Why was Obamacare necessary? Christians, it seems.


nyt-flowers-medicine-bw{abstract: My point in this post is pretty simple. Christians seek radical end-of-life care dramatically more than non-religious people, and this accounts for a huge portion of American Health Care cost. In this piece, I ask if this drove prices up, therefore creating the situation where, ironically, Obamacare (a policy Evangelicals widely despise) was necessary.}

I wrote a while ago about my own current preoccupation with my fear of death. It caused me to read several related things, including the amazing book, The Art of Dying. In it, Rob Moll carefully helps guide Christians back toward embracing death for what it is: our greatest enemy, yes, but an enemy whose sting has been turned into a doorway to Glory Itself.

And so, as the horror-turned-beauty that Death is, the book encourages us to spend our energy preparing for Death more than avoiding it. He encourages Christians to recapture the doctrine of the “good death”.

And yet, it seems that American Christians are prone to do everything but that.

Moll talks of a study published in the Journal of the American Medical Association that found that Christians were three times more likely than those without religious faith to pursue aggressive end-of-life care, even though they fully understood they were dying and that the treatments would most likely not add any time to their lives.

One researcher told Moll, “patients who received outside clergy visits had worse quality of death scores than those who did not.” And if you have problems with this particular study, know that the book is full of research, studies, and interviews that lay out the pretty clear case that American Evangelicalism widely avoids preparing for death.

Now, we can talk about why this is and whether or not this is a sound Christianly posture another day (I happen to think it is not). Hopefully I’ll write a full review of the book in the weeks ahead. Today, though, I wanted to point out a huge irony this made me think of.

In March 2010, after months of some of the most fascinating politicking I’ve seen in my lifetime, President Obama signed the Affordable Care Act (“Obamacare”). The whole point of the bill is to lower the costs that Americans pay for health care in America. And indeed, American health care prices are absolutely insane.

Studies have tried to figure out why this is. There are many theories, and so the best studies I was able to find were those that debunked common ideas. It’s not research or innovation or amount of care; it’s not even quality of care, technology, or “lack of competition.” Why does it cost so much in America? As this study summarized: “it’s the prices, stupid.” (By the way, read the article that link goes to. It’s so helpful.)

It seems that when you create a private market that everyone is guaranteed to want and use, and you don’t really have any mediating third-party actor to negotiate on behalf of consumers, the Invisible Hand, for many of us, turns into the Invisible Backhand. The prices are higher simply because insurance companies and hospitals have been able to set those crazy prices with little or no incentive or restriction not to.

So why are health care prices able to be set so high? In this study by the American Heart Association looking at the final care of patients that died similarly and evaluating the costs, they said this (emphasis mine):

Because all patients had the same fatal outcome, the authors believe that the extra care provided at high-cost centers was unrelated to illness severity and therefore unwarranted. On the basis of prior work, they also believe that such care generally is physician mandated and supply and profit driven such that, if all physicians were trained and incentivized to practice [efficiently],… billions of dollars would be saved without sacrificing quality or outcome.

In my reading of this and other studies, it seems to me that the health care industry is able to set crazy prices because (1) there’s nothing stopping them from doing it, and (2) demand has created an in-grained supply-side surplus. In other words, when people want health care as much as we do, the unregulated markets respond by providing it and charging a premium comparable to our desire to use it. The prices are set by how much we are willing to pay to get it.

So where is the source of this huge demand that brings prices up? End-of-Life care. Check these stats out:

A quarter of Medicare is spent on the 5% of beneficiaries in the last year of life. 40% of Medicare money cover the last month of dying individuals. 10% of Medicare recipients make up 70% of total costs. In more than 40% of households with someone in their last five years of life, the medical bills from just those five years are more expensive than all of their financial assets combined (so much “fiscal conservatism”).

What’s also interesting is that these percentages have not really changed in over 30 years! This tells me two things: (1) Neither regulation nor technology costs account for these prices, and (2) something deeply-ingrained into the American psyche is what drives these costs. What is it?

I think it’s Christianity. Or more precisely, Evangelicalism (thought this is just my intuition. I have no evidence for that level of specificity. I could be wrong.)

