PNHP

Pointing the way forward for primary care

Pointing the way forward for primary care

By A.R. Strobeck Jr.
March 21, 2012

“Breaking Point: How the primary care crisis endangers the lives of Americans”
By John Geyman, M.D.
Copernicus Healthcare, 2011
Softcover, 231 pp., $18.95

Dr. John Geyman has written another tour de force on a health care topic. This time he examines the “silent crisis” which is rapidly unfolding in health care delivery: the unraveling and decline of the primary care structure.

Recognizing the flaws and limitations of the Affordable Care Act, and noting the decades-long decline in the number of primary care providers, Geyman asks: Going forward, how will patients and their families obtain medical care that is “affordable, readily accessible, continuity-based, and comprehensive”?

Assuming the ACA passes constitutional muster, millions of additional Americans will have new, limited coverage from either subsidized private insurers or Medicaid, but “Insurance without a physician — how much of a gain is that?”

Geyman divides his analysis into two parts. In Part I, he looks at the many dimensions of the crisis and its impacts on the system, particularly on patients and their families. In Part 2, he examines various policy alternatives, including lessons from other countries, and finally proposes “a comprehensive agenda for rebuilding primary care.”

Geyman believes the problem is such a challenge that its solution requires a long view, possibly over one or two generations. Successfully dealing with this problem would involve “a complete reorientation of the goals of health care, the roles of physicians and other health professionals” as well as fundamental changes in the way health care is financed. He warns that failure to do so will hasten an implosion “for much of our population, and potentially become a growing force that could bankrupt the nation.”

Geyman notes that less than one-third of U.S. physicians are practicing primary care, and “their numbers are falling fast.” Less than 20 percent of graduating U.S. medical students are selecting fields in primary care and only 7 percent are choosing family medicine. Largely because of the financial pressures associated with going to medical school, notably the heavy burden of student debt, many students are turning to specialties that they believe will be more lucrative.

At the same time, many primary care doctors have stopped seeing patients in the hospital and now confine their practice to their offices, where they are poorly reimbursed by third-party insurers. They are also experiencing higher levels of dissatisfaction with their work. Meanwhile, government policy appears to be out of touch with the magnitude of the crisis.

Yet studies show “consistent cost savings across the board in regions with most primary care physicians,” including fewer emergency room visits and hospitalizations, and a consistent increase in the quality of care in areas with a larger density of primary care doctors.

Patients are confronting greater financial barriers in accessing health care, including rising premiums and higher co-payments, deductibles and co-insurance. As for the uninsured, they are lucky to find any physician who will see them.

Patients are victimized in other ways, too. In their quest for ever greater profit, financing companies have even discovered “a highly profitable business in medical credit cards.” Interest rates can rise to 26.99 percent for G.E.’s Care Credit, and most people who obtain these cards have limited resources to begin with. They “are vulnerable to various abuses by hospitals and other providers who push these cards without transparent disclosure of their risks.”

In Part 2 of his work, Geyman looks at various policy alternatives, using key yardsticks such as accessibility, continuity of primary care, prevention, and financial neutrality in medical decision-making.

The author cites three basic policy alternatives: (1) Cede primary care to non-physicians such as nurse practitioners and physician assistants, (2) Continue our specialist dominated physician workforce; (3) Build a generalist physician workforce with primary care teams and a generalist-specialist mix of 50-50.

Geyman believes that the third choice is the obviously best course and he focuses on this solution. He views the building of a strong generalist base as the only way out of our national health care crisis.

He explains that this approach has worked well in the few areas where it has been tried, including at The Group Health Cooperative of Puget Sound, Rocky Mountain Health Plans, and the Mesa County Physicians Independent Practice Association.

At the same time, he remarks: “We cannot get to real health care reform without rebuilding our primary care infrastructure, and we can’t get that done without other fundamental system reforms — they are completely interdependent.”

Geyman takes a look at what other countries have done and how some of their experiences might be applied in the United States. He finds that we are clearly at a disadvantage: “All other countries around the world meet the challenges of access, quality, and fairness for comprehensive health care at costs that are affordable and sustainable.”

The author observes that while there is no such thing as a perfect health care system, we have much to learn from other advanced countries if we remove our ideological blinders and “give up our unfounded attitude of American exceptionalism.” We also have to give up the myths that we have the best health care and our health problems are unique to us.

Geyman looks to Ontario, Canada’s, system for an example of organized health care as “a model worth organizing and fighting for.” The Family Health Team model there has expanded the capacity of primary care through interdisciplinary teams and resolved many hitherto nettlesome problems.

The teams include family physicians, nurse practitioners, pharmacists, social workers and health educators. They provide 24/7 care, handle most of the care themselves, and are coordinators of care provided by specialists as well as from other community resources. The teams now serve 2 million people and show every sign of success.

Geyman outlines 10 “primary building blocks for rebuilding primary care in the U.S.,” including evidence-based coverage, revised physician payment, new goals and paradigm, re-design of primary care, general medical education, emphasis on ethics, expanded research, increased regulation, and malpractice liability reform. But at the foundation of the entire structure is universal coverage through a single-payer national health insurance plan, a sine qua non for the overhaul’s success.

