Ability to Pay is Out of One's Control: An Argument Against the Commercial Model of Health Care

1. The commercial model of health care states that quality health care (QHC) hinges upon one's ability to pay monetarily for the services of medical professionals.
2. Ability to pay for such health services is determined by one's ability to either acquire money oneself  – for example, through employment – and/or one's ability to solicit charity from others – such as from acquaintances or family members.
3. Among others, the conditions of stable personal employment requires that one be able bodied and able minded (i.e. not disabled or critically ill) and have received years of support from others in the form of constructive upbringing and formative education.
4. Both such conditions are out of one's control in that one cannot choose one's physical capacities and susceptibility and/or immunity to disease before birth (and in many cases after birth), and because one cannot control the actions of others (esp. as an infant, when one is most vulnerable).
5. Soliciting monetary charity from others, be it children from parents or stranger from stranger, is out of one's control for the same reason -- the actions of others are out of one's control.
6. Thus, in either case, the ability to pay monetarily for QHC is out of one's control.
7. Yet, irrespective of one's ability to pay, all humans are mortal, and being mortal, all humans are in need of QHC from time to time in order to continue to lead constructive lives.
8. Either no one deserves QHC, everyone deserves QHC, only those who can pay monetarily for QHC deserve it, or desert hinges upon a hitherto unarticulated matter.
9. If no one deserves QHC, then neither mortal need nor the ability to pay for QHC matters.
10. If everyone deserves QHC, then the commercial model is problematic, for it neglects those mortals who cannot pay for it.
11. If only those who can pay deserve QHC, then mortal need does not matter – what matters is only the chance (out-of-one's-control) circumstance that one is able to pay.
12. Given that QHC depends upon the actions of many individuals other than oneself, including those who developed medical science and care over the course of thousands of years, and given that it is both out of one's control whether one was born today and not (say) 10,000 years ago (or before the development of medical care), it is also out of one's control that one lives in a time wherein health care is a commercial transaction.
13. Thus, one does not deserve QHC simply because one can pay for it – for the historical development and present existence of medical care is out of one's control in the same way that a society of commercial transactions is out of one's control.
14. Thus, we are left with a choice between no one deserving QHC, everyone deserving QHC, or desert hinging upon some other factor than ability to pay.

Health Care and the Community: Thoughts Presented at a Social Justice Forum

What I'd like to bring to your attention on the topic of health care and the community, is the degree to which persons of low income can be trapped in qualitatively poor health care. Recently this problem entered directly into my life, as I have been diagnosed and treated for advanced skin cancer over the course of the last year. As I came to realize, there is a marked difference between health care and health coverage. At present – while there may be ever wider health coverage (health insurance, say) – we are still a community where quality of care, that is the ability to receive proper medical support and treatment in a timely manner, hinges upon income (or wealth). Your ability to pay more money than I for coverage, means that you are entitled to a greater quality of care than I. 

Yet, there is of course a problem here: Equating health care with a commercial transaction, neglects the fact that quality health care is a requirement of continued human existence, not to mention human flourishing. Quality care is like quality food or clean water: without these you soon perish. It doesn't matter whether you are wealthy.

But when it comes to the fair and equal distribution of quality health care as a resource, our community turns to money. How will we pay for it? is often the first question. Notice in this reflex, that money and self-protection so easily come to mind. How will we pay for it? The impulse here is the same impulse that has us walk past a homeless person with our eyes ahead, and the moral imagination only on oneself: I hope no one sees me ignoring them. When we are insulated by quality health care it is not so hard to fall into a similar kind of thinking: Yes I've heard about the quality crisis, but someone else (the government, say) will fix it; meanwhile I have good quality care.  

Well, in a small effort to stimulate our moral imagination, I'd like to share a bit from my own experiences being trapped in poor quality health care while in the grips of a life threatening illness.

So, three years ago – when I was twenty five, and still covered by my parents high quality health insurance – I noticed a weird mole on my left hand. To make a long story short: while it was ultimately thought benign, some of it's pathological properties were concerning. While skin cancer doesn't run in my family, as a precaution I was asked to see an oncologist and take ct scans for a two year observation period.

Moving forward two years: In May of last year – right after my final ct scan had been all clear – my wife –who was my girlfriend at the time, noticed a lump on my left arm. While I thought it was some kind of a cist which I had experienced before, given my history I went to have it checked out by my primary care doctor a few days later, and he authorized an ultrasound referral for me.

