June 05, 2004

Governor Lamm on health care

Former Colorado Governor Dick Lamm makes some interesting comments about our health care system in an interview with the Rocky Mountain News:

Both you and I know our current systems of handling retirement are unsustainable. Social Security is unsustainable. Medicare is unsustainable. I can see a path to Social Security's solvency where we raise the retirement age and do some other things. But with Medicare I can see no path.

I'm looking you in the eye and telling you I don't think you deserve a heart transplant if you're over 75. You just don't. We had 70,000 women give birth last year without adequate prenatal care.

Lamm is one of the few politicians to come out of Colorado in my lifetime that I'm proud of. He was a three-term Governor, which is shocking when you consider how un-weaselly he is when he talks about important issues. Health care has always been an issue Lamm has concentrated on, and what he says is usually all the more valuable because no one else has the guts to say it.

Take the comment quoted above about heart transplants, for example. If you read the whole interview, Lamm doesn't say you shouldn't get a heart transplant if you're old, only that, if you want a transplant at that age, you should pay for it yourself. That, to me, sounds right. When we don't have enough public dollars to provide basic, preventive health care to our citizens, it's absurd to spend those dollars on astronomically expensive high-tech treatments for people nearing the end of their natural lives. (It's also just as crazy to give away all that money to the pharmaceutical companies as part of the Medicare prescription drug benefit--but by preventing Medicare from negotiating for lower prices from Big Pharma, we're doing just that.)

Elsewhere in the interview, Lamm makes the point that "People's best doctors are themselves; they've got to understand that. One of the things that I'm really talking about is the new sense of self-responsibility in health care. Just a few factors are the most likely indicators of future health: smoking, diet, the use of alcohol, those kinds of things." This is, in my opinion, something that everyone ought to be able to agree on (even myself and Chris Rangel). Take heart transplants for old people. Apart from genetic factors, the health of your heart at age 75 is something that's largely within your control. If you're worried that you might not be able to afford a transplant at 75, you can stop going to McDonald's now. Quit smoking. Take the stairs instead of the elevator.

Some critics of Lamm will argue that the same logic applies to prenatal care, or to any other basic preventive health care service. Why should we spend public dollars on poor people's diabetes when we won't buy Grampa a new heart?

This gets to the question not of whether people should take responsiblity for their health care, but of whether we as a society have any interest in something called "public health." Libertarians like Trent McBride, although their views are crucially necessary and sometimes flat-out right, often make it seem as though health is purely a private matter. The state of my health, the libertarians argue, is as relevant for the community as what color litter box I buy for my cat. On these matters, the argument goes, all community involvement is community interference.

Ok, so most of you will now be complaining that I've set up a straw man, and you'll be right. Not even the libertarians make this extreme argument, because even the libertarians realize it's wrong. Like it or not, we must live together, and living together with sick people threatens my own health and well-being. We spend public dollars on sewers for a reason. We require immunizations for a reason. The question is not whether we should spend public money on health care; the question is what kinds of health care our public dollars should be spent on. We can't afford everything, so we'll have to make choices: heart transplants for 75-year olds? No. Prenatal care for pregnant women? Yes.

One suggestion that clearly isn't helpful in this context is Donald E. L. Johnson's off-the-cuff remark that we don't have a health care "system" at all, just an aggregate of individual providers, insurers, and "markets". Apart from the obvious fact that markets are simply a type of system, and acknowledging Johnson's valid emphasis on real entities and not intellectual constructs, the problem with Johnson's remark is that it ends the debate before it even begins. If there's no system, we can't ask systemic questions. We can't ask the very questions Lamm raises: why are we buying heart transplants when so many of us don't have access to basic (and cheap) preventive health care? These questions need to be debated, not foreclosed by the not-so-subtle privileging of laissez-faire that Johnson engages in.

Posted by Carey at June 5, 2004 03:23 PM