Oak Park Temple
B'nai Abraham Zion

1235 N. Harlem Avenue
Oak Park, IL 60302
(708) 386-3937

L'Chaim: To Your Health - Part One
Yom Kippur Evening 5764

An old stereotype suggests that we Jews are obsessed with our health. Consider the story about the German, the Frenchman, and the Jew. The three were shipwrecked, tossed at sea for three days and nights, with no food or water. And then they landed on a barren, deserted island. The German said: "I'm tired, I'm hungry; I'm thirsty. I really need a beer." The Frenchman said: "I'm tired, I'm hungry; I'm thirsty. I must have a fine bottle of wine." The Jew said: "I'm tired, I'm hungry; I'm thirsty. I must have diabetes."

Yes, it's a stereotype, but in this case, it's one based in reality -- for seeking appropriate health care is not just a Jewish obsession, it's a mitzvah, a religious obligation before God.

When we say a toast, we say, "L'Chaim - to life." But have you ever asked, "why these particular words?" Why not to wealth, or power- or to pleasure, knowledge, or beauty? It is because Life itself is the most central value in Judaism.

Most of us have, at one time or another, been asked, "What do Jews believe about the afterlife?" We answer something like this: "We Jews understand that our relationship and covenant with God is in and for this world. We have been assigned the task of making the most of the miraculous gift of life - of consciousness, of joy and pleasure and meaning - and to help leave this existence a bit better for our having been in it."

Ours is a faith of this world - concerned with the Life with which we have been blessed and our responsibilities and rewards in the here and now. That is why we do not condone asceticism -- because God has placed us in this garden to enjoy its fruits - and to tend it and till it.

The words "L'Chaim" are, in a single phrase, the clearest, simplest statement of what our tradition teaches us to hold most precious.

What, then, is Judaism's commitment to the art and science of healing? And what has Judaism to say concerning the responsibilities of society to provide for the optimal health of its members? What counsel does our faith give us as we grapple with the ever-eroding state of health care in the United State?

In order to organize our thinking about our "sick" health care system here in the United States, I would like to borrow a medical model. I would like to review the SYMPTOMS, then to offer a DIAGNOSIS, then to suggest a course of TREATMENT, and finally, to reflect on the PROGNOSIS. Due to the complex nature of this problem, I believe we will best be served by approaching this discussion in two parts: tonight and tomorrow morning. For tonight, let us consider the symptoms and begin to broach a process of diagnosis. Then, tomorrow morning, on the basis of our diagnosis, I will suggest a course of treatment in keeping with Jewish tradition, and a prognosis of what the future holds.

SYMPTOMS

First of all, a few statistics:

Almost 75 million Americans under 65 were uninsured sometime during 2001 or 2002. The number of people without health insurance shot up last year by nearly two and a half million. The total number of people without health insurance now stands at over 15% of Americans

As of mid-2001, 1 in 5 children in the United States were not covered by any health insurance plan.

The United States has the highest infant mortality of any industrialized country. The United Kingdom, Canada, Germany, and France all have lower rates of infant death.

Except for the United States, all of these countries have some form of universal, national health care or insurance system:

Now I could go on citing statistics for hours, offering a picture of the dark side of the positive health related statistics I shared on Rosh Hashanah evening. But I won't. If we are to be faithful to Jewish teachings, we may not look upon the "symptoms" of our "sick" health care system only from the standpoint of the statistical. The human dimension must not be lost.

Consider this sad story shared by Bob Herbert in the New York Times:

"Donna Marie McIlwaine was 22 when she died on February 8, 1997. She is buried in the Chili Rural Cemetery in upstate Scottsville, N.Y.

Ms. McIlwaine went to the doctor several times in the week before she died, complaining of pains in her chest and shortness of breath. According to her family, she was diagnosed with an upper respiratory infection and ''panic attacks.''

In fact, she was suffering from pneumonia and a blood clot in her left lung. Her mother, Mary Munnings, said that her daughter had been screaming from the excruciating pain before finally lapsing into unconsciousness and dying at home on a Saturday night.

There was no need for her to die. Ms. Munnings said that when she contacted the office of her daughter's primary-care physician the following Monday, she learned that Ms. McIlwaine had not been sent for the laboratory tests that would have properly diagnosed her condition. She said that when she asked why not, she was told that ''they couldn't justify'' the tests to her health maintenance organization.

So we have Donna Marie McIlwaine dead at 22.