Now, at this moment in time I was a full time graduate student covered by Medi-caid – I qualified for California's Medi-cal program because while I worked part time, I didn't make enough money to be allowed to purchase publicly subsidized insurance (like Obamacare). Nor, of course, was it financially feasible for me to purchase private insurance.

I mention this because bureaucratic delays and high patient volume are well known in Medi-caid clinics, and would indeed be routine during my care. After waiting a few weeks I was informed that the first available appointment was the beginning of September - three months away!

So, September roles around, and the ultrasound looks concerning to the radiologist. A biopsy is performed. The biopsy results take a month to come back, but when they do I'm told that the growth is cancerous. Surgery is prescribed. But there are more delays, such that it was not until late October, almost five months after signaling the alarms with my primary care doctor, that the original tumor, all of my lymph nodes in my left armpit, and a newly developed tumor, are surgically removed.  

As you know, when it comes to cancer the sooner you catch it, the better. Simply given the delays I faced, it is likely that a treatable disease became a chronic or terminal illness. I recently read a study from the Case Western Reserve School of Medicine in Cleveland which indicated that "patients were two and a half times likelier to be diagnosed with late-stage melanoma if they were covered by Medicaid" as opposed to being diagnosed at an earlier stage with private insurance. No doubt delays play an important role in this data.

But unfortunately, diagnostic and scheduling delays are not the only issue. Doctor appointments often took all day: I'd arrive for a 9am appointment and not leave until 3pm or sometimes 6pm. Bear in mind that I'm a full time graduate student working part time during all of this, and when I'd arrive at the clinic, thirty or forty people would also be there waiting, due to overbooking.

More troubling, was that more times than not I would be treated by a medical Fellow I had never met before and knew next to nothing about my case, despite the fact I had been receiving treatment there for months.

The fact that no one was really acting as my doctor, it seems to me, led to a number of absurdities that I experienced with my subsequent treatment after surgery. First, when it came time to receive radiation treatment a few weeks after recuperating from my surgery the short window of time in which radiation is viable was mishandled and I never received it.

The next few absurdities are related. In January of this year – another ct scan showed that the cancer had spread to my liver and lungs. This was a great blow. Looking at the five year survival curves for stage four melanoma, and then realizing you are subject to the same prognosis is nearly unfathomable in your twenties.

As soon as they saw cancer in my liver and lungs, I was put on what's called targeted therapy – drugs designed to slow the growth of cancer. The issue, as I learned later, was that there is a high chance of toxicity when taking targeted therapy in combination with the immunotherapy drug I was also receiving since November. While I fortunately didn't have to learn this first hand, there was nevertheless a 30% chance I could have developed a ruptured colon from receiving both treatments – something I was not informed of at the time. In fact, the two drugs are never prescribed together.

The next absurdity was that my insurance denied me the targeted therapy I just mentioned. On the same day I was told I was stage 4, the head of the oncology department gave me a two week supply of the drugs – which were FDA approved – and wrote me a prescription. These samples ran out while myself, my girlfriend, and my mother battled with the insurance company. In the bureaucratic maze, no one could tell us why the drugs were denied until five weeks later: a different set of targeted therapy drugs that did the same thing were preferred, but they failed to make this clear to the doctors or to myself. 

The last absurdity I will relay, although I could go on, is perhaps the most symbolic of how income inequality determines quality of care:

I shall have to simplify this for time, but a week after I had ran out of the samples of the targeted therapy drugs had an appointment at the oncology clinic. A medical fellow I had never met before saw me, and I explained the battle I was having with the insurance company. I then asked the most obvious question: Might there be any more samples I could have? The fellow said that she was surprised that I was given samples at all: they were generally not given to county patients on Medi-caid, and instead reserved for patients at the fancy university cancer clinic down the street. 

The irony is that previously, when I was on my parents insurance, I had myself been a patient at the fancy university cancer clinic.

Needless to say, I didn't get any more samples. I found myself dying of a disease that was itself preventable if properly treated. I found myself being denied (what I thought was) life saving treatment because I didn't make enough money to be qualitatively insured. 

Anyway, after this absurd and intense period of delays, denials, and bureaucratic nihilism, myself, my girlfriend, and my family decided that we would pay out of pocket to see a melanoma specialist. This ended up being the right path. After extensive reasearch, we lucked into getting a consultation in February with one of the foremost experts of melanoma, and decided that I should be under his care.

But like everyone in my circumstance (except potentially Warren Buffet), I couldn't pay out of pocket for treatment when one months worth of prescriptions would total $10,000's and a standard PET scan cost nearly the same amount.

My way out was that I was in a loving relationship, and so had an additional option denied by most: get married, and assume health insurance together.

