of the countries with which American businesses compete in the world market, health care is provided to all citizens with tax dollars. In American companies, it is a “labor cost” putting American companies at a severe disadvantage in competitively pricing their products. As these costs escalated, smaller businesses first tried to buy group insurance plans to lower their costs. When that failed to halt the rising price of health care, some began to cut benefits. Next they sought to move a larger share of these costs from the company to the employees, which represented a cut in compensation and thus in the employee’s standard of living. Some companies simply dropped health insurance as a perk. It was said by many small business owners that this was the only alternative to bankruptcy and its resulting unemployment. Larger businesses then followed suit and began to shift some of their health care costs to the employees. They also began to put pressure on the health care companies to lower their costs. These companies then began to pressure hospitals and doctors to make the delivery of health care more cost efficient. It was not unknown for businesses to dismiss employees who had developed chronic diseases that had the effect of raising the premiums their company had to pay or for health care companies to cancel the policies held by those who developed diseases that needed costly and long term treatment.
Of course the Affordable Care Act is going to involve costs, but the only way to discuss these costs legitimately in the public arena is in the context of what the costs without “Obamacare” would have been. In the meantime it is quite easy to win political points by mounting emotional attacks on “Obamacare,” or by launching five star alarms about health care being rationed or about death panels to decide how long “Grandma” should be allowed to live, raising people’s anxiety to a fever pitch. Radical dishonesty has thus crept into the public discussion and has become standard, regularly invoking half truths and using anecdotal horror stories to arouse negativity and fear. It is, in my opinion, the most dishonest political discourse I have ever witnessed. Critics of any new initiative are prone to be both nostalgic and excessive in their claims for the health care system under which this nation has operated in the past. It was “the best health care in the world,” they say. That is patently not so. There is not one major health issue, including longevity, where America is statistically ranked number one in the world. What is a fact is that American health care is the world’s most expensive. The single payer plans operating in Canada, Great Britain, France, Germany, Norway, Sweden and Denmark, for example, are far less expensive and, in terms of the ratio between sickness and cure, also produce better results and greater longevity. Far too many people and businesses in America are feeding at the trough of America’s health care and they are prepared to defend their sources of income at any cost. Drug companies charge excessive rates for their drugs. This is defended on the basis of their need to spend millions of dollars on research and development. Fair enough, but why do they sell the same drugs to other nations of the world at a discounted rate? Does this not mean that the United States is being asked by the drug companies to subsidize their bottom line at the expense of US citizens? Do we assume that the drug makers do not make a profit in the price they receive from non-American companies? Trial lawyers also feed off their malpractice work by suing doctors, hospitals and health device makers? Yes, of course, mistakes occur in the practice of medicine, but they also occur in money management, investment advice, legal advice and environmental disasters. There is a difference, however, between calculated malfeasance and the mistakes of judgment when a choice is made between two therapeutic approaches, both of which have been known to work in the world of medicine. Medicine will never be an exact science, but is an unrestricted legal recourse always proper? When I served for 24 years as the chairman of the board and the chair of the executive committee of a 300-bed urban hospital in Jersey City, we worked with about 400 doctors. The vast majority of them were deeply conscientious, but none of them was perfect. There is a huge difference between making an informed judgment, based on the choices that are available to a doctor even when it does not work out and malfeasance or gross negligence. The courts should be able to make that discernment and laws should be passed putting caps on financial penalties doctors have to pay when the results are not positive. That step alone would lower the cost of medical insurance that doctors must carry and that savings could serve to lower the cost of medical care for individuals.
Insurance companies are pressing hospitals and doctors to develop new efficiencies. That is why hospital stays have been shortened so dramatically. That is why no one enters a hospital on the day before surgery to be prepared; they enter early on the day of surgery. That is why elderly patients are moved from acute care in hospitals to chronic care in nursing home facilities. That is why same-day surgical centers have been built outside of hospital structures. That is why patient care is not nearly so personal and that in turn is why patient complaints are rising.
Doctors today have hired more auxiliary staff and have delegated all specifically non-professional duties to them. We all have seen these things happening. I personally watched a close friend go through an orthopedic surgical procedure performed at a same day surgical center. This friend has thus far returned to her doctor’s office for three post-operative visits. I checked the actual time the doctor spent with this patient on these three visits. It was ten seconds on the first visit, fifteen seconds on the second and a full minute on the third. Non-medical personnel did everything else that once the doctor did. The competence of the care my friend received is not in dispute. The procedure was successful and the cure was complete. Such cuts in the doctor’s time are part of the price the public will pay for cost containment. It does, however, introduce a danger that patient care might become so streamlined as to be compromised in order to serve the doctor’s bottom line. The symbol I look for here is how long did the patient have to wait beyond the scheduled time of the appointment. In this orthopedic practice it was one hour and fifteen minutes on the first visit, forty-five minutes on the second and thirty-five minutes on the third. Others have confirmed to me that this is a regular occurrence in this orthopedic office.
A second study revealed that efficiencies can be accomplished while still honoring each patient’s time. I have also watched a retina specialist, a single practitioner, who literally sees hundreds of patients each day. He has 5-6 examination rooms and he has employed five trained technicians who do everything in that office except inject the drug into the eyeball. This doctor spends about a minute, perhaps a minute and a half with each patient on each visit thus maximizing the number of patients he can see each day, but he and all who work for him seem trained to put the patient first. I have never waited more than fifteen minutes past the scheduled appointment time and more frequently go in exactly on time. The doctor, each of the technicians and even the receptionist are incredibly sensitive to each patient’s needs. That is a skill that does not require extra time. This doctor is also available and caring in his minute or so of presence. Medical practice can be more efficient and still be patient-sensitive. Doctors and patients need to understand why these cost cutting activities are necessary and seek to make them work.
Medical care is evolving, but the political debate seldom focuses on the right issues. Have we not already decided that health care is a right of citizenship and not a luxury only for those who can afford it? Do we need to re-argue that issue? If that is clear then the debate ought to focus on how to accomplish that goal. There are only two possible alternatives. One is to develop a single payer, tax-supported system like the developed nations of the world with the single exception of the United States have done. The alternative is to develop a market-based nearly universal system which is what the Affordable Care Act was designed to achieve. There are no other options. The attempt to kill the Affordable Care Act, which was developed by the Heritage Foundation as a conservative alternative to a National Health Service, is irrational. The political need is to fix it not kill it. The debate will be dishonest until that fact is grasped. The opponents of the Affordable Care Act offer no “conservative” alternative because the Affordable Care Act is the conservative alternative. There is no other. It is time for honesty in this debate!
~John Shelby Spong
Read the essay online here.