The author views American society as divided into two Americas: “a buoyant, bailed-out Wall Street and a depressed Main Street.” i.e. it’s the 1 percent vs. the 99 percent. He discusses how corporate America has profited at the expense of sick and vulnerable Americans, and notes that even with the ACA, there is a “continuing emphasis of our market-based culture and medical-industrial complex” to turn “quick profits with little regard for the public interest.”

But Dr. Geyman has pointed a way forward.

A.R. Strobeck Jr. holds a masters in health planning and policy from the University of Illinois at Chicago as well as a masters in history from Northern Illinois University. He worked as a research associate for over 10 years for an association of health care executives.

PNHP note: “Breaking Point” by Dr. John Geyman, past president of Physicians for a National Health Program, is available at PNHP’s store at the special price of $10 with free shipping. You can purchase the book here and you can review other books by Dr. Geyman and other authors at the PNHP store site.

Health Care Compact lessons for state single payer efforts

Utah fifth state to join Health Care Compact

By Kirsten Stewart
The Salt Lake Tribune, March 20, 2012

Utah Gov. Gary Herbert on Tuesday signed a controversial measure to replace Medicare and Medicaid with a block grant to the states.
SB208 would have Utah join an interstate “Health Care Compact” designed to allow states to opt out of federal health reform without forgoing billions in federal funding.
But hospitals and consumer advocates warned the bill risks tying Utah’s fate to states with poorer health and higher health costs.
It also would also mean sacrificing $132 million in federal funding by 2014 because the block grants are not designed to keep pace with medical inflation, they said.
To date, four states have pledged to join the compact: Texas, Missouri, Oklahoma and Georgia. Two governors have vetoed the idea, including Arizona Gov. Jan Brewer.
http://www.sltrib.com/sltrib/news/53757475-78/health-compact-states-bill…
And…

Indiana Gov. Mitch Daniels Signs Health Care Compact Into Law

By Shonda Werry
Health Care Compact Blog, March 21, 2012
Gov. Mitch Daniels Monday signed the Health Care Compact into law, paving the way for restoring state control over health care policy and providing Hoosiers an alternative to the federally-run system.
The Health Care Compact is an initiative of the Health Care Compact Alliance, a nonpartisan organization dedicated to providing Americans more authority over decisions that govern their health care. It does not make suggestions on what policies individual states should pursue but advocates that health care policy decisions be made at the state level.
The Compact has been introduced in 13 states since February of 2011 and has been adopted in Texas, Georgia, Oklahoma, Missouri, and now Indiana.
For the Health Care Compact to become law, it must be approved by Congress. Once it is ratified, states will then be responsible for crafting their own policies.
http://healthcarecompact.org/blog

Since the political barriers to enacting a national single payer program seem to be insurmountable, at least for the near future, many single payer activists are pursuing state level single payer models of reform. To be truly single payer, federal legislation would be required to free up funds from federal programs. The Health Care Compact should give us pause as to whether or not we want to give states that much control over our federal tax funds.
Under the Health Care Compact, Medicare and Medicaid funds would be transferred to the states under a block grant. To understand the significance of block grants for programs such as these, one need look no further than the House Budget proposal introduced yesterday by Congressman Paul Ryan. His proposal for block grants for Medicaid would eventually cut the federal contribution in half, leaving the states to fill in the gap.
With the budget problems that states already face, what would happen to coverage for Medicaid-eligible beneficiaries under a block grant? Even if all funds were combined into a single risk pool, these Medicaid cuts would result in either benefit reductions or in the need for higher state-based revenues, whether as taxes or premiums.
Six states – Texas, Georgia, Oklahoma, Missouri, Indiana, and Utah – have now passed the Health Care Compact. They are asking to use funds from existing federal programs to establish their own state health care programs. With their tight budgets and a further decrease in federal funding, would any of these states pass a single payer program that provided all necessary health care services for everyone? Of course not. Instead they seek to establish insurance markets that cross state lines, promoting the sale of low-premium, lowest-common-denominator plans that would destroy the financial security that health plans should be offering.
Keep this in mind as you work on state single payer solutions. When we ask for waivers (federal legislation) to allow states to use existing federal funds for state single payer programs, that process would also allow other states that are in the process of crushing unions, destroying retirement security, wiping out public primary and secondary education, driving up state college tuition to unaffordable levels, and so forth, to use their freedom to wipe out health security for their own people.
That seems like too dear of a price for our fellow Americans to pay. We can avoid that simply by enacting a national single payer program – an improved Medicare for everyone.

The Health Law Mandate

By Arnold S. Relman, M.D.
Letters, The New York Times, March 19, 2012

“White House Set to Shape Debate Over Health Law” (front page, March 9), about the Supreme Court’s hearings on the health law, doesn’t mention an important new argument against the Affordable Care Act’s mandated purchase of private insurance, the key issue before the Supreme Court.

Last month, an amicus brief was filed by 50 doctors and two nonprofit organizations arguing that Congress could avoid a mandate by legislating a national single-payer system that provides nearly universal insurance coverage.

Congress has already created two limited single-payer systems — Medicare and the veterans’ health system — and no legal barriers prevent doing more. Since a mandate isn’t necessary for Congress to exercise its legitimate role in regulating health insurance, there is no justification under the Constitution’s “necessary and proper” clause for such a legislative requirement.

How this argument will influence the court remains to be seen. But the brief is another reminder that the single-payer idea, although currently off the table in Washington, should not be counted out.

