On inequality and healthcare

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

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40 Responses

  1. Roger says:


    Excellent contribution to the dialogue. It went in an enexpected direction. Unequal expenses for a particular segment.

    Having discussions on cost benefit tradeoffs is a difficult thing to do as a monolithic decsion. We simply do not have the same values or contextual frames One decision, I fear, will be the wrong decision for just about everyone.

    Markets would address this by allowing consumers to decide. Of course in health care, we have separated connections between who pays and who benefits, so market solutions cannot work either.Report

    • Christopher Carr in reply to Roger says:

      Market solutions would create a new, more ethically-questionable inequality, where access to care is not determined by seriousness of condition, but by wealth.Report

    • Russell Saunders in reply to Roger says:

      Thanks, Roger. As Rose can tell you (I had her read early drafts), I had about half a dozen directions I wanted to go in, and finally had to settle on this one.

      The issues you allude to were among the other aspects I had to jettison. In order for market solutions to work, the consumers (patients) must be directly involved in the market. Since most insured people have no earthly idea what their healthcare costs (and I’ll wager most doctors are similarly clueless), it’s hard for them to make informed decisions about their own care. Instead, the insurance company makes decisions for them, based on incentives that often have little to do with the health of the patient. Which is how we get to our current spaghetti-pile of a healthcare system.Report

      • Roger in reply to Russell Saunders says:

        I am as “free market” as they get, and I fail to see how market freedom will fix this mess. Health care requires a hybrid problem solving system that blends political, scientific and markets.

        I see culture as advancing from the cumulative gain of solutions to the problems of thriving. Along the way, we came up with some meta solutions. We discovered ways to solve tougher problems better. We need to start discovering a tougher meta solution soon on health care.Report

        • Russell Saunders in reply to Roger says:

          I think there is a role for market solutions. I think if there were less of a buffer between patients of standard means and the costs of routine care, those costs might come down.

          However, for some people the costs of even routine care are prohibitive, and there must be a well-structured safety net for those populations.

          Finally, just about anyone would be financially ruined by a devastating diagnosis. Market solutions are a poor remedy for just about anyone faced with the costs of the induction phase of chemotherapy.Report

  2. I disagree with this:

    “It is so much safer politically and happier for everyone to focus on the ounce of prevention. But the pounds of cure (which are often necessary and beneficial) will keep piling up if nobody has the nerve to ask how we might go about trimming them.”

    And with this:

    “The implication underlying our national obsession with wellness is that proper diligence will forestall the depredations of age, and infirmity is a moral failure.”

    American’s are not obsessed with health. We suffer from a paradoxical form of learned stupidity when it comes to health and nutrition, where we tell ourselves that an 80-calorie doughnut is a healthier choice than a 110-calorie banana. The consequence is a nation of twentysomethings with pot bellies who’ve spent the physical prime years of their lives sitting on couches and at desks eating doughnuts. I think there’s a lot of room for us to move towards an ethic of fitness, and I think the primary vehicle for this must be a public health policy that focuses on preventative care.

    I agree that end-of-life care costs are an intractable issue in our culture, and I don’t have any good ideas for how to lower them, except for more and more people to choose to die like physicians (http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/), and/or for more people to start living their lives for future generations, to develop a “seventh-generation ethic” (http://en.wikipedia.org/wiki/Seven_generation_sustainability).

    None of these cultural Hail Marys are even conceivable for the Baby Boomer generation – they require a brand new generation and brand new ideas towards life and death, but, in the meantime, if spending gets truly out of control, it might force us to choose between raining death down upon more Middle Eastern nations or vainly fighting death domestically, so there might be a silver lining in it all.Report

    • American’s are not obsessed with health. We suffer from a paradoxical form of learned stupidity when it comes to health and nutrition, where we tell ourselves that an 80-calorie doughnut is a healthier choice than a 110-calorie banana.

      Just because we come to erroneous conclusions doesn’t mean we’re not obsessed. The mere fact that your hypothetical American knows the calorie differential between Snack A and Snack B supports the notion that we’re all fixated on such things.

      And making a decision to die like a physician (which is, incidentally, a conversation I had over dinner during Leagufest) requires a frank dialogue about how physicians choose to die, and why they’re not talking to their own patients on those terms. I would welcome that dialogue.Report

      • “Just because we come to erroneous conclusions doesn’t mean we’re not obsessed. The mere fact that your hypothetical American knows the calorie differential between Snack A and Snack B supports the notion that we’re all fixated on such things.”

        Good point. My wording was careless.

