Opinion: Moral hazards and the health care debate


Last week, many of us followed with much anxiety the Supreme Court debate about the constitutionality of the Affordable Care Act, referred to in some circles as “Obamacare.”

Of great interest to the average American was the challenge to the requirement that almost all Americans have health insurance coverage. This requirement is needed, economists say, to avoid the situation of “moral hazard”—in this case, the possibility of people putting off buying insurance until after they get sick, thus driving up costs for everyone else. If, however, everyone buys insurance before they actually need it, the risk is spread among sick and healthy alike and premiums are lower.

There are also other “moral hazards” the new law seeks to address. One of them is how to ensure that millions of Americans who are too poor to buy it even with subsidies will have health insurance when they need it.

Those are the people who would continue to flood emergency rooms with problems that could have been treated before they reached expensive crisis proportions. They are the people who lack the resources for routine screening and preventive care, and so develop diseases and conditions that shorten their lives and cause them and their families undue pain and suffering. And they are the ones who are counted among the estimated 45,000 people a year who die sooner because they lacked health insurance.

Our system’s historic inability to provide for all of these people as contributing members of our human society is a moral failing for us all.

The new healthcare law’s answer to this moral dilemma was to require that Medicaid expand from the groups now covered—poor children, pregnant women and the elderly poor in need of nursing care—to all Americans whose incomes fall below a certain level. This expansion to 16 million more people would be financed entirely by the federal government at first, and would eventually require a small contribution from the states if they want to retain the Medicaid program in its entirety.

To the surprise of most legal observers, the Medicaid expansion became the second major constitutional challenge to the law. The Supreme Court chose to hear a challenge by 26 states to that expanded funding, even though the challenge was rejected by all the lower courts.

In the Supreme Court debate, it became clear to all that a conservative block of justices was seriously contemplating reversing the constitutional support not only for the Medicaid expansion but also for similar federal-state programs that have been in place for 75 years.

This is the true moral hazard in the challenge to the Affordable Care Act—the idea that the federal government can do nothing on the scale that is required to ensure that all Americans have access to health care. Furthermore, the even broader danger is the notion that the federal government should not be able to provide money to states with a required match in state funding, no matter the proportion, for anything including transportation, education and many other program categories that rely on federal-state partnerships.

Our view of our responsibility to one other cannot be so constrained or we will surely be back where we started when this whole debate began.

During the upcoming Passover Seder, as we begin to tell the story of our transformation from enslavement to a free people, Jews everywhere will lift up the matzah and say, “This is the bread of affliction, which our ancestors ate in the land of Egypt. Let all who are hungry come and eat. Let all who are in need, come and celebrate Passover.” This invitation reminds us that both in our suffering, as slaves in Pharaoh’s land when we remember our oppression and hasty exodus, and in our joy of redemption when we cross the Red Sea to the Promised Land, we have an obligation to remember those in need around us.

Surely in this modern world, that obligation includes finding a way to provide health care to those in most need around us. In the spirit of Passover, let’s remember those who have been left behind because of inadequate access to quality health care and envision a future that avoids “moral hazards.” And let’s all who are in need of help reach the promised land.

Nancy K. Kaufman is the chief executive officer of the National Council of Jewish Women.

Jews Should Oppose Universal Health Care


In part of an ongoing debate on health care reform, JewishJournal.com is hosting this dialogue on the pros and cons of universal health care.

Related: Why we must support universal health care

From BeliefNet.com:

In the always lively Jewish Journal of Los Angeles, Rabbi Elliot Dorff writes in a cover essay that “support for universal health care is an imperative in Jewish law.” Is it now? On health care reform, Rabbi Dorff has his classical sources all lined up—most having to do with obligations on the community to rescue its needy, the captive, and those otherwise endangered. The communal court system can compel a person to give charity in support of the poor. Proper medical services are a necessity in a Jewish community. And so on. Whether through socialized medicine or government health insurance, something must be done: the fact of there being 40 million uninsured Americans is “intolerable.”

Do you notice how many times the words “community” or “communal” appear in the foregoing paragraph? Rabbi Dorff is chairman of the Committee on Jewish Law and Standards of Conservative (i.e., liberal) Judaism. He knows that Jewish laws of the kind he cites are specifically communal laws. They were never envisioned as applying en masse to a non-Jewish country of 300 million people. Liberal Jewish analysts often lose sight of this simple fact. So too in the abortion debate where, simply put, Jewish law for Jews is more liberal on abortion than Jewish law for Gentiles. We are more protective of the unborn non-Jewish life. In Torah, there are separate legal tracks—the Mosaic and the Noachide, for Jewish and Gentile communities respectively. Yet liberal Jews invariably cite Jewish abortion law, not the Gentile one which makes abortion a death penalty offense. They forget that we live in a non-Jewish country.