The writer, professor emeritus of medicine and social medicine at Harvard Medical School, is a former editor in chief of The New England Journal of Medicine. He resides in Cambridge, Mass.

http://www.nytimes.com/2012/03/20/opinion/the-health-law-mandate.html

Also in The New York Times of March 20, a profile of Dr. Relman and Dr. Marcia Angell titled “A Drumbeat on Profit Takers,” and a 6-minute video interview with these two past editors of The New England Journal of Medicine:

http://video.nytimes.com/video/playlist/science/1194811622277/index.html

Marmor and Oberlander – Controlling costs through emulation, not innovation

From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy

By Theodore Marmor, PhD and Jonathan Oberlander, PhD
Journal of General Internal Medicine, March 13, 2012 (Online)

The United States has been singularly unsuccessful at controlling health care spending. During the past four decades, American policymakers and analysts have embraced an ever changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing. Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical care spending. We argue that accountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern. We explain why the United States persistently pursues health policy fads — despite their poor record — and how the promotion of panaceas obscures critical debate about controlling health care costs. Americans spend too much time on the quest for the “holy grail” — a reform that will decisively curtail spending while simultaneously improving quality of care — and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, systemwide fee schedules, and concentrated purchasing.
 
Emulation, Not Innovation
 
We do not know how far ACOs will spread or what impact they, medical homes or other delivery system reforms will have on health care spending. But our history of failed cost control offers sobering lessons about exaggerated expectations, the limits of organizational reforms, and the recurring temptation to oversell reform ideas like ACOs as panaceas and the harbingers of a new, radically transformed, and vastly improved health care system. Such ideas should be seen as supplements, rather than the basis for a national strategy of health care cost control.

We believe that the U.S. needs less innovation and more emulation. That is, in order to control costs effectively Americans should focus less on (re)inventing the latest delivery system or payment method, and instead pay more attention to what other countries do to slow health care spending. Global budgets, fee schedules, systemwide payment rules, and concentrated purchasing power may not be modern, exciting or “transformational”. But they have the advantage of working.

http://www.springerlink.com/content/m86245k22018507n/

Comment:

By Don McCanne, MD

Why have we spent decades trying to circumvent the obvious? We need to emulate the health care policies that do work in other nations, and give up on pursuing our many innovations that haven’t worked. Haven’t we had enough of modern, exciting and transformational failures?

Marmor and Oberlander – Controlling costs through emulation, not innovation

From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy

By Theodore Marmor, PhD and Jonathan Oberlander, PhD
Journal of General Internal Medicine, March 13, 2012 (Online)
The United States has been singularly unsuccessful at controlling health care spending. During the past four decades, American policymakers and analysts have embraced an ever changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing. Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical care spending. We argue that accountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern. We explain why the United States persistently pursues health policy fads — despite their poor record — and how the promotion of panaceas obscures critical debate about controlling health care costs. Americans spend too much time on the quest for the “holy grail” — a reform that will decisively curtail spending while simultaneously improving quality of care — and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, systemwide fee schedules, and concentrated purchasing.
Emulation, Not Innovation
We do not know how far ACOs will spread or what impact they, medical homes or other delivery system reforms will have on health care spending. But our history of failed cost control offers sobering lessons about exaggerated expectations, the limits of organizational reforms, and the recurring temptation to oversell reform ideas like ACOs as panaceas and the harbingers of a new, radically transformed, and vastly improved health care system. Such ideas should be seen as supplements, rather than the basis for a national strategy of health care cost control.
We believe that the U.S. needs less innovation and more emulation. That is, in order to control costs effectively Americans should focus less on (re)inventing the latest delivery system or payment method, and instead pay more attention to what other countries do to slow health care spending. Global budgets, fee schedules, systemwide payment rules, and concentrated purchasing power may not be modern, exciting or “transformational”. But they have the advantage of working.
http://www.springerlink.com/content/m86245k22018507n/

Why have we spent decades trying to circumvent the obvious? We need to emulate the health care policies that do work in other nations, and give up on pursuing our many innovations that haven’t worked. Haven’t we had enough of modern, exciting and transformational failures?

Jonathan Haidt's "The Righteous Mind" – good people divided by politics

The Righteous Mind: Why Good People Are Divided by Politics and Religion

By Jonathan Haidt
Pantheon Books

We can define moral capital as the resources that sustain a moral community. More specifically, moral capital refers to “the degree to which a community possesses interlocking sets of values, virtues, norms, practices, identities, institutions, and technologies that mesh well with evolved psychological mechanisms and thereby enable the community to suppress or regulate selfishness and make cooperation possible.”

The Moral Matrix

Care/harm
Liberty/oppression
Fairness/cheating
Loyalty/betrayal
Authority/subversion
Sanctity/degradation

Liberal Wisdom

The left builds its moral matrix an three of the six foundations, but it rests most firmly and consistently on the Care foundation.

Liberals are often suspicious of appeals to loyalty, authority,and sanctity, although they don’t reject these intuitions in all cases (think of the sanctification of nature). For American liberals since the 1960s, I believe that the most sacred value is caring for victims of oppression. Anyone who blames such victims for their own problems or who displays or merely excuses prejudice against sacralized victim groups can expect a vehement tribal response.

