Tactical Ninja - Thoughts on the public good and why half-and-half healthcare doesn't serve it
Jul. 18th, 2014
10:16 am - Thoughts on the public good and why half-and-half healthcare doesn't serve it
So I got a letter last night from the rheumatologist. To summarise, they are underfunded and only taking 'the most urgent' cases. They regret that they can't offer me an appointment. They realise that this will probably cause me some distress, but they wish to be honest, and I should go back to my doctor to discuss my options.
This is the first time in my life I have ever been refused a health service. I have, previously, been put on waiting lists for non-urgent specialist care, but never before have I experienced the feeling that goes with "We are not going to help you at all, ever."
Now, I am one of the lucky ones. Financially, I'm in a position where I can afford to see a specialist on my own dime. Only just - specialists are expensive - but I can, and it won't mean going hungry or getting behind in rent. I consider myself to be privileged in that sense. I actually do have options to discuss with my doctor at $65 a pop. If I were poor, I would probably be screaming right now.
Which brings me to a question. What exactly constitutes 'the most urgent'? Is it people with higher counts of antibodies than me? More symptoms than me*? Or people whose health records show they qualify for a community services card and therefore could not afford to pay for private healthcare? My guess is that it's probably a combination - perhaps if I were poorer I'd get an appointment, or if I were more immune-full I'd get an appointment.
Either way, I don't get an appointment, unless I shell out to go private. Do I need to pay another $65 to see my doctor to find out my options?
1. Don't take it any further, wonder forever what the fuck's wrong with me, put up with symptoms.
2. See doctor, decide to investigate other options without seeing specialist.
3. Pay out of my own pocket to see a private specialist.
At this point I will probably go with 2. I have a couple of ideas for things that could be looked at before going down the RA/lupus track. I'd like to do that without the exorbitant fee if possible.
It's nice to have options. It's also kind of nice to know that they are still taking 'more urgent' cases than mine. But it really bothers me that I was refused state healthcare, and that my refusal is based on underfunding. See here's the thing.
I pay tax. I pay the most tax you're supposed to pay in a graded tax system. I'm one of those middle class they keep talking about - high income, high tax, but not able to dodge tax like a business owner is able. I pay more tax than the rich, generally. I have a fair amount of disposable income, but the fact remains that I'm in the highest tax bracket and thus pay more into our shared pool than many people. I don't begrudge that. In fact, I've often said I'd happily pay more tax if I knew it were going to be used for things that make everyone's life better - like education and healthcare.
I'm one of those wankers that buys the top-tier-cost ticket to Kiwiburn because I believe that those who can afford to, should. I quite like that in our socialised healthcare system, I pay more for the doctor because I can afford to pay more, and someone with less income pays less. I think that's as it should be.
The problem, for me, is that our healthcare system (and education, but that's a different rant) is becoming less socialised. We still all pay into a coffer, and most healthcare is still subsidised, but we have this weird hybrid system where you can choose to pay for health insurance and that allows you to jump the socialised healthcare queues for non-urgent things by going private. This means that since the 1990s, private hospitals have sprung up everywhere. The government, meanwhile, seems happy to continue to shove its head up the US's arse and this is threatening (through the TPPA) our subsidies on medication. I found out from the lady who took my blood the other day that the government is 'urging' doctors to request fewer blood tests - blood tests being one of the few things that's still completely covered. She thinks it's a precursor to bringing in user-pays on that as well.
So why is this a problem for me? I mean, apart from the obvious thing that the US has the most expensive and least effective healthcare system in the Western world, so copying them is just stupid, I mean.
You know what I was saying about the upsurge in private hospitals? Well, they are being used by very specific groups of people - those with insurance, and those with the income to pay up front. In other words, people with disposable income. Or, to put it another way, the well-to-do. You don't have to be quite as well-to-do to have medical insurance, but you have to be able to afford the regular payments and that cuts out anyone earning below about $40,000 (which is more than half of the country, btw).
So you end up with two separate health services - the one used by the wealthy, and the one used by the poor. The wealthy have a choice whether to go on a waiting list for the funded service, or to get seen quickly by paying extra. The poor have no such choice.
Now you'd think this would be a good thing because it'd take the people who don't really need the subsidy out of the public system and leave more spaces for those who really need the help. But I get the feeling that what is actually happening is that the government is using the increased usage of private healthcare by the wealthy as a justification for reductions in funding to the public system, in the guise of 'streamilining' services. So the more people like me who end up going private, the less the government gives to fund public rheumatologists, so the fewer people they can see, so the higher they put the benchmark for how sick you need to be to get seen, so the more people like me end up going private and altering the usage stats..