Since Christians are three times more likely to pursue extremely-aggressive, extremely-unfruitful end-of-life care than non-religious individuals, it makes sense to me that these individuals, adding this level of price-distorting demand, are in large part responsible for America’s price disparity in health care. A disparity that brought about Obamacare.

In fact, in this climate of such high demand from this Christian end-of-life group, the only realistic policy suggestions for lowering health care prices sound a lot like what’s in Obamacare.

And yet, Christians are overwhelmingly more against Obamacare than other groups.  In my assessment (and limited economic understanding), then, it seems that decades of there being a lack of an American Evangelical emphasis on the “good death” with dignity and confidence, that American health care costs have become so high, creating the need for health reform in the first place.

What do you think? For all my economist friends out there, have I got this right or am I missing something? Let me know your reaction in the comments below.

P.S. If you want to know my views on health reform: I personally think that the Affordable Care Act is a truly untested hybrid model, and no one genuinely knows right now what it will do in the long run. I used to think that it was a give-away to the private insurance companies and really just continued that status quo. But the closer we get to its full implementation, the more I’m optimistic and fascinated to see how it works out.

I think tying health insurance to employment was the worst thing to ever happen to health care, and it was a backward way–through tax benefits–that the government has been subsidizing health care for the employed and rich for decades now (with no Republican outcry).

I personally would be okay with a fully privatized, free-market, “crossing state lines” (though that wouldn’t affect much at all) sort-of health insurance system, completely untethered from employment, as long as it was set up next to a non-profit “public option” that would compete on equal footing with the private companies. I would also be okay with a single-payer option with a minimal standard of care for all, and then converting the current insurance industry into an industry of supplemental insurance providers for more specialized packages of care. 

[image credit: Illustration by Maëlle Doliveux, and found on this related New York Times letter to the editor]

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7 thoughts on “Why was Obamacare necessary? Christians, it seems.

  1. Really Paul? Should I even bother to ask how you determined that those who are driving up health care costs with end-of-life treatments are truly followers of Christ? Should I even bother to mention how my own experience as a pastor who often cares for dying Christians has led me to a vastly different view of the Evangelical Christian when he or she is facing death?

    I think you should apologize to Evangelical Christians for even writing such a post.

    And, so that no one will think that I have anything personal against you, let me thank you publicly for the advice that you gave me regarding one of our church members who recently went through a moment of crisis. Your advice was extremely wise and it proved to be such a blessing to that you g man and his family. Peace to you my friend, but give your fellow Evangelicals a break.

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    • I’ve got to say, I’m pretty confused by the edge in your comment. I don’t know what you think I was saying. I guess I could understand it if you really saw Obama care as some sort of inherently wicked thing and that I was saying that Christians were bringing about evil. But I don’t. It’s just a political policy they (generally) don’t like (although the margin of dislike is only like 60%–nothing especially overwhelming) and I find it ironic, is all. Is that where you’re coming from? If so, then the disagreement is political and not moral, and so it doesn’t need the weight you place on it.

      Outside of that, I don’t know how you took this. As an attack on people that don’t want to die? Absolutely not–I’m one of them. I have a great fear of death that I wrestle with a lot. That they are inherently hypocrites for opposing a policy that they may have help create the need for? No, none of us see the possible policy implications of our actions in the moment, and those personal decisions should not be judged by what possible policy might come out of it Are Christians bad for seeking end-of-life care? No, God has gifted humans with the capacity to research and find ways to sustain this gift of life for longer and longer periods. Am I saying that Christians are irresponsible and if they were “true” Christians they’d forego end of life care? No! That’s a personal moral and theological decision. I was merely writing about the economic and policy side of it. I wasn’t at all getting into the ethics or theology behind this.

      As far as who are the “real” Christians, I don’t know what to tell you. The book (which by the way, is one of the most pastorally sensitive and sound books you’ll read) lays out the clear case that the American Evangelical Church has greatly diminished the idea of “dying well” and has wholesale embraced a radical avoidance of death disproportionate to the rest of the world or other groups. It’s pretty stark. The book is FULL of studies and interviews and statistics to this effect. I suppose someone could say “well they don’t represent me!” Okay, Great. But this wasn’t just some random one-off survey. This was a full-on study, walking people through the process of treatment and death. It wasn’t really your standard robo-call that asks “are you a Christian?” It wasn’t that simple. It was deeper than that. If you still want to say “well we don’t know that they were Christians!” Then I’d say (1) that doesn’t change the broad American Evangelical avoidance of death that this study is simply a REFLECTION of, and (2) it represents an incredibly insensitive place of distrust, undue skepticism, and scrutiny of people in their final days–not a group that I’ve known to simply give pat, routine answers religious demographic questions.

