This article is in response to Adam Barsouk’s recent article published on in-Training, “How Jimmy Kimmel Failed His Own Test.” The opinions expressed in this article are those of the author and do not necessarily reflect those in-Training or the editorial board.
Health care is complicated, to paraphrase President Trump, and appropriately so. It accounts for an estimated one-sixth of the American economy. For each of the roughly $3.4 trillion we spend annually, there are parties with something to lose — insurance companies, drug manufacturers, doctors, patients, business owners, civil servants, hospitals, and so on. Often, the stakes are financial. For Jimmy Kimmel, the stakes were higher. Kimmel’s monologue about his infant son became a clarifying moment in a fractious debate. It emphasized that beneath the complex economics of health care, there are foundational moral questions. Do we value the health of our families more than profit margins and high-income tax rates? What are our obligations to each other as members of a civil society?
In Kimmel’s eyes, I saw the hundreds of families I encountered in medical school, particularly the pediatric patients to whom I am dedicating my career. Children with cerebral palsy or serious complications of prematurity. Adolescents struggling with weight and mental illness. Infants with congenital heart lesions, including the very same condition as Kimmel’s son.
Adam Barsouk saw something different — something that was “politicized” and “uninformed,” “reckless and manipulative.” Now, no two people see the same thing the same way, and I freely acknowledge my partisan political preferences. We are each entitled to our own opinions, but not our own facts. In his op-ed, Mr. Barsouk makes a number of statements that contradict the facts, eroding the credibility of his arguments. I hope to address the six most problematic statements here.
“[T]here has not been a case of a child in the United States dying because his parents were too poor to afford treatment since 1986.”
Mr. Barsouk is referring to the Emergency Medical Treatment and Labor Act (EMTALA). The law requires hospitals receiving Medicare payments to provide emergency life-saving treatment to patients in acute crisis, regardless of ability to pay. This strikes me as a low bar, and it doesn’t require that hospitals provide any follow-up care. An uninsured patient experiencing acute hemoptysis will be rescued, but as for the newly discovered lung tumor causing that hemoptysis, the patient is on his own.
Mr. Barsouk specifically mentions children here, saying that not a single child has died due to an inability to pay. This piqued my interest as a pediatrician. It’s a bold claim. It also isn’t true. Almost 20 years of pediatric data have shown that within that time 17,000 children died due to a lack of insurance, with a mortality rate 1.6 times higher than that of insured children. Conveniently, the study began with data from 1988, after EMTALA. Mr. Barsouk neglects that EMTALA protects only emergency treatments; it has not prevented the 17,000 uninsured child deaths between 1988 and 2015. Similarly, EMTALA does not address the adverse health outcomes that uninsured children are more likely to experience, including delays in care and increased morbidity from common, and commonly controlled, pediatric conditions, like iron deficiency anemia and asthma.
“Americans donate a greater percentage to charity than any other country, far outpacing the ‘generous’ socialist societies of Europe, this…will continue to ensure that the infirm, regardless of income, receive the care they need.”
I won’t comment on the conflation of European charitability with generosity — I think it speaks for itself. American charitable giving is laudable, but the notion that it could satisfy our health needs is laughable. Americans gave $375 billion in 2015. Put every dime of that toward annual health care costs, and you’d still come up $3 trillion short. American charitable giving wouldn’t even cover the annual cost of the Medicaid program alone. And while Americans are more charitable as a percentage of GDP, this has not prevented us from consistently experiencing health outcomes worse than our OECD counterparts, including a lower life expectancy, an infant mortality rate of 6.1/1000 live births compared to a median 3.5/1000 live births, and a maternal mortality rate of 26.4/100,000 live births — almost three times as high as the next country on the list. These real-world statistics are nowhere to be found in Mr. Barsouk’s piece.
“There were no throngs of dying Americans on the streets in 2006, and there will be none under Trump.”/ “There is no indication that our neediest citizens, or even a significant proportion of Americans, will be adversely affected.”
In my experience, actively dying Americans don’t often aggregate in throngs on the streets, but I might be missing something. What Mr. Barsouk is missing is that, prior to the ACA, 45,000 Americans died annually directly due to a lack of health insurance — one every 12 minutes. I don’t know if that number is large enough to count as a throng. Jokes aside, claiming that nobody dies due to a lack of insurance just because you haven’t seen them isn’t much of an argument. I haven’t seen a million dollars, but I know it exists.
Mr. Barsouk makes the broad assertion that our neediest citizens will experience no harm under the proposed changes. It’s worth digging into the details. The Congressional Budget Office estimates that 24 million people would lose their insurance under the House bill and 22 million under the Senate bill — predominantly because of reduced Medicaid enrollment. That’s the simplest consequence. More complicated are the “per capita caps.” These would set federal contributions to state Medicaid costs at a pre-determined level, irrespective of the health care economics of that state. If a state’s Medicaid cost exceeds what the federal government is willing to provide, that state would be forced to make significant cuts in enrollment, services, and provider payments. All of this would occur despite the fact that Medicaid has had a lower annual inflation rate than Medicare and the entire private sector.