        I agree that we should have a frank dialogue about end-of-life care. How would people feel about the next symposium being (cue organ music) the Symposium of Death!?Report

  3. Jaybird says:

    One of the things I point out in my own muddled essay (that seriously is almost done it just needs a conclusion and better middle) is that the average life expectancy of a 20 year old in 1890 was 40 years but the average life expectancy of a 20 year old today is 55.

    The “dying at 60” problem has been solved for entire swaths of the country… and instead of “Hurray! More *TIME*!!!” we’re hearing “people still have to eat! They still need shelter!” as if this gift is instead an imposition.

    “People didn’t used to have to worry about their retirements!”
    “That’s because they were dead.”Report

    • Roger in reply to Jaybird says:


      Most solutions create new problems. Then we focus on the problem and forget how much better we are.Report

        • Health nuts are going to feel stupid someday, lying in hospitals dying of nothing.–Redd FoxxReport

          • Kazzy in reply to Tom Van Dyke says:

            Heh. I’m a health nuts of sorts, in that I enjoy how I feel when I’m working out and eating well (and I define “well” as a peefectly cooked steak from time to time, homemade pizza with fresh ingredients… Not alfalfa sprouts and tofurkey). If this lengthens my time, so be it. But I don’t believe in eschewing life’s joys to live a longer, joyfree life.

            On that last note, I’ve got a date with a hooker!Report

            • Tom Van Dyke in reply to Kazzy says:

              Tip o’the brim then, Kaz. Sinatra said he felt sorry for people who don’t drink—when they get up in the morning, that’s the best they’re going to feel all day.Report

              • greginak in reply to Tom Van Dyke says:

                Charlie Parker probably felt the same way about heroin.Report

              • Kazzy in reply to Tom Van Dyke says:

                I had heard that saying before, though didn’t know it was Sinatra.

                Life should be happy. End. Of. Story.

                (And I *WAS* joking about the hooker, by the way. I hope that was assumed. I’d NEVER pay for sex… Though I’m happy to barter for it.)Report

              • Jeff in reply to Kazzy says:

                I don’t know why prople feel so strongly about paying for sex. We pay for everything else, including most forms of pleasure, but no sex, oh no, mustn’t pay for sex!!!!1!!!

                I have gladly paid for sex, both with a real live person and for pr0n. I will probably do so again. As long as there is informed consent on all sides [*] , I see no problem with it.

                [*] I realize that there is a LOT of coercion in the sex industry. The best I can do as a consumer is look for situations where coercion SEEMS unlikely. (I probably don’t know how much coercion actually exists, but then the burger-flipper at Mickey D’s might be coerded as well.)Report

              • Kazzy in reply to Jeff says:


                Generally speaking, I don’t really have any problem with people paying for sex (with the same hesitations with regards to coercion that you express). The main reason I don’t pay for sex is that my wife doesn’t take credit cards and I rarely carry cash. 🙂Report

  4. M.A. says:

    That whole ridiculous brouhaha erupted over the perfectly reasonable provision in the Affordable Care Act that would have reimbursed physicians for time spent discussing end-of-life care with their patients, despite several prominent conservatives having thought it was a good idea once upon a time.

    It’s the hypocrisy that really annoys me.

    Conservatives thought discussing the reality of end-of-life care was a good thing, once.
    The insurance mandate to eliminate free-rider problems started out as a Heritage Foundation proposal, in the early 1990s.

    And when it came time to implement them, just because the guy who would be signing the bill was a biracial Democrat… hooboy did they scream bloody murder. Sigh.Report

    • Brandon Berg in reply to M.A. says:

      You cry bloody murder when you imagine that I’m accusing you of antisemitism, but here you are making an actual bogus accusation of racism when it’s quite clear that the “Democrat” is doing all the heavy lifting in “biracial Democrat.”

      All the while complaining about hypocrisy. Is there a word for a hypocrite accusing someone of hypocrisy? Hypercrite?Report

  5. Tod Kelly says:

    This was just outstanding, both the argument and the writing. I have very little add, other than repeating that last observation over and over again. Well, maybe this:

    One of the interesting things that has started happening over the past year is that conversations and meetings are happening in closed doored rooms with experts in HC, insurance and federal public policy. The doors are closed primarily because the partisan nature of this discussion has made it impossible to have a constructive public conversation. I think it’s a good bet that whatever happens in those rooms will eventually become our new healthcare reality for generations to come. Which means, to me anyway, that one of the sad outcomes of using this issue as a political football might well be that we as a people don’t ever get a chance to have much of a say as to what our own future will really look like.Report

    • Thanks, Tod!