      And lastly, I’d be fascinated to hear how your view has “drastically” changed of the Evangelical when they’re facing death. What was it before? What changed it? Where is it now? Is it uniquely “Evangelical” or does it apply to ANY Christians?

      Thanks for the comment.

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      • Oh, and I know plenty of secular progressives (and Christian ones) who REALLY support Obamacare and would see it as a great good that Christians may have brought this situation about. So again, I don’t understand what particularly frustrated you.

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      • I think he may be reacting to the idea that Christians in particular are (to put it bluntly) refusing to die and hanging on. I may have misread, but I think you used that as an assumption to the post and did not argue it?

        I’m not really sure it matters for the argument of your post, and I thought it was well written.

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  2. Paul, I find the statistics you present fascinating – I had not heard that before about Christians. Certainly end of life care is a significant aspect of what is driving up healthcare costs. And I think you rightly point out how insane the law is that employer provided health insurance has tax benefits but individually purchased health insurance does not. (How that is still the case is mind-boggling depressing to me. Talk about unambiguously unfair.). I would just add that there are other aspects of the healthcare system that are also contributing to the increase. For one, the private market is not really working well. There have been recent articles in the press about how widely the costs of procedures vary (by multiples, not a few percentage points) from one hospital to the next, for instance. There is also the argument that healthcare, as a percentage of GDP, should actually rise over time. Medical care is very labor intensive (it’s hard to find economies of scale, etc.), so you don’t get the dramatic cost drops due to efficiency you see in other sectors. As I understand it, Obamacare actually tries to address some of this issue by giving more responsibility to other health care providers, such as Nurse Practitioners (i.e., “physician extenders”). This in effect provides physicians leverage (although they have traditionally fought against reforms like this because to some degree, other providers represent a competitor). Anyway, there are other factors as well, but I though I’d just throw this out there. BTW – I have also come around to reluctantly support Obamacare. I’m sure there will be turbulence along the way, but it just makes sense. Much like we have to have car insurance to drive, some form of universal health insurance just makes sense. You shouldn’t get health insurance when you are sick, just like you don’t get car insurance once you have an accident. Even young, relatively healthy people can get hit with a terrible and expensive illness completely out of the blue.

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  3. Two main things: Chargemaster <that is a biggie,

    http://healthland.time.com/2013/02/20/bitter-pill-inside-times-cover-story-on-medical-bills/

    http://content.time.com/time/magazine/article/0,9171,2136864,00.html

    It used to be a free article for awhile, but idk if you can find it for free now.

    Also, catholics are, I hear, quite obsessed with death, moreso than evangelicals even.

    "I think tying health insurance to employment was the worst thing to ever happen to health care"

    Somehow I get the feeling you don't know how health insurance started. The reason that it is that way is because that is the legacy from how it got started and there has never been the political will to stop it in this country. Remember, the insurance industry wasn't created by the government back in the 20's or something. The insurance companies were private companies that started up, and the usual people that could afford their services were large companies looking out for their valued team members and trying to attract the most skilled workforce. Back then healthcare certainly wasn't a "right", hardly anyone was getting any care period. Today we have this vision of universal healthcare because many countries have gone to lengths to provide it but the tying of health insurance to employment wasn't the worst thing to ever happen to health care, because that was the only reason common people started getting an appreciable bit of healthcare in the first place in this country.

    In any event, get rid of the chargemaster, adopt a psuedo japanese (perhaps mixed with french) model, and all is well. Except the insurance companies take a huge hit of course and our whole economy probably takes a dive. You know, there is that.

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  4. Also, I have to ask Paul, what exact perspective on death would you expect from a death religion? One that was wholly unconcerned with it, or one that focused on it all the time? Spend every Sunday being reminded about how someone died for you, and that will tend to stick in your head I’d think. Not to mention reminders about avoiding hell, and needing to save others from that dastardly place that is mentioned all of a handful of times in the whole bible.

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