So, Leanne and I went and got married first thing on a Monday morning in February so that I would have reasonable insurance and be able to see our current doctor. By March we were covered by Obamacare, affording us the possibility of being treated with the quality of health care necessary to someone of my circumstance.

Now, at a Phase 1 trial clinic, all of my appointments are coordinated professionally, scans can be scheduled at a days notice, and support is granted whenever it is needed – I can essentially call my oncologist or a nurse who knows me and my case anytime.

I would like stress that through all that I have shared, I was the lucky one: I had a team of people researching and making phone calls, I had the privilege of a graduate education, and unlike many of the people I witnessed at the county clinics, speaking English wasn't a challenge to me.

Nevertheless the kind of neglect I experienced and witnessed in our health care system seems to me indicative of an invisible dark side of our community – a dark side that our current administration is a symptom of. It should be alarming to everyone that the dialogue about health care begins with money, esp. when no one would seriously challenge that quality care is a basic necessity (in the league of clean water). If there is a way out of the neglect and entrapment I've spoken of, I would wager that it starts with cultivating in ourselves and especially in our youth, a moral imagination suitable for citizens of a democracy. My experience in public schools growing up was that controversial topics – political, religious, ethical – were off limits for discussion. If we produce citizens incapable of critically discussing such things, we produce citizens who cannot fight the dark side of the community, the side that consumed by the impulse of self-protection, fails to recognize the interconnectedness of all life and our responsibilities to one another.

Excerpt from "A Man of the People" by Ursula K. Le Guin

"After a long silence, he nodded.

            She sat stricken, understanding that she had won. She had won badly.

            She reached across to him, trying to comfort him and herself. She was scared by the darkness in him, his grief, his mute acceptance of betrayal. But it wasn't betrayal - she rejected the word at once. She wouldn't betray him. They were in love. They loved each other. He would follow her in a year, two years at the most. They were adults, they must not cling together like children. Adult relationships are based on mutual freedom, mutual trust. She told herself all these things as she said them to him. He said yes, and held her, and comforted her. In the night, in the utter silence of the desert, the blood singing in his ears, he lay awake and though, 'It has died unborn. It was never conceived.'

            They stayed together in their little apartment at the School for the few more weeks before Tiu left. They made love cautiously, gently, talked about history and economics and ethnology, kept busy. Tiu had to prepare herself to work with the team she was going with, studying the Terran concepts of hiearchy; Zhiv had a paper to write on social-energy generation of Werel. They worked hard. Their friends gave Tiu a big farewell party. The next day Zhiv went with her to Ve Port. She kissed and held him, telling him to hurry, hurry and come to Terra. He saw her board the flyer that would take her up to the NAFAL ship waiting in orbit. He went back to the apartment on the South Campus of the School. There a friend found him three days later sitting at his desk in a curious condition, passive, speaking very slowly if at all, unable to eat or drink. Being pueblo-born, the friend recognized this state and called in the medicine man (the Hainish do not call them doctors). Having ascertained that he was from one of the Southern pueblos, the medicine man said, 'Havzhiva! The god cannot die in you here!'

            After a long silence the young man said softly in a voice which did not sound like his  voice, 'I need to go home.'

            'That is not possible now,' said the medicine man. 'But we can arrange a Staying chant while I find a person able to address the god.' He promptly put out a call for students who were ex-People of the South. Four responded. They sat all night with Havzhiva singing the Staying Chant in two languages and four dialects, until Havzhiva joined in a fifth dialect, whispering the words hoarsely, till he collapsed and slept for thirty hours.

            He woke in his own room. An old woman was having a conversation with nobody beside him. 'You aren't here,' she said. 'No, you are mistaken. You can't die here. It would not be right, it would be quite wrong. You now that. This is the wrong place. This is the wrong life. You know that! What are you doing here? Are you lost? Do you want to know the way home? Here it is. Listen.' She began singing in a thin, high voice, an almost tuneless, almost wordless song that was familiar to Havzhiva, as if he had heard it long ago. He fell asleep again while the old woman went on talking to nobody.

            When he woke again she was gone. He never knew who she was or where she came from; he never asked. She had spoke and sung in his own language, in the dialect of Stse."

--Ursula K. Le Guin, "A Man of the People," Four Ways to Forgiveness (Harper Perennial, 1995), pp. 153-155

A Challenge to Impersonalism of Philosophic Space: From Red Mars

"The only part of an argument that really matters is what we think of the people arguing. X claims a, Y claims b. They make arguments to support their claims, with any number of points. But when their listeners remember the discussion, what matters is simply that X believes a, and Y believes b. People then form their judgment on what they think of X and Y."

