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Unofficial Prognosis

Unofficial Prognosis


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Thinking through health care reform: a compilation of diverse perspectives

The views expressed are those of the author and are not necessarily those of Scientific American.


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When it comes to health care, people can have very strong opinions. Conversations can get heated and personal. Understandably so; we are talking about something that directly and inevitably affects us, our families, and all Americans. No one, after all, is safe from illness.

From my discussions with others, I’ve found there are two basic routes to a strong conclusion. One is by gathering as much evidence as possible, from as many angles as possible, and reasoning through ideas with a critical eye to form a decision. The other is by having a conclusion in mind first and then looking, after the fact, for evidence to support it.

In the second case, where might those preconceived conclusions come from? Perhaps they are based on what group a person identifies with: “I’m a Democrat, and most Democrats support the reform, so I probably do, too,” or “I’m a registered Republican, so I’ll probably think Obamacare is a bad idea.” Or, maybe everyone around you tends to believe one thing. Or, maybe a person whose knowledge you generally trust believes something, and it’s easier to listen to one person who has already worked it all out.

Compounding the problem is that people have a natural tendency to surround themselves with friends, coworkers, and news sources that largely confirm, rather than dispute, what they already believe. It’s simply more pleasant to interact with someone who agrees with you.

While the two routes are not so black and white, I do think it’s all too easy to fall into the second type of reasoning. And it’s much more difficult to come to a new conclusion if you’re cornered by everyone chirping in unison.

So, I decided to compile my selections for the some of the most clear, thoughtful, and diverse pieces about the Supreme Court ruling and its implications I’ve come across. Taken alone, each is insightful and well-written. Taken together, they portray health care reform issues from valuably distinct perspectives. I hope you’ll give them a read, and that you’ll power through the ones that don’t immediately resonate with your political instincts.

Because the Internet is a vast, vast space, and it’s hard to triage.

“Something Wicked This Way Comes,” by Atul Gawande, published in the New Yorker. Gawande takes a step back and captures the uncertainty in any health reform initiative – an inherently complex and “wicked” problem in which “Trade-offs are unavoidable. Unanticipated complications and benefits are both common. And opportunities to learn by trial and error are limited.” No step forward will be perfect, Gawande reminds us, but taking no action comes with its own risks. “All that leaders can do is weigh the possibilities as best they can and find a way forward.”

“Chief Justice Roberts and His Apologists,” by John Yoo, published in the Wall Street Journal. Even though the Affordable Care Act was upheld, the reasoning behind the decision has been interpreted as a victory for fiscal conservatives, too. But the restrictions on “congressional coercion” may not be as significant as they appear, Yoo argues, with Chief Justice John Roberts not the hero for both sides some are making him out to be. “Congress may not be able to directly force us to buy electric cars, eat organic kale, or replace oil heaters with solar panels. But if it enforces the mandates with a financial penalty then suddenly, thanks to Justice Roberts’s tortured reasoning in Sebelius, the mandate is transformed into a constitutional exercise of Congress’s power to tax.”

“Unpopular Mandate,” by Ezra Klein, published in the New Yorker. Two years ago, the odds that the individual mandate would be overturned were considered slim to none; yet a few days before the decision, experts predicted them at closer to fifty-fifty. Why did the Republican party change its opinion, making the clause they once supported the main target to oppose? That’s the question at hand, but to answer it, Klein expands beyond the Republican party into why people change their opinions – and how in politics, on both sides, it has to do more with adhering to the beliefs of the group than rational reasoning. “But parties, though based on a set of principles, aren’t disinterested teachers in search of truth,” he writes. “They’re organized groups looking to increase their power. Or, as the psychologists would put it, their reasoning may be motivated by something other than accuracy.”

“A Doctor’s View of the Supreme Court’s Health-Care Ruling,” by Kent Sepkowitz, published in The Daily Beast. To Sepkowitz, the Supreme Court ruling was recognition of the idea that “health care is not just another commodity, but is, like death and taxes, a requirement.” Why is health care different? Because, he says, every single American has an unavoidable relationship with the health care system starting from birth. Because we all are mortal – “destined to become ill and destined to die.”

“Don’t Celebrate Yet – The Supreme Court’s decision will make it much harder to extend health insurance to America’s poor,” by Darshak Sanghavi, published in Slate. “Just what problems have we solved now that the Affordable Care Act has been upheld?” Sanghavi asks. One that hasn’t, he argues, is the problem of un-insurance, citing projections that even with the Affordable Care Act the number of uninsured will decrease only by half. For that reason, Sanghavi cares less about the individual mandate and more about Medicaid, arguing that the Affordable Care Act’s “real impact will derive from its expansion of Medicaid, the Supreme Court’s decision seems more worrisome. By limiting the federal government’s power to expand Medicaid in many states, the Supreme Court has seriously damaged the liberal dream of universal health coverage.”