“Recent research has suggested that the greatest determinant of health outcomes is lifestyle…”
This assertion flies in the face of much of what we know about public health. Mr. Barsouk cites a Health Affairs Health Policy Brief from 2014 to support this statement. There’s just one problem. Nowhere in their article do the authors make that argument. Nowhere.
In fact, the brief makes precisely the opposite case. “[M]any benefits from the extremely high health care spending in the United States are undermined by the nation’s very low investments in social services … there is an increasing awareness that other nonclinical factors such as education and income have a major impact on health.” It highlights the role of social determinants of health, psychosocial stress and early childhood experiences. And while Health Affairs recognizes the contribution of adverse health behaviors (tobacco use, etc.), the authors urge caution: “However, health behaviors happen in larger social contexts. They are a downstream link … and should, therefore, not be thought to be the sole drivers of health disparities.”
“…which may explain why 5% of patients, who suffer from multiple preventable chronic conditions, account for over 50% of health care spending, leaving the rest of us to foot their bill.”
A small proportion of patients does accrue a disproportionate level of health spending, often due to chronic diseases. Mr. Barsouk suggests these are wholly preventable, but he fundamentally misunderstands the complex and overlapping pathophysiology of these diseases. I’ve already cared for more patients that I can count with the trifecta of diabetes, hypertension, and hyperlipidemia — three illnesses that feed on each other to wreak havoc on the vasculature, and by extent, entire organ systems. While lifestyle certainly plays a role, it is often not the driving factor. Moreover, studies have repeatedly shown the importance of insurance in mitigating these illnesses. The uninsured are more likely to have more severe strokes, advanced cancers and poorer glycemic and blood pressure control. And more sickness means higher costs. Mr. Barsouk seems to argue that insurance is a reward for good health, rather than recognizing how essential it is to achieve that health.
Furthermore, Mr. Barsouk ignores the fact that the AHCA goes far beyond stripping protections for those with allegedly preventable conditions. An estimated 27% of non-Medicare eligible adults have a declinable pre-existing condition, and under the proposals, waivers would allow insurers to charge higher premiums and cut benefits for these patients. Among these “preventable” pre-existing conditions are pregnancy, HIV, cancer, multiple sclerosis, paraplegia, Parkinson’s, hemophilia, epilepsy, cerebral palsy, rheumatoid arthritis, Alzheimer’s disease and so on. Not so preventable.
“…patients who make expensive choices should pay more for health insurance.”
I’ve addressed the problem with the word “choices” previously. Here, I’ll focus on two basic concepts of insurance economics — adverse selection and death spirals. Mr. Barsouk argues that patients with costly needs should bear the burden of those needs so that the rest of us don’t have to “foot their bill.” But as high-cost patients face expensive premiums, the least sick (read: least in need of insurance) of that cohort will slowly fall out, resulting in a smaller pool with higher per capita expenses. Then the cycle happens again. And again, and again. Finally, only the sickest, most expensive, and most in need of insurance will remain in the market. Insurance only works with distributed risk, and when the market shrinks to that extent, the risk becomes unsustainable, the cost explodes and the market collapses. It’s a death spiral, and it renders people with pre-existing conditions uninsurable.
Facts are stubborn things
I have other issues with Mr. Barsouk’s piece — his assertions that the AHCA will reduce premiums for everyone (it won’t), his use of divisive and politically loaded rhetoric like “socialist” and “social loafing,” and his implication that Kimmel was “reckless” for “politicizing his son’s condition” (I thought the whole point of politics was to address shared human challenges). I could go on, but I think you get my point.
It’s safe to assume that Mr. Barsouk and I have different political world-views. That’s our right. That’s why I’ve largely ignored our philosophical disagreements on the size of government, or whether health care is a right or a privilege. Instead, I endeavored to focus on the factual inaccuracies in the article, as borne out by objective health and budgetary statistics and peer-reviewed scientific literature. Only after a shared acknowledgment of reality can we have those debates. Without mutually accepted facts, the ideological argument is irrelevant. That’s why we’ve seen opposition to these proposals from politicians as politically diverse as Bernie Sanders and John Kasich.
Is this really about health care?
The disregard for facts is what worries me most about the House and Senate proposals. Amidst the wanton cuts to health services, predominantly affecting low-income and poor Americans, are over $500 billion in tax cuts that primarily benefit the wealthy. This is not a health care bill based on facts. This is a transfer-of-wealth bill, disingenuously driven by ideology under the guise of health reform. I couldn’t help noticing the same pattern in Mr. Barsouk’s piece. Not once does it mention the uninsured rate, the infant mortality rate or other critical health metrics. But there are references to “taxation and socialized medicine,” restoring the “federalist system,” and “social loafing.” Is this really about health care? Or is this about ideology? Shrink government, transfer wealth upwards, and let the chips fall where they may.
I won’t comment on the wisdom of this philosophy. A medical degree doesn’t address how big the government should be or what kind of society we should live in. But it does tell me this: we are doctors. Those chips are our patients.