Question & Answer
Britton B. Dennis, Sr.,  via the Internet writes:
Question:
I am a Lay Eucharistic Minister in the Episcopal Church. When I read one of the lessons from scripture, I am instructed to say at the end of the reading: "This is the Word of the Lord." My preference actually would be to say: "Here ends the Reading" or “Here ends the Lesson." Any thoughts you have on this subject would be most appreciated.

Answer:
Dear Britton,

I share your passion to change the way we end the scripture lessons that are read in church. Only someone who has never read the Bible in its entirety and who thus does not know its content, would want to refer to every reading from that book as “the Word of the Lord.” The book of Deuteronomy, for example, says that children who are willfully disobedient to their parents shall be stoned to death at the gates of the city. Is that the word of the Lord? Leviticus tells us that people who commit adultery, people who are homosexual and people who worship a false God shall be executed. Is that the word of the Lord? II Samuel suggests that God will cause the baby born out of an adulterous relationship to die as punishment for the adultery of the child’s parents! Is that the word of the Lord? The book of Psalms suggests that the people of Israel will not be happy until they have dashed the heads of their enemies’ children against the rocks. The Epistle to the Colossians instructs slaves to be obedient to their masters. Are these attitudes in compliance with “the Word of the Lord?” Paul writes that women should be silent in the churches and the author of I Timothy says: “I forbid a woman to have authority over a man.” Are we reading in these instances “the Word of the Lord?” Surely Not! These words are nothing less than expressions of the cultural sinfulness of patriarchy.

To refer to all of the words of the Bible as “the Word of God” encourages a kind of ignorant fundamentalism that sucks the very life out of Christianity today. Other traditional, liturgical customs feed this same heresy. What are we as a church communicating to our congregations when we process into our Sunday services holding the Gospel Book high as if it is to be worshipped or adored? What are we communicating when the one reading the Gospel for that Sunday goes through all kinds of physical acts of crossing oneself or making crosses on the text of the Gospel before it is read? What are we communicating when we use incense on the Gospel Book so as to cover its words with a “mystical” smell? All of these practices suggest that it is the Gospel itself, rather than the God to whom the words of the Gospel point that is the object of worship. Even the long established custom of printing the Bible with two columns on each page is little more than subliminal propaganda. The only books we print in columns other than the Bible are dictionaries, encyclopedias and telephone directories. The thing that each of these columned books has in common is that no one is ever supposed to read them. We go to these books, rather, in search of answers to specific questions. All of these books give literal answers about which, the contention is, there should be no dispute. This custom of printing the Bible in a manner that no other book we read is printed feeds the attitude of the unchallengeable and thus the inerrant nature of the words contained on its pages, reflecting a form of idolatry that is called “bibliolatry.” Biblical literalism has plagued the church for centuries. It needs to be exposed for what it is. These “pious practices,” which we have so universally wrapped around the Bible, are not just, as their defenders claim, acts of devotion; they are rather practices rooted in the claims we have made for a fundamentalistic attitude toward the Bible. That attitude has had no credibility in Christian academic circles for at least the last 200 years.

As this critical biblical scholarship finally begins to seep into the awareness of the people who attend our churches, we are at last able to see changes being made. The Anglican Prayer Book of New Zealand, for example, has the reader end the reading of the lesson by saying: “Hear what the Spirit is saying to the Church.” I would be happy to see us return to the descriptive and therefore neutral words: “Here ends the reading” or “Here ends the lesson.” I have been in church when the phrase “This is the Word of the Lord,” has been uttered at the end of a strange passage from the Bible and it has been difficult for me not to scream out: “No, No! That is not the word of a deity that I would ever be drawn to in worship!” Propriety has thus far not been violated for which I am grateful!

Before we can feel the weight of that issue, however, a consciousness about what the sacred scriptures are and knowledge about all that the Bible contains needs to be developed. That requires a rigorous program of adult education, which takes both time and hard work. Because institutional Christian churches, both Protestant and Catholic, have never really been interested in having an educated laity, that consciousness has been slow in developing. The “sheep” are supposed to be both dumb and quiet.

Perhaps your letter will aid that process of consciousness growth and get others to think about these issues. Thanks for writing.

John Shelby Spong

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