Libertarian Wisdom

Some liberals began to see powerful corporations and wealthy industrialists as the chief threats to liberty. These “new liberals” (also known as “left liberals” or “progressives”) looked to government as the only force capable of protecting the public and rescuing the many victims of the brutal practices of early industrial capitalism. Liberals who continued to fear government as the chief threat to liberty became known as “classical liberals,” “right liberals” (in some countries), or libertarians (in the United States).

You can see the fork in the road by looking at the liberal moral matrix. It rests on two foundations primarily: Care and Liberty (plus some Fairness, because everybody values proportionality to some extent). Liberals in 1900 who relied most heavily on the Care foundation – those who felt the pain of others most keenly – were predisposed to take the left-hand (progressive) fork. But liberals in 1900 who relied more heavily on the Liberty foundation – those who felt the bite of restrictions on their liberty most keenly – refused to follow. In fact, libertarian writer Will Wlkinson has recently suggested that libertarians are basically liberals who love markets and lack bleeding hearts.

Social Conservative Wisdom

We have found that social conservatives have the broadest set of moral concerns, valuing all six foundations relatively equally. Their breadth – and particularly their relatively high settings on the Loyalty, Authority, and Sanctity foundations – give them insights I think are valuable, from a Durkheimian utilitarian perspective (i.e., recognizing that human flourishing requires social order and embeddedness).

A more positive way to describe conservatives is to say that their broader moral matrix allows them to detect threats to moral capital that liberals cannot perceive. They do not oppose change of all kinds (such as the Internet), but they fight back ferociously when they believe that change will damage the institutions and traditions that provide our moral exoskeletons (such as the family). Preserving those institutions and traditions is their most sacred value.

In sum

Morality binds and blinds. It binds us into ideological teams that fight each other as though the fate of the world depended on our side winning each battle. It blinds us to the fact that each team is composed of good people who have something important to say.

This book explained why people are divided by politics and religion. The answer is not, as Manichaeans would have it (i.e., battleground of forces of light and of darkness), because some people are good and others are evil. Instead, the explanation is that our minds were designed for groupish righteousness. We are deeply intuitive creatures whose gut feelings drive our strategic reasoning. This makes it difficult – but not impossible – to connect with those who live in other matrices, which are often built on different configurations of the available moral foundations.

http://righteousmind.com/

Comment: 

By Don McCanne, MD

Social psychologist Jonathan Haidt, in “The Righteous Mind,” provides us with a background on the evolution and development of the moral matrices that have contributed to our political divide. Although some might want to challenge details of his Moral Foundations Theory, there is absolutely no doubt that moral differences do exist, and he has provided plenty of experimental data to show that political views do correlate with the six moral foundations described.

Single payer supporters certainly identify with the Care foundation. That’s what single payer is all about – making sure that absolutely everyone is able to receive needed health care. Care is the most defining moral foundation of liberals. In contrast, Loyalty, Authority, and Sanctity are barely on the radar screen of many liberals.

Social conservatives are driven by all six foundations of the moral matrix, especially Loyalty, Authority, and Sanctity. Although they are also driven by Care, Care can be suppressed to some extent by by the “groupish righteousness” of Loyalty, Authority, and Sanctity. Although libertarians are often included on the right with conservatives, libertarians are unique in that they are influenced very little by the moral foundation of Care. Unabashed libertarians likely would never be single payer supporters.

So if social conservatives are partly driven by the moral foundation of Care, would they ever support single payer reform? In fact, many of them do. Most believe that everyone should have health care, and many recognize the efficiency of the single payer model. However, the groupish righteousness of Loyalty, Authority, and Sanctity often keeps them from breaking ranks with their conservative peer groups. Nevertheless, there does seem to be an opening for conservatives to join forces with liberals in advancing the concepts of single payer.

What about the liberals? They would certainly welcome the opportunity to work with conservatives on single payer. But if we listen to Jonathan Haidt, the liberals have been making a mistake by remaining oblivious to the conservatives’ moral values of Loyalty, Authority, and Sanctity – fundamentals of moral capital.

He writes, “If you are trying to change an organization or a society and you do not consider the effects of your changes on moral capital, you’re asking for trouble. This, I believe, is the fundamental blind spot of the left. It explains why liberal reforms so often backfire, and why communist revolutions usually end up in despotism. It is the reason I believe that liberalism – which has done so much to bring about freedom and equal opportunity – is not sufficient as a governing philosophy. It tends to overreach, change too many things too quickly, and reduce the stock of moral capital inadvertently. Conversely, while conservatives do a better job of preserving moral capital, they often fail to notice certain classes of victims, fail to limit the predations of certain powerful interests, and fail to see the need to change or update institutions as times change.”

As a liberal, I confess that I am fixated on the moral foundation of Care. I also confess that I have a blind spot on the full range of moral capital. However, the conservatives do not have a blind spot on Care, even
if they seem to have other priorities. Do you suppose that the conservatives would be willing to help us liberals understand the moral capital hidden in that blind spot, in exchange for liberals helping the conservatives understand better what it means to Care?