Kim Stanley Robinson, Red Mars (Bantam Spectra, 1993), p 77.

In The Shade

You come out here on some old hunt

limping

from formative wounds

dents to the fender

Friendless, new, shy

your eyes spin and squint

from culture shock and sun

Everyone who passes by

you think-ask: 

Won't you come kiss me
hold me
share this warmth

by the air-conditioner?

Stare into my eyes

under the ceiling fan?

In the shade
with your daemon

squirt gun in hand

a pack of sandwiches
upon your lap
you'll wait
heavy

heavy with knots
not drawn here 
tired from the bad chemicals
that follow

Movies I Like: L'Illusionniste

For some reason I want to say a few things about a handful of movies that I like. I don't know...

Ok (no order):

1. L'Illusionniste (The Illusionist - 2010). This is a hand drawn (romanticized-realist?) animation about a traveling magician and a protege he picks up along the way - a pretty young girl. There are no words; well, actually, there are Englishy mumbles, but that's as far as it goes. I had this movie saved to my parents DVR and would watch it before going to bed when I lived there. A kind of salve. I'm wondering if this has to do with the quality of whimsy present. A graying, middle aged whimsy. One doesn't leave this movie feeling bad.

There are parts of L'Illusionniste that I always want to watch (this is a preoccupation of mine, which will make other appearances in "Movies I like" to come) - like the magician taking boat rides out to Scotland, with all this wonderful green overcastness. God... And the music hits the spot - soulful soft classical piano, often in breathtaking waltz timing, occasionally accompanied by xylophones, jazz drums, and another thing or two. Clean and well-wishing, in an elderly way (as though you are spending the day with a sophisticated grandparent, and, incidentally, you two go to a doughnut shop and sip strangely good coffee and eat two frosting donuts, one with coconut and the other with chocolate chips). Reminds me of parts of Michael Giacchino's Up's score, but less heavyhanded with the melancholy/nostalgia. Here is an example.

As far as what the movie is about, to be honest I'm not really sure. I'll have to watch it again with that project in mind. I wasn't watching it for plot, though, and so it's hard to say what the meaning of the thing is. I've been taking it in episodically - to borrow Galen Strawson's term (see this paper for a run down on what episodism means, if you are interested). Nevertheless, I've seen the movie enough to know that the plot is like this: An understated, underdog-like magician performs in some big city, then travels to Scotland to perform, then travels back to the continent to perform, where he strikes the fancy of a girl (I'm thinking 15-18 years old) who follows him as a kind of stowaway. They eventually come to share an apartment, and the girl seems to want to learn magic - she thinks it's real, and the magician is having difficulties telling her to the contrary. Anyway, the magician is having a hard time getting any more gigs - as are all the other entertainment persons that surround them (clowns, gymnasts, etc.) - and he takes up other means of employment. The girl is presented with gifts (a coat, shoes, a dress) throughout the movie by the magician, and comes to affect some poise. This gains her the interest of a young man in town. When the magician sees them together, he decides to leave her some money and a note ("Magicians do no exist."), before taking a train out of town. We see the magician look at a handheld photograph longingly as he rides away (in fact, he eyeballs the photo a few time during the movie).

Maybe it has something to do with the destructive ramifications of consumerism. Maybe not. I tend to think everything I encounter now has this theme. I should probably look into that. The movie also seems to be about loss or something like that. I wouldn't have emphasized this connection, though, without reading the wikipedia page.

I will say, though, that fortunately, L'Illusionniste is not about a romance between the young woman (maybe girl?) and the middle aged magician. Every time I show L'Illusionniste to a friend, they always think it will go in that direction. But it doesn't. There is a purity about the movie. Maybe that's not quite right.

In any case the full movie is here.

I wonder what you think.

Initiation Song from the Finder's Lodge

Please bring strange things.
Please come bringing new things.
Let very old things come into your hands.
Let what you do not know come into your eyes.
Let desert sand harden your feet.
Let the arch of your feet be the mountains.
Let the paths of your fingertips be your maps
and the ways you go be the lines on your palms.
Let there be deep snow in your inbreathing
and your outbreath be the shining of ice.
May your mouth contain the shapes of strange words.
May you smell food cooking you have not eaten.
May the spring of a foreign river be your navel.
May your soul be at home where there are no houses.
Walk carefully, well loved one,
walk mindfully, well loved one,
walk fearlessly, well loved one.
Return with us, return to us,
be always coming home.

- Ursula K. Le Guin

From Always Coming Home (Harper & Row, 1985)