You can see where that leads - to an underfunded public system that is refusing healthcare to people who are paying into it, which forces them to pay again for private healthcare. Thinking about this situation is the first time I've felt resentful towards our public healthcare system - because while I'm happy to pay my share, or more than my share, the minute I'm told that I'm not going to receive a service *at all* for my money, I start to wonder why I'm paying.
I'm not stupid, and I like to think I'm compassionate. I'm aware that my Mum used far more dollars' worth of healthcare when she was sick than our entire family probably paid into the system. I'm glad that my 'place' at the rheumatologist is going to be given to someone who needs it more than me. But I'm not representative of people in general. Many many people, especially it seems rich people, would simply go "I am paying for a service I'm not getting, and I don't want to keep paying for it." So you get tax dodgers, which reduce the tax pool, which reduces the amount given to the public health system, and so on and so forth.
Sound familiar? The development of separate health systems - a good, effective and timely one for those who can afford it, and a slow, underfunded and overworked one for everyone else. It's like every dystopian future movie ever. And we're doing it to ourselves by having a half-pie socialised healthcare system that allows rich people to pay for better treatment.
Oddly enough, I finished Michael Sandel's book Justice yesterday. The book essentially discusses three main ideas of what justice is:
1. Justice is doing the thing that has the most utility (benefit) for the most people. Socialised healthcare would normally come under this. So I pay more tax cos I have more money. My money goes to fund the health system, and we all get to use it. It's a small reduction in benefit to me, which provides a larger benefit to a larger number of people.
2. Justice is doing the thing that provides the most freedom. Entirely private (free market) healthcare would come under this. People can choose what level of healthcare they receive, including to not receive any, and they can negotiate for themselves what they are willing to pay for it. Nobody's being forced or coerced into paying for something they aren't using.
3. Justice is doing the thing that is most in line with the living of a good life. This involves deciding what a good life is, and making moral judgements about what is good and right. This approach is generally avoided by people when talking about political issues, because we struggle a great deal to agree on morals, and it's generally accepted that forcing one's morals on another is 'wrong'.
In terms of healthcare, what does a good life mean? Does it mean that everyone gets the healthcare they need regardless of their income, and everyone is required to pay whether they need it or not? Or does it mean doctors are paid sufficiently well by those who use them to ensure that high-quality healthcare is always available, and people can choose for themselves whether to pay the fees?
I had a really hard time typing that second sentence. Sorry, I'm a filthy socialist, and I firmly believe that we are all in this together, that there is absolutely no such thing as a truly free market, and that if we're going to have socialised healthcare that means we should have UNIVERSAL healthcare. To me, this means that it should be sufficiently well funded that *everyone* gets to use it in a timely manner regardless of income, and that those of us with higher incomes should pay more into it because we can afford to, because looking after each other is the right thing to do.
And this is the basis of my resentment. This half-pie thing we have in New Zealand is not working, because I was refused healthcare that I am paying more than most people for. I am being directed by this system to shun the public good that I put 30% of my income into, and instead to use my privilege of income to pay for more privilege, which separates me further from any vested interest in helping support public health. I am trying to do the right thing, and it's being subverted into the complete opposite of what I believe is a good life.
I can see that someone who was less stubbornly determined to live by their principles than me, would very easily think "Why should I pay into this at all? It's not as if I use it!" and start working out ways to pay less into the public good. And from there, it's not hard to see how a class of wealthy people with zero interest in furthering the public good can become so detached from the concept of shared wellbeing that they no longer feel any sense of social responsibility - which leads to being completely ok with some people being unable to have the same access to quality of life that they themselves have.
I think Sandel is right. There are some issues that can't be effectively discussed without including moral judgements about what is right and good. And in my opinion, 'the good life' is one where we are all invested in each other's wellbeing, where we share difficult burdens and where those who have advantages use them to make everyone's life better. I would happily pay more tax if I knew it were going to make sure everyone gets to see a rheumatologist when they need one. But everyone includes me, and our system is excluding me because the tax I pay is not going to universal healthcare. It's going to fly ministers to the US to discuss dodgy trade deals - made by people who can afford to go private - that will put healthcare even more out of reach for most kiwis. But probably not me, because I have a high income. So that's ok, right? Because choice is justice!
I don't think the current managers of our healthcare system have the same view of what is good as I do, somehow.
* I have had moments since I got that letter in which I've berated myself for being a hypochondriac. Maybe I'm not really sick enough to warrant wasting valuable healthcare resources finding out what's wrong with me. But then I remember that I've been waking up in pain every day for the last 10 months - pain bad enough so that I've on occasion needed help to get dressed - and that the only reason that right now I feel ok enough to question myself is because I'm taking twice-daily doses of a medication that'll eventually destroy my stomach. I deserve healthcare. I have to keep telling myself this.