“How American Health Care Killed My Father,” by David Goldhill, published in The Atlantic. This one was published in 2009, but definitely worth a read. After Goldhill lost his father to a hospital-borne infection, his “survivor’s grief [took] the form of an obsession with our health-care system.” For over a year, he researched everything he could about the health care system. Goldhill’s article identifies specific arenas where the old system was broken and also draws attention to things we accept as fact but perhaps should not. Example: when insured, we have a sense that someone else is paying for our health care bills, but it’s really you – and the rest of Americans. He concludes, “The most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers… we’d find that consumers could buy much more of their care directlythan we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.”

“In Obama’s Victory, a Loss for Congress,” by James B. Stewart, published in the New York Times. Who really “won” with this Supreme Court decision? Many have been debating that question, and Stewart says that even though reform was upheld, it was truly “conservatives and libertarians” that won, while Congress lost. Stewart explains why this is, and why he sees it as a bad thing.

“The GOP’s selection woes,” by Marc A. Thiessen, published in the Washington Post. Chief Justice John Roberts, appointed by Bush and believed to have conservative philosophies, ultimately swayed to the left in upholding the Affordable Care Act. That switch is something that commonly happens among Republicans on the Supreme Court, Thiessen describes, while switches in the other direction (liberals becoming conservative) virtually never happen. Why? “For one thing, the whole legal and political culture pushes the court to the left.  Conservatives are pariahs if they vote against the left on certain issues. But if they cross over vote with the left, they are hailed as statesmen.” Thiessen is writing about the Supreme Court, but his ideas on “conservatives as pariahs” also tap into a broader point on the stigmatization of conservative philosophy.

“The Bomb Buried In Obamacare Explodes Today – Hallelujah!” by Rick Ungar, published in Forbes. Ungar published this piece in December 2011, but it since regained its popularity. He draws attention to one aspect of the Affordable Care Act that he says will have major, positive, long-lasting impact: the medical loss ratio, which “requires health insurance companies to spend 80% of the consumers’ premium dollars they collect—85% for large group insurers—on actual medical care rather than overhead, marketing expenses and profit.” The provision that is often overlooked will eventually “lead to the death of large parts of the private, for-profit health insurance industry,” Ungar says.

“What Does Health Care Decision Mean For Patients,” Michel Martin interviews Mary Agnes Carey, NPR. Carey, a reporter for Kaiser Health News, speaks articulately about implications for patients. Recommended as a straightforward guide for issues as they might affect you.

Finally, here’s the full text of the Supreme Court health care decision, put up by The Washington Post.

With thanks to my well-read friends for introducing me to some of these, and more.

*Have you come across an analysis that you feel is a must-read? Link to it in the comments section.*

Ilana Yurkiewicz About the Author: Ilana Yurkiewicz is a fourth-year student at Harvard Medical School who graduated from Yale University with a B.S. in biology. She was an AAAS Mass Media Fellow, and her work has appeared in the New England Journal of Medicine, Aeon Magazine, Science Progress, The News & Observer, and The Best Science Writing Online 2013. She has an academic interest in bioethics, currently conducting ethics research at Harvard after previously interning at the Presidential Commission for the Study of Bioethical Issues. She is going into internal medicine and is also interested in quality and systems improvement. Follow on Twitter @ilanayurkiewicz.

The views expressed are those of the author and are not necessarily those of Scientific American.





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  1. 1. rnoanon 2:20 pm 07/2/2012

    Great article, Ilana!

    For my user submission, I like this rather incisive article about the economic effects of insurance regulations.

    http://mises.org/daily/6014/

    Link to this
  2. 2. jctyler 5:49 pm 07/2/2012

    Some of the reasoning above would make a perfect point for anyone wanting to abolish car insurance. The whole discussion just proves how brainwashed the US electorate is:

    - who profits (a little, more, most) from the present situation? (in case you didn’t notice, private health profiteers use the same strategies to sabotage Obama’s health care than the heartland institute-type paid spinners and shills to fight climate science)

    - why did the Republicans change their mind? (because they are against _anything_ that Obama pushes, even if it was a cure for cancer; it’s politics without a brain or conscience)

    - what is the opinion on the matter of US citizens who returned to the US after having worked in the European Union? (I never ever met a US citizen who ever lived in Europe who regretted European national health insurance, not one. OTOH all said that they would regret having to return to the US one day and live without it.)

    This discussion has one great advantage though: it is the ultimate proof that US politics is run by a nouveau-riche bunch of anti-social parvenus.

    Link to this

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