Jonathan Haidt’s “The Righteous Mind” – good people divided by politics

The Righteous Mind: Why Good People Are Divided by Politics and Religion

By Jonathan Haidt
Pantheon Books

We can define moral capital as the resources that sustain a moral community. More specifically, moral capital refers to “the degree to which a community possesses interlocking sets of values, virtues, norms, practices, identities, institutions, and technologies that mesh well with evolved psychological mechanisms and thereby enable the community to suppress or regulate selfishness and make cooperation possible.”

The Moral Matrix

Care/harm
Liberty/oppression
Fairness/cheating
Loyalty/betrayal
Authority/subversion
Sanctity/degradation

Liberal Wisdom

The left builds its moral matrix an three of the six foundations, but it rests most firmly and consistently on the Care foundation.

Liberals are often suspicious of appeals to loyalty, authority,and sanctity, although they don’t reject these intuitions in all cases (think of the sanctification of nature). For American liberals since the 1960s, I believe that the most sacred value is caring for victims of oppression. Anyone who blames such victims for their own problems or who displays or merely excuses prejudice against sacralized victim groups can expect a vehement tribal response.

Libertarian Wisdom

Some liberals began to see powerful corporations and wealthy industrialists as the chief threats to liberty. These “new liberals” (also known as “left liberals” or “progressives”) looked to government as the only force capable of protecting the public and rescuing the many victims of the brutal practices of early industrial capitalism. Liberals who continued to fear government as the chief threat to liberty became known as “classical liberals,” “right liberals” (in some countries), or libertarians (in the United States).

You can see the fork in the road by looking at the liberal moral matrix. It rests on two foundations primarily: Care and Liberty (plus some Fairness, because everybody values proportionality to some extent). Liberals in 1900 who relied most heavily on the Care foundation – those who felt the pain of others most keenly – were predisposed to take the left-hand (progressive) fork. But liberals in 1900 who relied more heavily on the Liberty foundation – those who felt the bite of restrictions on their liberty most keenly – refused to follow. In fact, libertarian writer Will Wlkinson has recently suggested that libertarians are basically liberals who love markets and lack bleeding hearts.

Social Conservative Wisdom

We have found that social conservatives have the broadest set of moral concerns, valuing all six foundations relatively equally. Their breadth – and particularly their relatively high settings on the Loyalty, Authority, and Sanctity foundations – give them insights I think are valuable, from a Durkheimian utilitarian perspective (i.e., recognizing that human flourishing requires social order and embeddedness).

A more positive way to describe conservatives is to say that their broader moral matrix allows them to detect threats to moral capital that liberals cannot perceive. They do not oppose change of all kinds (such as the Internet), but they fight back ferociously when they believe that change will damage the institutions and traditions that provide our moral exoskeletons (such as the family). Preserving those institutions and traditions is their most sacred value.

In sum

Morality binds and blinds. It binds us into ideological teams that fight each other as though the fate of the world depended on our side winning each battle. It blinds us to the fact that each team is composed of good people who have something important to say.

This book explained why people are divided by politics and religion. The answer is not, as Manichaeans would have it (i.e., battleground of forces of light and of darkness), because some people are good and others are evil. Instead, the explanation is that our minds were designed for groupish righteousness. We are deeply intuitive creatures whose gut feelings drive our strategic reasoning. This makes it difficult – but not impossible – to connect with those who live in other matrices, which are often built on different configurations of the available moral foundations.

http://righteousmind.com/

Comment: 

By Don McCanne, MD

Social psychologist Jonathan Haidt, in “The Righteous Mind,” provides us with a background on the evolution and development of the moral matrices that have contributed to our political divide. Although some might want to challenge details of his Moral Foundations Theory, there is absolutely no doubt that moral differences do exist, and he has provided plenty of experimental data to show that political views do correlate with the six moral foundations described.

Single payer supporters certainly identify with the Care foundation. That’s what single payer is all about – making sure that absolutely everyone is able to receive needed health care. Care is the most defining moral foundation of liberals. In contrast, Loyalty, Authority, and Sanctity are barely on the radar screen of many liberals.

Social conservatives are driven by all six foundations of the moral matrix, especially Loyalty, Authority, and Sanctity. Although they are also driven by Care, Care can be suppressed to some extent by by the “groupish righteousness” of Loyalty, Authority, and Sanctity. Although libertarians are often included on the right with conservatives, libertarians are unique in that they are influenced very little by the moral foundation of Care. Unabashed libertarians likely would never be single payer supporters.

So if social conservatives are partly driven by the moral foundation of Care, would they ever support single payer reform? In fact, many of them do. Most believe that everyone should have health care, and many recognize the efficiency of the single payer model. However, the groupish righteousness of Loyalty, Authority, and Sanctity often keeps them from breaking ranks with their conservative peer groups. Nevertheless, there does seem to be an opening for conservatives to join forces with liberals in advancing the concepts of single payer.

What about the liberals? They would certainly welcome the opportunity to work with conservatives on single payer. But if we listen to Jonathan Haidt, the liberals have been making a mistake by remaining oblivious to the conservatives’ moral values of Loyalty, Authority, and Sanctity – fundamentals of moral capital.

He writes, “If you are trying to change an organization or a society and you do not consider the effects of your changes on moral capital, you’re asking for trouble. This, I believe, is the fundamental blind spot of the left. It explains why liberal reforms so often backfire, and why communist revolutions usually end up in despotism. It is the reason I believe that liberalism – which has done so much to bring about freedom and equal opportunity – is not sufficient as a governing philosophy. It tends to overreach, change too many things too quickly, and reduce the stock of moral capital inadvertently. Conversely, while conservatives do a better job of preserving moral capital, they often fail to notice certain classes of victims, fail to limit the predations of certain powerful interests, and fail to see the need to change or update institutions as times change.”