Read the full story at BeliefNet.com.

Why We Must Support Universal Health Care


Related: Jews Should Oppose Universal Health Care

Whether or not we are believers in the Obama plan, or any of the particular plans for universal health care currently winding their way through Congress, support for universal health care is an imperative in Jewish law. Although what is available in medicine and its cost have changed radically, particularly over the past century, the fundamental right to receive good care — and to be compensated for giving it — goes very far back in our heritage, though perhaps, ironically, not all the way to the Torah or even the Mishnah.

When physicians could not do much to heal a sick patient, their services were easily attainable, relatively cheap, and, frankly, not much sought after. “The best of physicians should go to hell,” the Mishnah says, reflecting people’s frustration in the second century C.E. with doctors’ inability to cure. 

With the advent of antibiotics in 1938, as well as other new drug therapies, and, especially, new diagnostic and surgical techniques, however, there has been an immense increase in the demand for medical care, precisely as it has become much more expensive. This raises not only the “micro” questions of how physicians should treat a given person’s disease, but also the “macro” questions of how we, as a society, should arrange for medical care to be distributed. It is precisely this argument that is taking place in town halls and in the halls of Congress these days, sometimes in rational arguments but all too often in shouting matches that are clouding the real issues.

Jewish tradition imposes a clear duty to try to heal, and this duty devolves upon both the physician and the society. Jewish sources on distributing and paying for health care are understandably sparse, however, because before the 20th century, medical care was largely ineffective and inexpensive. The classical sources that describe distribution of scarce resources and apportioning the financial burden for communal services deal instead with questions like providing for the needy or rescuing someone from captivity, from highway robbers or from drowning. Still, those discussions raise moral problems and suggest solutions that are often similar to those associated with scarcity and cost in modern medical care. 

One set of issues is this: Who should get what when medical interventions are scarce and/or expensive? The other set of questions is this: Who should pay for health care? I discuss at some length the answers that emerge from the Jewish tradition to both of these questions in Chapter 12 of my book, “Matters of Life and Death: A Jewish Approach to Modern Medical Ethics” (Jewish Publication Society, 1998). I will share here a general sense of how the Jewish tradition responds to these questions, which are at once so ancient and so contemporary. (For specific source references, visit this article at jewishjournal.com.)

The Distribution of Health Care: Five Criteria for Triage

If particular forms of medical treatment are scarce or expensive, who should get them? Although this question of triage is most dramatic when the decision is one of life or death, it affects the quality of people’s lives in less threatening situations as well. Who, for example, should get a hip replacement when society cannot afford to provide one for everyone who needs one? Who should have the benefit of a heart bypass operation or transplant, and who shall be denied that? Which AIDS patients should get the regimen of drugs now available to lengthen their lives, and for whom is that just too expensive? In the High Holy Days liturgy, “who shall live and who shall die” is God’s decision; but with the benefit and responsibility of today’s technology, we find ourselves all too often in the uncomfortable position of having the responsibility to decide that ourselves.

The rabbinic passages that might give us some guidance about triage go in five different directions:

Social hierarchy. One passage in the Mishnah determines priorities on the basis of the victim’s position in the hierarchy of society — with knowledge of Torah trumping all other social stations.

Close relationship. Jewish laws on charity provide a second reservoir of precedents that may guide the provision of health care. In concentric circles, you are most responsible for yourself first, then for those closest in relationship to you, then for the rest of your local Jewish community, then for all other Jews, and then for all other people. 

A hierarchy of social needs. A third set of sources we might use as the basis for a Jewish ethic of the distribution of health care concerns the prioritizing of the community’s duties to fund specific needs. The Shulchan Arukh specifies the order of preferences as follows: “There are those who say that the commandment to [build and support] a synagogue takes precedence over the commandment to give charity [tzedakah, to the poor], but the commandment to give money to the youth to learn Torah or to the sick among the poor takes precedence over the commandment to build and support a synagogue.

One must feed the hungry before one clothes the naked [since starvation is taken to be a more direct threat to the person’s life than exposure]. If a man and a woman came to ask for food, we [Jews acting in accordance with Jewish law] put the woman before the man [because the man can beg with less danger to himself]; similarly, if a man and a woman came to ask for clothing, and similarly, if a male orphan and a female orphan came to ask for funds to be married, we put the woman before the man.