And there are tens of thousands of similar stories. In an article in the Journal of the American Medical Association, one physician writes about:

A man came to an emergency room with a sore throat, and after waiting more than 16 hours, left. When seen later, it was determined he had a throat abscess.

A child sent home from school with "pink eye." The child's school administration would not readmit her without a doctor's note, and her parents needed two weeks to gather the money for a doctor visit so they could obtain the necessary note.

A 22 year old man with shortness of breath, a heart rate of 160, and an enlarged heart. He came to an emergency room instead of his usual physician because he had recently lost his job and his health insurance because of frequent medical absences caused by his lupus.

If we are to reflect on the state of our national health care system, we must never let the faces of these flesh and blood human beings become lost behind the numbers we cite.

In her recent book entitled, "Health Care and the Ethics of Encounter: A Jewish Discussion of Social Justice", Laurie Zoloth calls on us to enter into a discussion of the health care crisis in relational terms. That is, the personal encounter with the poor and the dispossessed: the orphan, the widow, the stranger at the gate, the traveler on the road -- and now, in our generation, the uninsured.

Drawing on the writings of Jewish thinkers such as Martin Buber and Emmanuel Levinas, contemporary feminist thought, and, finally, a lovingly careful reading of the Book of Ruth, Laurie Zoloth calls on us to always look upon the Other, to imagine the Other as a real presence before us, making claims on us, asking us to SEE EACH OF THEM. For Zoloth, and for all of Jewish tradition, we must never depart from honoring the infinite value of every human life. From this standpoint, who is to stand before the Other and say no? Not only are they dehumanized, but we, who would refuse them, are simultaneously dehumanized as well.

Always holding the claims of the Other before us, let's look closer to home - to our own congregation. We have members who are ineligible for adequate medical insurance due to preexisting conditions. Then there are members who are eligible for medical insurance, but only for annual rates as high as $20,000 for family coverage. And we have members who cannot pay the cost and go without insurance. Or most distressing of all: the temple family whose toddler had two major hospitalizations and several operations by the age of three. When this child was approaching the one million dollar maximum lifetime benefit on the family's insurance, they were advised that to receive additional coverage, he would have to become a ward of the state.

Now extend the discussion of our failed health care system to the care givers, the ones who daily must look into the eyes of patients. And then say to him or her - limit your time. Don't waste your time on the human, spiritual dimension of healing - just use your skills in the most efficient and cost effective manner. This is the kind of medicine our economy demands.

Consider the decisions of managed care plans in California, Texas and Washington, DC, which have "de-listed" thousands of physicians - both primary care doctors and specialists - based solely on economic criteria. One Texas physician was featured in Aetna's newsletter as "Primary Care Physician of the Month", and thrown out of the plan shortly afterward when he accumulated high cost patients in his practice. Now add to this the impact of our litigious society and the affects of capricious medical malpractice suits and the awarding of excessive compensation.

The impact of the increasing litigation on the ways in which doctors provide health care, or on their decisions to provide any health care, is enormous. Most of us know that more and more Obstetrician/Gynecologists have stopped delivering babies.

All of you who are physicians have had your malpractice insurance costs rise dramatically.

How many of you are midwives or nurse practitioners whose programs have been scrubbed or attenuated because they are not cost effective enough?

And how many of you who are physicians have had to double and triple the number of your office staff to wade through the bureaucratic quagmire that managed care providers force on you in order to receive but a modest portion of what your services actually cost?

DIAGNOSIS

These are the conditions that contribute to the failure of our health care system to achieve its full potential and to provide quality care to all Americans. And what is the disease process that is in play here? I have been sifting through research and public policy material for months, and it seems to me that there is one underlying cause from which all of the rest seem to follow. Except for government programs and out of pocket payments, health care costs are paid by FOR PROFIT COMPANIES. The one underlying disease is GREED.

With more and more managed care companies being traded on Wall Street, industry leaders say managed care is a business, and the public needs to accept that. It's the business of selling healthcare. And while the quality of the product is important, critics say the bottom line is even more important.

"I have no problem with people making money and profits," says Brenda Pederson, "but.big profits are being made and patients at the other end are being denied care."

Brenda Pederson is talking about her struggle to get care for her daughter Sarah, who "was diagnosed with a brain tumor when she was seven months old."