As a liberal, I confess that I am fixated on the moral foundation of Care. I also confess that I have a blind spot on the full range of moral capital. However, the conservatives do not have a blind spot on Care, even if they seem to have other priorities. Do you suppose that the conservatives would be willing to help us liberals understand the moral capital hidden in that blind spot, in exchange for liberals helping the conservatives understand better what it means to Care?

Jonathan Haidt's "The Righteous Mind" – good people divided by politics

The Righteous Mind: Why Good People Are Divided by Politics and Religion

By Jonathan Haidt
Pantheon Books
We can define moral capital as the resources that sustain a moral community. More specifically, moral capital refers to “the degree to which a community possesses interlocking sets of values, virtues, norms, practices, identities, institutions, and technologies that mesh well with evolved psychological mechanisms and thereby enable the community to suppress or regulate selfishness and make cooperation possible.”
The Moral Matrix
Care/harm
Liberty/oppression
Fairness/cheating
Loyalty/betrayal
Authority/subversion
Sanctity/degradation
Liberal Wisdom
The left builds its moral matrix an three of the six foundations, but it rests most firmly and consistently on the Care foundation.
Liberals are often suspicious of appeals to loyalty, authority,and sanctity, although they don’t reject these intuitions in all cases (think of the sanctification of nature). For American liberals since the 1960s, I believe that the most sacred value is caring for victims of oppression. Anyone who blames such victims for their own problems or who displays or merely excuses prejudice against sacralized victim groups can expect a vehement tribal response.
Libertarian Wisdom
Some liberals began to see powerful corporations and wealthy industrialists as the chief threats to liberty. These “new liberals” (also known as “left liberals” or “progressives”) looked to government as the only force capable of protecting the public and rescuing the many victims of the brutal practices of early industrial capitalism. Liberals who continued to fear government as the chief threat to liberty became known as “classical liberals,” “right liberals” (in some countries), or libertarians (in the United States).
You can see the fork in the road by looking at the liberal moral matrix. It rests on two foundations primarily: Care and Liberty (plus some Fairness, because everybody values proportionality to some extent). Liberals in 1900 who relied most heavily on the Care foundation – those who felt the pain of others most keenly – were predisposed to take the left-hand (progressive) fork. But liberals in 1900 who relied more heavily on the Liberty foundation – those who felt the bite of restrictions on their liberty most keenly – refused to follow. In fact, libertarian writer Will Wlkinson has recently suggested that libertarians are basically liberals who love markets and lack bleeding hearts.
Social Conservative Wisdom
We have found that social conservatives have the broadest set of moral concerns, valuing all six foundations relatively equally. Their breadth – and particularly their relatively high settings on the Loyalty, Authority, and Sanctity foundations – give them insights I think are valuable, from a Durkheimian utilitarian perspective (i.e., recognizing that human flourishing requires social order and embeddedness).
A more positive way to describe conservatives is to say that their broader moral matrix allows them to detect threats to moral capital that liberals cannot perceive. They do not oppose change of all kinds (such as the Internet), but they fight back ferociously when they believe that change will damage the institutions and traditions that provide our moral exoskeletons (such as the family). Preserving those institutions and traditions is their most sacred value.
In sum
Morality binds and blinds. It binds us into ideological teams that fight each other as though the fate of the world depended on our side winning each battle. It blinds us to the fact that each team is composed of good people who have something important to say.
This book explained why people are divided by politics and religion. The answer is not, as Manichaeans would have it (i.e., battleground of forces of light and of darkness), because some people are good and others are evil. Instead, the explanation is that our minds were designed for groupish righteousness. We are deeply intuitive creatures whose gut feelings drive our strategic reasoning. This makes it difficult – but not impossible – to connect with those who live in other matrices, which are often built on different configurations of the available moral foundations.
http://righteousmind.com/