Redeeming captives takes precedence over sustaining the poor and clothing them [since the captive’s life is always in direct and immediate danger], and there is no commandment more important than redeeming captives…. Every moment that one delays redeeming captives where it is possible to do so quickly, one is like a person who sheds blood.”

The Shulchan Arukh recognizes the varying needs of the community — physical, educational, religious and social. Each can be easily justified in terms of broader Jewish commitments to life, human dignity, worship and other religious expression, education, economic solvency and close social ties. Consequently, if one were to create a contemporary list based on these Jewish values for funding communal projects in the United States, it would probably closely resemble the Shulchan Arukh’s list. Saving people who are threatened by human attackers would clearly come first, followed by providing food and clothing to prevent disease, followed by some order of curative health care, defense, education, culture and economic infrastructure.

The dream of a beautiful bat mitzvah — but whose dream would it fulfill?


For my daughter to have a bat mitzvah would be a dream come true — but for whom, for her or for me? Throughout my life, people have told me that I am only half Jewish, as my father is Jewish and mother is Japanese Buddhist, although Reform Jews now recognize children of Jewish fathers as Jews. I remember my own childhood as a series of colorful feasts of Jewish and Japanese tastes. But I still hunger for more meaningful cultural and religious traditions, as I had no formal rites of passage, no opportunity to study for a bat mitzvah or a tea ceremony.

Growing up with a Jewish father and Japanese mother did not mean I visited double the number of temples during holidays, like some special at your favorite restaurant. Instead I watched longingly as Jewish kids celebrated Chanukah and Japanese kids celebrated the Shichi-go-san, a festival for girls and boys that celebrates the 3rd, 5th and 7th birthday. At my house we celebrated Christmas as a secular holiday.

While life in my family was always amusing and entertaining as a multicultural and interfaith family, we sacrificed both cultures and faiths in the interest of supposed peace and avoidance of cultural conflict and disharmony. As a result, the absence of religious and ethnic identity has left me longing for a personal identity I am just now beginning to find.

When I look at my daughters, I see their faces as both azoy shayne and uruwashii, “so beautiful” in Yiddish and in Japanese. I hope they never have to share my experience of being shunned and shamed for not belonging truly to either one culture or another. As a child I found it laborious and dispiriting to explain to Jewish and Japanese kids why I did not look just like them with either perfectly straight or wavy hair.

We celebrated holidays with few customs except culinary ones, with both miso and chicken soup served at the celebratory table. Growing up with Jewish and Japanese parents meant I lived among two distinct cultures, with an identity that was less secure and more obscure. As I did back then, I continue to long for a stronger sense of my Jewish culture, as well as to be considered simply Jewish rather than half.

Since my parents were artists who believed individual faith was a personal decision, even for small children, there are no marked passages to remember. Except if you count the afternoon I wore my grandmother’s silk kimono with my best friend’s prayer shawl to a Jewish deli in Hollywood. OK, I concede, there were no ceremonies — but that was certainly a rite of passage!

I suppose I should listen to sympathetic friends who attempt to console me.

“Saying you’re only half-Jewish is like saying you’re only half-pregnant,” says one. “Even a bit Jewish means you’re one of the tribe!” he continues, as he passes me a piece of bacon.

Remind me not to consult him should I decide to make a kosher home.

Or there is my friend who lists all the “cool” famous people who are half-Jewish, like Sean Penn, Harrison Ford and Gloria Steinem. Even Geraldo Rivera got to have a bar mitzvah, although his mother was Jewish.

My middle daughter looked at me the other day and said, “Mommy, I think I am a Jewish girl. Can I attend Hebrew school like Daddy did?”

“Yes,” I answered, as I kissed her tan, cool forehead. “You are a Jewish girl, and you will know all of the traditions I never did.”

As my daughter will soon turn 10, my husband laments that she has not received any formal Jewish education. Dancing the hora at weddings, watching the Marx Brothers and trying on his yarmulke for laughs does not count.

Unlike me, my husband had a bar mitzvah when most ceremonies were still respectable, unlike a bat mitzvah I attended in which I couldn’t figure out which person on stage was the rapper for hire or rabbi for hire. Maybe they were the same person.

I can think of no parent who does not wish more for their children than they had, but I remain in a quandary: Do I wish my girls to have a bat mitzvah celebration because I missed out, or for more honorable reasons? Many American Jewish families consider having a bar or bat mitzvah to be the sole experience of their children’s Jewish education, a symbolic occasion securing them in the Jewish tradition.