      Insofar as openness corresponds with honest dealings, I am in favor of openness. Insofar as closed doors hide malfeasance, I am against closed doors. But if closed doors are a necessity for doing work that cannot be done with full transparency, then I am in favor of closing the doors to a limited degree. YMMV.Report

  6. BlaiseP says:

    Health care seems to have advanced faster and farther than the American has learned to cope with it. Are there any ethicists in your field of view who can provide any useful guidance?

    …Do not let me hear
    Of the wisdom of old men, but rather of their folly,
    Their fear of fear and frenzy, their fear of possession,
    Of belonging to another, or to others, or to God.
    The only wisdom we can hope to acquire
    Is the wisdom of humility: humility is endless.

  7. Kazzy says:

    I’ve long-maintained that when it’s time for me to go, I’m going. I have no intention of being part of that 5% if I can avoid it.Report

    • Tom Van Dyke in reply to Kazzy says:

      Me sees a saggy and faded “Hope I Die Before I Get Old” tattoo.Report

    • Russell Saunders in reply to Kazzy says:

      Kazzy, that would be kind of the “die like a doctor” mentality Chris is mentioning above. I hope I can be clear-eyed and honest with myself about my prospects when the time comes, and eschew fruitless treatments that will buy precious little time but more than their share of misery and needless expense.Report

      • Jeff in reply to Russell Saunders says:

        MY mom (see below) just signed a form (PAALT or PAART or something like that) that includes that sort of language IIRC. I know it can be included in the California Advance Directive (there’s a free-form section — I intend to put language like this in mine).

        Russell, if you don’t mind my asking, what kind of information like this does your advance directive contain?Report

        • Russell Saunders in reply to Jeff says:

          When the Better Half and I drew up the reams of legal documentation that we have in lieu of legal marriage, I made him my health care proxy and put in place my wishes with regard to lifesaving measures, which are predicated on reasonable expectations of recovery.Report

        • James Hanley in reply to Jeff says:

          My mom was able to make a good choice about when to draw the line with care for my father. Fortunately she had a doctor who was very upfront with her, telling her, “we can revive him again, and keep doing that for a while, but he’s not going to be leaving this place.”

          I think it was one of the bravest things she’s ever done.Report

  8. b-psycho says:

    This is why I’ve decided when I get to the point of extraordinary measures with diminishing odds, I’m folding up the tent & spending my last time on Earth trying as many psychedelic drugs as possible.

    What the hell, right?Report

  9. Jeff says:

    Great essay! I don’t much to add, other than my mom (84!!) isn’t using all that much in the way of care. She’s at Kaiser of Northern California (which is the best system I’ve seen — by far), so most of her coverage is routine. She has mothly blood labs, and periodic neurological tests (memory problems but not Alzheimer’s for which I am extremely grateful). But I realize she is extemely lucky in this regard.Report

    • Russell Saunders in reply to Jeff says:

      I’m delighted that your mother is in good health, and may she stay that way for years to come. When I’m 84, I hope I am so lucky.

      Obviously, there are plenty of healthy older people. Conversely, there are some gravely ill young people. It’s not age per se that leads to unnecessary cost, but needless interventions and tests when a more honest assessment of the patient’s condition would lead to not only less expense, but also improved quality of life during the time that remains.

      And I’m glad you enjoyed the essay. Thanks for commenting!Report

  10. Kazzy says:

    And, if I didn’t say it already, this was a great peace. It seemed to have gotten swallowed up with some, um, sexier posts before and after it, but this was a really interesting way to approach the symposium and I think you appropriately waded into a topic that can easily be a minefield with nary a misstep.Report

  11. Brandon Berg says:

    Those of you struck from above by falling pianos, congratulations on beating the system.

    Hardly. I caught H5N1 from one of the little birdies that started circling around my head after the piano fell on me.Report

  12. Brandon Berg says:

    Five percent of the population accounts for almost half (49 percent) of total health care expenses.

    Am I correct in assuming that this is for any given year, and not over a single birth cohort’s entire lifetime? That is, if we were to look back at lifetime health care expenditures for everyone born in 1900, we would see a much more even distribution, would we not?

    Come to think of it, this also applies to income inequality. By looking only at a single-year snapshot, we see higher highs and lower lows than we would if we were looking at lifetime or ten-year-average incomes. This could even account for some of the increase in intranational income inequality, if incomes are becoming more volatile due to a shift towards stock-based compensation at the high end.Report