Social psychologist Jonathan Haidt, in “The Righteous Mind,” provides us with a background on the evolution and development of the moral matrices that have contributed to our political divide. Although some might want to challenge details of his Moral Foundations Theory, there is absolutely no doubt that moral differences do exist, and he has provided plenty of experimental data to show that political views do correlate with the six moral foundations described.
Single payer supporters certainly identify with the Care foundation. That’s what single payer is all about – making sure that absolutely everyone is able to receive needed health care. Care is the most defining moral foundation of liberals. In contrast, Loyalty, Authority, and Sanctity are barely on the radar screen of many liberals.
Social conservatives are driven by all six foundations of the moral matrix, especially Loyalty, Authority, and Sanctity. Although they are also driven by Care, Care can be suppressed to some extent by by the “groupish righteousness” of Loyalty, Authority, and Sanctity. Although libertarians are often included on the right with conservatives, libertarians are unique in that they are influenced very little by the moral foundation of Care. Unabashed libertarians likely would never be single payer supporters.
So if social conservatives are partly driven by the moral foundation of Care, would they ever support single payer reform? In fact, many of them do. Most believe that everyone should have health care, and many recognize the efficiency of the single payer model. However, the groupish righteousness of Loyalty, Authority, and Sanctity often keeps them from breaking ranks with their conservative peer groups. Nevertheless, there does seem to be an opening for conservatives to join forces with liberals in advancing the concepts of single payer.
What about the liberals? They would certainly welcome the opportunity to work with conservatives on single payer. But if we listen to Jonathan Haidt, the liberals have been making a mistake by remaining oblivious to the conservatives’ moral values of Loyalty, Authority, and Sanctity – fundamentals of moral capital.
He writes, “If you are trying to change an organization or a society and you do not consider the effects of your changes on moral capital, you’re asking for trouble. This, I believe, is the fundamental blind spot of the left. It explains why liberal reforms so often backfire, and why communist revolutions usually end up in despotism. It is the reason I believe that liberalism – which has done so much to bring about freedom and equal opportunity – is not sufficient as a governing philosophy. It tends to overreach, change too many things too quickly, and reduce the stock of moral capital inadvertently. Conversely, while conservatives do a better job of preserving moral capital, they often fail to notice certain classes of victims, fail to limit the predations of certain powerful interests, and fail to see the need to change or update institutions as times change.”
As a liberal, I confess that I am fixated on the moral foundation of Care. I also confess that I have a blind spot on the full range of moral capital. However, the conservatives do not have a blind spot on Care, even if they seem to have other priorities. Do you suppose that the conservatives would be willing to help us liberals understand the moral capital hidden in that blind spot, in exchange for liberals helping the conservatives understand better what it means to Care?

Moving reform from the impossible to the inevitable

200th Anniversary Article: Major Trends in the U.S. Health Economy since 1950

By Victor R. Fuchs, Ph.D
The New England Journal of Medicine, March 15, 2012

It is difficult to see how the health sector can continue to expand rapidly at the expense of the rest of the economy, but every past prediction of a sustained slowing of the growth of health expenditures has been proved wrong. Rapid growth may continue as a result of political gridlock regarding the form that curbs on expenditures should take. There is no public consensus about how much care should be provided for the poor and sick or how it should be done. Similarly, there’s no public consensus regarding efforts to increase the efficiency of care. A rational approach to the financing, organization, and delivery of care seems politically impossible. However, the observation by de Tocqueville that in the United States “events can move from the impossible to the inevitable without ever stopping at the probable” may prove to be prescient.

http://www.nejm.org/doi/full/10.1056/NEJMp1200478?query=TOC

Comment: 

By Don McCanne, MD

Victor Fuchs tells us, “There is no public consensus about how much care should be provided for the poor and sick or how it should be done.” Why? We know that all health care reform efforts since 1950 have fallen short of our goal of health care for everyone. We know that a single payer national health program would provide all essential care for everyone. Why should this be politically impossible? Haven’t we already moved from the impossible to the inevitable? If so, let’s accept that and get to work on fixing our health care system so it takes care of everyone.

Single-payer system would cover birth control

By Joan Murray
Times Union (Albany, N.Y.), March 15, 2012

How do we ensure health care coverage, including the option of birth control, for all American women without troubling an employer’s private moral beliefs?

The answer is simple: By adopting a single-payer system, also known as universal health care or Medicare for all.

If our government — like those of Canada, England and Australia — were the sole payer of our medical bills, we wouldn’t be having a frenzied debate over birth control in 2012.

And all women who need birth control protection would be covered — whether they work for a Catholic employer or not. Yet in America, many workers have to deal with a convoluted health care system shaped by their employers and the health insurance companies they engage.

With a single-payer system, no Catholic institution would face the discomfort of paying an insurer for a standard health policy that covers birth control. And no woman would have to forgo needed coverage because of her employer’s beliefs.

Just picture all the non-Catholic faculty at Catholic colleges, and the non-Catholic nurses and physicians at Catholic hospitals — not to mention the maintenance and support staff at both — to get some idea of how many people, along with their spouses and dependents, might be denied that coverage — even though their own consciences or religions are fine with it.

Let’s clarify some things. Under the new law, churches, mosques and synagogues continue to be exempt from offering insurance coverage that includes birth control. So if a woman is a parish accountant, for example, she still won’t receive that coverage. The controversial part of the new law is that religiously-affiliated universities and hospitals, which receive tax-payer dollars, must now provide that coverage.

Many of them already do — including DePaul University in Chicago, the largest Catholic university in America.

Here’s how things should work under the new Affordable Care Act: A university — let’s call it Georgetown — would contract with an insurance company — let’s call it Blue Cross — to cover the medical costs of its employees, including flu shots, EKGs, and, if someone needs it, birth control.

It’s not as if a priest is being asked to hand out birth control pills in the rectory. Yet some church officials, institutional administrators and, most notably, politicians are arguing a broad exemption for any religiously affiliated institution.

The Catholic Church — my former church, by the way — argues this on the grounds of its private morality — a morality which, to my mind, seems too often focused on sex. There are many Americans whose private morality makes them believe, just as fervently and conscientiously, that they should be exempt from paying one-fifth of their taxes — the amount that goes to the military and its undeclared wars.

Yet the government obliges them to pay in full. Similarly, Catholic-affiliated institutions should be obliged to abide by the new law and to offer health insurance without cherry-picking the coverage.