Indeed, I have decided this is a gift I will give to our daughters, who are confident that they are Jewish and deserve to study in the traditional way all the more. Perhaps I am no different than my Jewish sisters and brothers, as I too want to ensure that my daughters feel secure in their Jewish identity, with this celebration a testament to their strong cultural history. The worst that might happen might be that they would study for a few years, receive a little more gelt than guilt and experience a valuable celebration they would neither be able to forget, nor wish to.

In the meantime, I have dreams of what my own bat mitzvah might have been like in laid-back, lackadaisical 1970s Southern California, when many expectations and traditions for children were abandoned, leaving many members of my generation feeling abandonment.

I see myself in a proper but pretty dress from my favorite Sears catalog I used to keep in a drawer by my bed. I am in a beautiful L.A. temple near my father’s Beverly Hills boyhood home and I begin to chant from the Torah in my songbird voice, while both my Jewish and Japanese relatives are verklempt and tokui — overcome with emotion and pride in two languages.

Too many mazel tovs and kisses are given to count, and my lyrical mother gently fixes a velvet ribbon in my hair while my father tells me how proud he is.

After that, my dream is not so clear, although there is some blurry vision of overeating knishes and California rolls simultaneously until I have to lie down, something I am still guilty of today.

Somebody please call the doctor.

Francesca Biller-Safran is an investigative print and broadcast journalist and recipient of The Edward R. Murrow Award. She specializes in political and social inequalities and is currently working on a book about her background. She is married with three daughters, lives in the Bay Area and can be reached at fsafran@hotmail.com.

Reprinted with permission from InterfaithFamily.com.


Beyond sicko


Because this was happening a short taxi ride from the White House, I half expected someone from Dick Cheney’s office to burst in at any moment, grab the
microphone and proclaim the conference kaput, dissolved like an inconvenient parliament.

“I think this may be the best day of my life,” Dr. Julie Gerberding, the director of the Centers for Disease Control and Prevention (CDC), said at the opening of the 2008 Leaders-to-Leaders Conference she convened last week, along with the country’s state and county public health officials. The agenda: To build a bottom-up coalition to change how America deals with health, to shift our focus from health care to healthiness and to the bigger social factors that determine our national healthiness.

Over two days, I heard so many encouraging ideas from the conference stage that didn’t reflexively demonize public policy-making as nanny-statism that, well, as I said, the whole thing left me looking nervously over my shoulder for political-correctness enforcers from The Cato Institute or The Heritage Foundation.

As one speaker after another pointed out, America today ranks first among industrial nations in terms of how much we spend on health care, but last in terms of how healthy we are as a country. Pick any national metric of healthiness — life expectancy, infant mortality, birth weight, chronic diseases incidence — and America’s comparative performance is in the cellar. It’s true even when you adjust for European populations’ relative homogeneity: if you only count white Americans, we are still the low man on the healthiness totem pole.

We Americans spend more than 90 percent of our health dollars on health care (on doctors, hospitals, insurance, machines, pharmaceuticals and the like), but it turns out that only 10 percent of how healthy we are as a nation is determined by what those health care dollars buy.

How can that be? What could possibly determine whether America is among the industrial world’s healthiest nations, if not the thing we’re all clamoring for: universal heath insurance? The answer — and this isn’t a political opinion, it’s an epidemiological finding — lies in the social determinants of our physical condition. Determinants like income, class, education, racism, the availability of public transportation, land-use policy, environmental policy, participation in the political process and a host of other factors that don’t depend on our genetic makeup or our propensity to take personal responsibility for diet and exercise. Determinants that flow not from luck or individual choices, but from laws, regulations and priorities set at all levels of government and in the private sector as well. (If you want an alarming eyeful about this, check out the new California Newsreel documentary “Unnatural Causes.”)

The way we currently think about health in America — about health care, that is — is completely understandable. We all want access to the best possible health care for our parents, our kids and ourselves, and we want it to be affordable, and we want plenty of choices. What’s astonishing is that even if we covered all the uninsured’s health care, we would still likely rank at the bottom of industrial countries for healthiness. The major causes of our country’s healthiness or unhealthiness are all upstream of the things that send us to doctors and hospitals and pharmacies. The causes are poverty, and stress, and the amount of control and autonomy we have at our jobs, and whether there are showers there, and what they put in the vending machines. The causes are access to early childhood education, and to day care, and whether schools are built near asthma-breeding freeways. They are whether your neighborhood offers public libraries and public transportation and walking trails, or public dumps and liquor stores and fast food franchises.

