Health care system

"The fulfillment of the basic needs of the poor is of the highest priority. Personal decisions, policies of private and public bodies, and power relationships must all be evaluated by their effects on those who lack the minimum necessities of nutrition, housing, education, and health care. In particular, this principle recognizes that meeting fundamental human needs must come before the fulfillment of desires for luxury consumer goods, for profits not conducive to the common good, and for unnecessary military hardware." (Economic Justice 90a).

But your eyes and heart are set on nothing except on your own gain, on shedding innocent blood, on practicing oppression and extortion. Jeremiah 22:17

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Health care is today more expensive than ever before. The reasons for this are many. There has been an increase in the complexity of medicine, new technology and drugs, and the cost of malpractice insurance and awards is rising. But this doesn't explain why basic care has become unavailable to so many.

In the early 20th century, there were 10,000 fraternal orders in the U.S. with 100,000 lodges and 18 million members (30% of adults over age 20), and 10% of workers belonged to unions. By 1910, most of these organizations included doctor's treatment as a service and benefit. They would contract with doctors on a per capita flat charge for their members. In the 1920s, in New Orleans alone, there were 600 fraternal societies among African Americans offering physician services. Throughout the south, fraternal organizations operated many hospitals for African Americans, some of which endured into the 1960s. For example, the Knights and Daughters of Tabor hospital in Mississippi cared for over 135,000 patients (1942-1964), most of whom were sharecroppers. The largest group controlled by women was the Ladies of the Maccabees, with 200,000 members (Beito 42-43).

By 1920, however, medical associations had begun to attack these organizations. They would sanction doctors who accepted such contracts, and persuaded hospitals to refuse contract patients. In the 1930s, these fraternal organizations went into a decline from which they have not recovered. This was joined with a crusade for state licensing of doctors (Beito 43). As a result, today everything in the medical system is held hostage to the physician; no drug can be prescribed without his authority, no treatment can be completed without his diagnosis, and his general attitude is that people are better off without any health care at all than to make any changes to this system. The cruelty of this common attitude among health care professionals is breathtaking in its indifference to the plight of the poor and working classes.

The rise of HMOs and large national insurance companies has resulted in a change in the way health care services are priced. In the past, doctors often charged poor patients less -- sometimes nothing. But that tradition has gone the way of the house call. Big insurance companies and large employers negotiate price discounts with health care providers. Medicare and Medicaid use the force of law to compel acceptance of their reimbursement schedules. The situation is such that the only squeeze room left to the industry is the cash payer -- who is often poor or working class. The person who walks in the front door of a doctor's office and pays cash almost always pays the highest price charged for that service.

Laws prevent nurse practitioners from practicing independently of doctors and offering low cost basic and preventive health care. Economically, services provided by such practitioners could be offered at lower rates than a doctor charges. A nurse would treat a less complex set of problems, and thus have less overhead and lower malpractice insurance costs. Less overhead equals lower prices to patients and lower prices mean more access. Doctors are a male dominated profession, and nursing is a female dominated profession. Can it be that doctors have a hard time imagining that women could treat patients without male supervision?

Dentists successfully have lobbied for restrictions on denturists that practice independently. Denturists provide low-cost dentures (often priced 50% below dentist services) and can provide even lower cost dental appliances (commonly called "flippers") for the very poor. The attitude of dentists is that people should not have dental appliances unless they pay the higher fees charged by dentists. This has serious consequences for both the self-image and employability of persons needing such treatment but who do not have the money to pay the extortionate prices charged by dentists. It is a curious commentary on an allegedly free market. This author found, in searching for low-cost dental treatment in the early 1990s in Salt Lake City, that no dentist listed in the phone book would recommend a "flipper" for someone who did not have the money for dentures, or even tell the author that such low-cost alternatives existed. Utah is one of the states that does not allow denturists to practice independently, and the author found the price differential between the Utah price and the Washington State price (where denturists are legal) to be 200%.

Such craziness extends to government programs. The need for access to medical care (via Medicaid) can cause a welfare recipient to delay or resist getting a job, or reject pay and work hour increases, in order not to jeopardize the only medical insurance they can get. The lack of portability of insurance, waiting periods, and odd and ill-conceived insurance mandates that increase the cost of insurance also contribute to the impasse.

This situation is not an accident, nor is it the unfortunate unintended consequence of impersonal economic forces that nobody understands. It is the foreseeable result of the deliberate and willing actions of doctors who were so greedy that they could not bear the thought of one single health care nickel escaping them. Individual doctors are certainly nice people who are kind to their dogs and so on and so forth, but the author's reading of Catholic social teaching is that they have personal responsibility for the structures of sin in health care that oppress the poor. The doctors may say, "It isn't our fault," but it was their medical associations that demanded the legal structure of the current medical marketplace, which by law is a doctor's monopoly. Having established the ground rules as a matter of law, and thus creating the structure, they are responsible for the consequences. Doctors are the ones who brought politics into the medical marketplace. Further, there has been no outcry from the medical associations calling for a liberalization of the medical marketplace nor have they offered to free nurses from their perpetual indentured servitude to the doctors. This is an example of how the personal greed, gluttony, and social irresponsibility of two generations ago is afflicting us with social problems today.

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