If employees of religiously affiliated institutions — and this includes most Catholic employees — wish to have birth control protection, let them discuss it with their physicians. Let it be a private matter, and let it be covered — just as it is by other employers. Women who don’t wish to have that protection need not ask for it. This is simple.

Yet until we have a single-payer system, some employers may attempt to interfere with employee health care, based on their private moral visions. Perhaps this birth-control furor will ignite a demand for a single-payer system. But until we can persuade our elected representatives to provide that system, we must at least make sure that, under the law, women will be able to choose this care for themselves.

Joan Murray is a writer living in Old Chatham.

http://www.timesunion.com/opinion/article/Single-payer-system-would-cover-birth-control-3411097.php#ixzz1pI45pfOB

Primary care doctors are going the way of the dinosaurs

By Philip Caper
Bangor Daily News, March 15, 2012

Health care reform has to be about more than just expanding health insurance coverage. It also has to be about making sure everyone has access to high-quality health care at a reasonable cost.

Most other wealthy countries provide health care to all of their residents, get as good or better results and pay an average of about half what we do per person. It’s generally agreed that one of the important factors is heavy reliance on primary caregivers.

Primary care is the portal through which most of us should enter the health care system. Other countries have about two primary care doctors for every specialist. We have about two specialists for every primary care doctors and it’s about to get worse. The number of young doctors choosing primary care in the U.S. is declining. It’s now fewer than 20 percent.

Yet the demand for primary care is growing due in part to the aging of our population. This is a big deal. The reasons for the dwindling numbers of primary care physicians are not hard to understand. Specialists have more prestige, generally have more control over their lives and can make much more money.

If young doctors, who often incur a lot of debt during their education, choose to specialize, they can make two to four times as much as they can as a primary care physician. That adds up to several millions of dollars over the course of a career.

This huge difference in earning power is largely a result of how doctors are paid and is pushing them away from primary care and toward a more lucrative specialty. This discrepancy was never planned, but it’s no accident either. Under the fee-for-service system, payment is for piecework. Doctors are paid for patient visits. Specialists are able to charge more than primary caregivers.

Revenue can be increased by shortening visits and cramming more of them into a day. But that shortchanges patients. By its nature, good primary care requires intimate knowledge of the patient, something that can’t be adequately accomplished in 15-minute increments.

In addition, specialists are paid for sophisticated tests and procedures that may require little of their time but can be very lucrative. It is much easier to maximize the number of tests and procedures than the number of visits.

In the past, this differential in income may have been justified because specialists required much more training than primary care doctors. That’s no longer the case. Primary care doctors now receive about as much training as many specialists. Yet the differential has stubbornly persisted despite serious efforts to level the playing field, due largely to the wealth and political clout of specialists and their corporate allies. Tweaks to the way we pay doctors will not solve this problem.

A few years ago, I was asked to help a group of young physicians-in-training understand why it seemed so hard to become a primary care doctor. After I ran through the list of barriers, I asked them why anyone would want to go into primary care. Their indignant answer: “Because we went to medical school to be doctors!”

Most people don’t become doctors primarily for the money. They don’t object to being well compensated (who would?), but that’s not what drives them. Most are motivated by wanting to help people and being good at it. But the health care system works against such altruism.

What makes primary caregivers so valuable? Let’s take another example. If you were to build a house but decided to use only subcontractors and you had no general contractor or overall budget, you might end up with a collection of superb parts. But the house could be very expensive and may not work very well.

Primary caregivers are much like general contractors. Ideally, they possess a deep understanding of their patients and their values, and a broad knowledge of illness and its causes. They also decide which treatments to prescribe, and which, if any, specialists to call in. They provide services directly and they manage and optimize expensive specialty resources. In doing so, they save more than they cost and often produce a better result.

Primary care doctors are on the path to extinction. If we are to provide health care for everyone, we have to find ways to reverse this trend. In my next column, I’ll suggest some of them.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

http://bangordailynews.com/2012/03/15/health/primary-care-doctors-are-going-the-way-of-the-dinosaurs/

Moving reform from the impossible to the inevitable

200th Anniversary Article: Major Trends in the U.S. Health Economy since 1950

By Victor R. Fuchs, Ph.D
The New England Journal of Medicine, March 15, 2012
It is difficult to see how the health sector can continue to expand rapidly at the expense of the rest of the economy, but every past prediction of a sustained slowing of the growth of health expenditures has been proved wrong. Rapid growth may continue as a result of political gridlock regarding the form that curbs on expenditures should take. There is no public consensus about how much care should be provided for the poor and sick or how it should be done. Similarly, there’s no public consensus regarding efforts to increase the efficiency of care. A rational approach to the financing, organization, and delivery of care seems politically impossible. However, the observation by de Tocqueville that in the United States “events can move from the impossible to the inevitable without ever stopping at the probable” may prove to be prescient.
http://www.nejm.org/doi/full/10.1056/NEJMp1200478?query=TOC

Victor Fuchs tells us, “There is no public consensus about how much care should be provided for the poor and sick or how it should be done.” Why? We know that all health care reform efforts since 1950 have fallen short of our goal of health care for everyone. We know that a single payer national health program would provide all essential care for everyone. Why should this be politically impossible? Haven’t we already moved from the impossible to the inevitable? If so, let’s accept that and get to work on fixing our health care system so it takes care of everyone.