Wednesday, May 6, 2009

Health Care Thought Experiments: Mile Long Questions Traveling at the Speed of Light

This piece was written by Donald Frey, MD, Professor and Chair of the Department of Family Medicine at Creighton University in Omaha, NE. I think his point is very well made, and may help us in figuring out how to respond to the over-technical questions we sometimes get.
Dr. Frey has previously contributed to this blog, Medicare Costs in Rural America: A case of reaping what we haven't sown?, March 26, 2009.

Recently, I had the privilege of giving the Keynote Address to the annual meeting of the Nebraska Academy of Sciences. To say this was a highly improbable event is an understatement. Although I enjoyed science, and wound up majoring in chemistry, I was never someone who lived to go to the lab every afternoon. In fact, coming from a small rural community where the majority of my classmates didn’t even attend college, my initial year after high school was difficult (I still have nightmares about calculus). I never dreamed that one day I would address a group of scientists.
The group was concerned about health care cost and access, and had asked me to speak about current reform approaches. As with most presentations I make to public groups, I described the high costs of care, as well as our dismal outcomes here in the U.S., and then discussed various reform proposals. Finally, I underscored the reasons why I felt that a single payer approach was the most reasonable choice, given the body of evidence that has been accumulated with respect to costs and outcomes. Then I asked for questions.
Several hands were raised, but one gentleman at the front of the room nearly leapt out of his seat as his hand shot into the air. I called on him first.
“First of all, I don’t believe what you’ve said,” the man began. Immediately I felt dejected. Weren’t these supposed to be scientists, the people who had to contend on a regular basis with those who chose to ignore evidence and “not believe” in evolution? If you can’t convince a scientist to look at evidence with respect to single payer, I thought, who can you convince?
The man continued, “I’d like to propose a Thought Experiment.” Now I was really worried. Thought Experiments. This guy had to be a physicist.
Thought Experiments. When Einstein and Bohr would debate the merits of relativity and quantum theory, they would often do so through Thought Experiments; experiments so difficult they could only be carried out in the mind, because the testing components didn’t exist. My favorite was the one about what changes might occur in the dimensions of a mile long space ship travelling at the speed of light.
This was going to be interesting. I nodded at the gentleman, and he continued. “Let’s say we were to pay for homeowner’s insurance the way we pay for health insurance. What would it look like? How could we afford it? What if every minor repair we wanted to make on a house was covered by some sort of single payer home owner’s insurance, every minor addition? How could we afford that?”
I tried to sound as scientific as possible. “Before we can proceed with the experiment, we must challenge its assumption,” I said. “Your experiment assumes that all insurances are interchangeable. They are not. Insuring your health is not the same as insuring your home, your car, or your RV. Much more is at stake when we are talking about health.”
The physicist was not deterred. “But I think you know where I’m coming from.” (Actually, I didn’t). “Insurance by its very nature is meant to insure against catastrophic events. Your home is severely damaged. You get a severe illness. Your insurance should cover that. But routine expenses should be paid out of pocket. You shop around for the best prices for basic home repairs. But that doesn’t happen in health care. Consumers should be empowered in health care just like they are in the rest of the market place, with price data. Then they should make their own decisions.”
So that’s where your coming from, I thought. A Consumer-Directed Health Care advocate. “The problem with what you are proposing is that the decision making that confronts the health care consumer is much more complex than in home repair,” I said. “That’s why people go to doctors. If you thought you might be seriously ill, would you really ignore the doctor’s advice and just shop around?”
“But you’re ignoring the basic issue here,” the physicist shot back. “Let’s say I wanted to build a deck on my house, and I evaluate the cost. Now if I decide not to build that deck—“
At this point, I ignored what my Mother had always taught me—never interrupt someone in mid-sentence. “If you decide not to build that deck,” I interjected, “you’re not going to die.”
The physicist looked stunned. “Well—well—if I don’t do what the doctor says, I may not die, either,” he stammered.
“No,” I responded as calmly as I could, “you may not die. Instead, you might wind up on a ventilator in an ICU for several weeks because of complications from a delayed diagnosis. You exhaust your insurance benefits, then deplete your savings. You have no way to pay for your care. But this being a just society,” (I smiled at the irony) “you won’t be kicked out into the street. And then what happens to your costs?” I looked out at the rest of the audience. “They will be shifted to everyone else in this room through higher premiums and charges.
“So the cost of your consumer-based decision not to follow your doctor’s advice, unlike a decision not to build a deck, won’t just affect you. It will have a significant economic impact on everyone else, too.” I turned back to the questioning physicist, to give him a chance to reply. Instead, he simply glared at me.
I turned back to the rest of the audience. “So what have we learned from this Thought Experiment? First, that health care is so unique, with such enormous economic risk for all of us, that to ‘insure’ it really falls into a different category than any other form of insurance. It’s different than insuring our homes. Consequently, if we approach health insurance from the standpoint of it being just another form of insurance, following the same rules as every other form of insurance, we set ourselves up for a failed system of delivery.
“In that sense,” I concluded, “maybe we shouldn’t even talk about health ‘insurance’ because it detracts from the critical nature of what confronts us. Perhaps we need to be talking about health care access as a part of our national economic infrastructure, like roads and highways—an item too vital to simply be thrown into the general category of insurance.” Around the room, heads nodded.
I wish I could have spoken to the physicist privately after the lecture, but he rose from his seat, turned, and quickly strode from the room. But the experience stayed with me as I reflected on the challenge that faces all of us as we carry the message of the critical importance of universal health care. It reminded me once again how many opponents will use tactics such as shifting the discussion away from health care itself, to more arcane issues such as the nature of insurance. It underscored the importance of promoting the value of health care, first and foremost, in any discussion of policy change.
Finally, it was one more reminder that questions about single payer health care must be answered one question at a time, and one citizen at a time. For many Americans, the amount of misinformation regarding universal health care is staggering, and those of us committed to reform must use every tool at our disposal to see that the truth gets out there.
Even if it means sometimes speaking in terms of mile long space ships travelling at the speed of light.

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