Health Reform and Post-Truth Politics

As a physician, I have a hard time understanding post-truth politics.  Wikipedia defines the post-truth culture as “a political culture in which debate is framed largely by appeals to emotion disconnected from the details of policy and by the repeated assertion of talking points to which factual rebuttals are ignored. . . (it) differs from traditional contesting . . . falsifying of truth . . .(is viewed as) . .  . of  secondary  importance.”

I live in a world where the absolute values of lab tests such as INR levels, (prothrombin time (PT) is a test used to help detect and diagnose a bleeding disorder or excessive clotting disorder; the international normalized ratio (INR) is calculated from a PT result and is used to monitor how well a blood-thinning medication is working to prevent blood clots); ejection fractions, (which is a measurement of the percentage of blood leaving the heart each time it contracts), Creatinine levels, (used to assess kidney function), and Hemoglobin levels (hemoglobin is the substance in red blood cells that carries oxygen), affect function, quality of life, and the potential life or death for my patients. I live in a world where for my geriatric patients, the commonly accept truth of gravity plays a huge role in falls. I spend much of my time as a geriatrician trying to prevent falls and treating the outcome of falls. In my 32 years of practice, I have seen how details of policy and falsifying of truth have tangible consequences.

Mortimer Adler, who died in 2001, was a philosopher in the Aristotelian and Thomistic traditions. He was the Chairman of the Board of Directors of the Encyclopaedia Britannica and Co-founder of the Center for the Study of Great Ideas. He wrote many books regarding what he called the Great Ideas, including a book called Six Great Ideas. While on the Encyclopaedia Britannica project, he worked with a principal professor of mine at the University of Notre Dame’s Program of Liberal Studies, a Great Books Program, the late Dr. Otto Bird. In this book, he wrote a chapter entitled, “The Pursuit of Truth,” where he made a distinction between truth and taste. He said “While the complete realization of the ideal that is the goal—the whole truth and nothing but the truth—will never be achieved in any stretch of time. We find that experts who are competent to judge—mathematicians, scientists, historians, each in their own departments of learning—have reached agreement about a host of judgments that they have come to be regarded as settled or established truths in their respective fields.”

Separately, regarding taste, he uses Latin, “De gustibus non disputandum est” or “About matters of taste, there is no point in arguing. Disputes are fruitless. . . On the contrary, we should wisely live with and gladly tolerate difference of opinion that express divergent tastes.” Finally, he said, “I am only saying that we should never abandon our effort to reach the agreement we ought to seek in all matters that fall within the sphere of truth rather than the sphere of taste. To give up is to abandon the pursuit of truth.”

In the Post-Truth Politics of 2016, we are told that we can eliminate the individual mandate of the Affordable Care Act (ACA) and substitute it with a world of voluntary individual insurance and high-risk pools with no loss of patients’ health or lives.

This week one of my patient who I have written about before on this blog came in for her annual exam.  She is a 57-year-old patient who has Type 1 Diabetes and due to her severe eye disease, she required frequent injections that cost $3,000 per injection. For years, she has been in the State of Iowa High-Risk Pool Insurance Program which has helped her pay for those injections, but then and now this insurance program does not pay for screening colonoscopies which an ACA-compliant policy is required to pay for.  My patient has chosen to stay in the High-Risk Pool against my advice and because of cost, has never had a screening colonoscopy. In the post-ACA world of the future, due to the cost, neither the individuals who do not have an individual health insurance policy nor those with an Iowa High-Risk Pool insurance policy will likely have screening colonoscopies.

According to Mortimer Adler’s definition of truth, where truth is determined by a collective group of appropriate experts, screening colonoscopies with the removal of pre-cancerous polyps will save people from a cancer diagnosis and potentially from dying from colon cancer. This is not a matter of taste; it is a matter of truth. I believe details of public policy matter.  Post-Truth Politics may use emotions to divide the electorate for the purpose of elections but the consequences of Post-Truth Politics will not save people’s lives. I hope we quickly advance beyond the age of Post-Truth Politics.

John Adams once said, “Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the facts and evidence.” As a physician, a husband, a father, grandfather, and a hopeful American, I would have us listen to Mortimer Adler and John Adams and continue to pursue truth.

Health Reform and Pre-existing Conditions

I was tempted to titled this blog entry, “Health Reform and ‘I won’t let people die in the streets.” I also was tempted to describe the November 8 election as the day health reform died. One retort could be that the Republicans are now in charge of health reform. They need to play offense as oppose to only playing defense. And, we should move forward.

For starters, let’s discuss the dual action of repealing the Accountable Care Act (ACA) and maintaining the Republican pledge not have individuals with pre-existing conditions be excluded from health insurance in the post-ACA world.

Making health insurance available to individuals with pre-existing conditions provision is one of the key pieces of how health reform works or does not work.  The choices available for the country are single payer or private insurance with an individual mandate. The choice is not high-risk pools which, even in a well-insured state such as Iowa, did not work in pre-ACA days. Unfortunately, high-risk pools appear to be in strong consideration if one reads  proposals from Speaker Paul Ryan and the nominee for Secretary of Health and Human Service Tom Price. High-risk pools concentrate very sick individuals in a single category that will be extraordinarily expensive. Even worse, in a world of employer group health insurance, individuals without a mandate and without a business connection will avoid buying health insurance or will not be able to afford health insurance and will go without health care coverage. We will go back to the days of uninsured patients, free medical clinics, delayed medical diagnoses, and lack of early diagnosis now made possible by preventive evaluations.

I have live at a time when my previously insured patients, patients I was seeing in a free medical clinic; or one of my diabetic patients in Iowa’s High-Risk Pool were not receiving top-notch health care due to the cost. I had patients coming in to see me too late with health conditions I could have resolved in my office had I seen them sooner.

What to do? As I said in a previous post on this blog, my first proposal would be to open up Medicare to individuals 55 years of age and older. I have also said the ACA needs to be “tweaked,” not eliminated.

This is the time to speak out for a future that moves health care forward for all Americans. We cannot go backward. Twenty million people now have health care insurance because of the ACA. More Americans are now insured than ever before. We need to continue to move health care forward. Speak out. We all must do it. We all must do it now.