“I had a colonoscopy the other week,” the CDC’s Dr. Gerberding told the 400 public health officials, business leaders and nonprofits she was hoping would sign on to a “healthiest nation alliance.” “Actually,” she added, “I was billed for two colonoscopies, though I’m sure I only had one.”

Clearly she’s not unaware of the madness of our present health care system. No one facing a family medical crisis wants anything but the best possible treatment at that moment. No one should lack access to quality health care. But prevention is even more important to the country as a whole than treatment is, and the free market alone hasn’t and won’t deliver the level of prevention we need.

To me, the underlying reason America has fallen so far behind in the healthiest nation race is the exhausted dogmas that have dominated public discourse for something like 30 years — Horatio Algerism, social Darwinism, the magic of the marketplace, deregulation is good, government is bad, pull yourself up by your own bootstraps and devil take the hindmost.

We now know what America looks like when those kinds of ideas rule, and not only in the health sector. I’m glad that, at long last, public officials are finding their voice to express politically transgressive thoughts, like the idea that income inequity and racism are bad for America’s healthiness.

I just hope that the Ayn Rand Society doesn’t get on their case.

Marty Kaplan is director of the USC Annenberg School’s Norman Lear Center, where some work is supported by the CDC. His column appears weekly in this space. He can be reached at martyk@jewishjournal.com.

For the Kids


UNIVERSAL FUN

Cats, monsters, horses and dinosaurs — you can see all this and more if you head over to Universal Studios Hollywood. You have until Jan. 15 to get in for a reduced price. Buy the tickets through your synagogue or find a coupon in The Jewish Journal!

Things You Know

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Ten Days in L.A.


A Jewish Federation of Greater Los Angeles reception welcomed 18 students participating in a cultural exchange sponsored by the Federation’s Tel Aviv-Los Angeles Partnership. Fourteen students from Tel Aviv’s A.D. Gordon School and four students from their paired partner, Northridge’s Abraham Heschel Day School, gathered to reflect on their experience as the Israeli students — all ages 13 and 14 — wrapped up their 10-day visit to Los Angeles.

"This trip was very important to me, because I actually got to meet the kids I’ve been writing to for four years and see how they live in Israel," Gordon student Maya Levit said.

While in Los Angeles, the Israeli students experienced American culture, both exotic and mundane, including trips to the mall, Disneyland and Universal Studios. The students also took part in some charitable work: half the group participated in helping the homeless, while the other half volunteered at an AIDS Project Los Angeles food bank.

On the penultimate day of their visit, the Israeli teens conveyed their impressions of American culture and of their life in Israel, which is rarely divorced from the ongoing violence and political turmoil. The Israeli students unanimously feel that their country, in recent years, has become isolated and inoculated from worldwide support.

Merav Schechter even considered her stay a diplomatic mission.

"I wanted to get more support for Israel from Jews in L.A.," she said.

"We need support from Jews here, even if they don’t think Ariel Sharon is doing the right thing," Eliran Raz said, to which Gil Asher added, "Israel needs support in the media."

The Israeli students said they were struck by cultural differences with their American counterparts, who seemed more connected to Jewish tradition. Aviv Benn-Sa’ar said he admired the inclusion of religious ritual at their host Conservative day school.

"In Heschel, every Friday they go to beit midrash," Benn-Sa’ar said. "In Gordon, we don’t do it."

Heschel’s students were equally moved by their Israeli pen pals’ visit.

"It has impacted me a lot," said Ali Baron. "Now the situation in Israel is actually more real to me."

"It reinforced for me how every Jew in the world is connected," Daniel Kattan said.

Gisele Feldman learned that Los Angeles was not as religiously polarized as Israel is. "There, it’s Orthodox or nothing," Feldman said.

The Federation reception was organized by Galia Avidar, Tel Aviv-Los Angeles Partnership’s assistant director of Israel and overseas relations. Also present were Judy Taff, director of Judaic studies and exchange coordinator at Heschel, who oversaw the L.A. visit with the help of Pam Teitelbaum, mother of Heschel participant Adam Teitelbaum. Lois Weinsaft, the Federation’s vice president of international planning, heads the Tel Aviv-Los Angeles Partnership.

The Israeli teens were accompanied to Los Angeles by Gordon staff members Maya Mendel and Tal Atiya and Gordon parents Shoshanna Gatenio and Menachem Reiss. Special programs leaders Sara Brennglass and Hyim Brandes also took part.

The Tel Aviv students said that they would leave with good impressions of Los Angeles’ way of life.

"It was a really good experience for me," Tal Erdinast said. "It will change my life forever."