When Sarah was three, the tumor was growing. Doctors said that without chemotherapy, she could die. But when the time came to treat the tumor, Sarah's insurance company stalled over the cost. "She got delayed with the MRI's, she got delayed with the treatment," says Brenda. "Every day was trouble when we had to deal with the HMO."

For months, Brenda Pederson waged an almost daily battle pushing the insurance company to cover Sarah's treatments. But when Sarah was given chemotherapy and then needed medication to fight the nausea that the chemo caused, her HMO said no. "And their excuse for not giving her that medicine is it's too expensive," says Brenda.

The drug cost just $54 a month. And what is painfully etched in Brenda's memory is that at the same time Sarah was being denied, her insurer, U.S. Healthcare, was merging with Aetna. The merger earned Leonard Abramson, chairman of U.S. Healthcare, more than one billion dollars in cash, stock and perks.

So Leonard Abramson becomes a billionaire and Sarah can't get care.

Stories like Brenda and Sarah Pederson's tell people exactly what is wrong with managed care. "Whatever they do not spend on you from the fixed budget that they receive from employers, the HMOs keep for themselves and they earn interest on and they pay their executives tremendous bonuses for."

It's about profit -- it's about greed.

While some HMOs like Kaiser Permanente spend less than four percent of their income on administration, others spend up to 30 percent. That's for everything from huge executive salaries to marketing, even political lobbying. Critics say if that money were ploughed back into the system, it could pay for a lot of patient care.

Just two weeks ago, the results of the 16 th annual survey of employer-sponsored health care costs were released. According to that report, health insurance premiums paid by employers and their workers have risen nearly 50 percent in three years and are likely to face sharp increases again next year. Locally, temple members who own businesses have seen the health insurance premiums they pay for their workers climb as much as 40 percent a year for several years in a row. At the same time, the actual increase in health costs was about 10 percent in 2002 and is approaching 10 percent this year. This is significantly below rate hikes insurers charge. According to Jon Gabel, principal author of the report, "insurers are now adding to their profitability," adding that insurance company profits are at their highest point since the mid 1990s.

It's about profit - it's about greed.

Many of us have negative feelings toward government, and examples of government inefficiency and incompetence abound. Yet the record of private insurers is far worse. Their overhead is, on average, 600% above that of public programs, and no private insurer's overhead is as low as Medicare's. Dozens of financial scandals have wracked insurers and HMOs in the past year alone (my personal favorite is the $500,000 travel budget consumed by the head of one Blue Cross plan, including a $7000 junket to Africa to lecture on insurance fraud).

It's about greed.

A physician in New York wrote a letter to the editor of the New York Times, saying:

"The payment process drives the system. The process rewards expensive care of late-stage illness, where the illnesses may be irreversible, and penalizes early intervention, patient education and preventive care, all poorly reimbursed...The payment process must be revised."

And, of course, there is a political connection:

Bob Herbert of the New York Times has done an outstanding job of chronicling the extent to which the managed care industry virtually owns the votes of conservatives in Congress.

The so-called patients' bill of rights, sponsored by Senators Tom Daschle and Edward Kennedy, was an attempt to curb a range of abuses. The managed-care industry wanted no part of the legislation, which meant that conservatives wanted no part of it.

They were hostile to Medicare dating back to the Presidency of Ronald Regan, who saw Medicare as the advance wave of socialism, which would invade every area of freedom in this country. Reagan predicted that Medicare would compel Americans to spend their "sunset years telling our children and our children's children what it was like in America when men were free."

In the mid-1990's, when they were trying to cut taxes while at the same time eliminating $270 billion in anticipated Medicare expenditures, Bob Dole was bragging about the fact that he had opposed the original Medicare bill in 1965, opting instead to support a voluntary alternative.

Now comes Mr. Bush, whose own state of Texas did not bother to comply with a 1996 consent decree requiring it to provide appropriate health care services to more than 1.5 million children who were eligible for Medicaid.

Adam Clymer of the New York Times reminded us a few years ago that "'Texas has had one of the nation's worst public health records for decades." The state ranked near the top in rates of AIDS, diabetes, tuberculosis and teenage pregnancy, and near the bottom in immunizations, mammograms and access to physicians.

There is no telling how much bad news lies ahead. On a whole range of issues, the president appears committed to bringing the Texas model to the rest of the nation.

In particular, consider, President Bush's program of tax cuts:

As Paul Krugman has written in the New York Times:

".if medical care is a priority, which it surely is for the voters, why doesn't the government simply provide the necessary resources? You already know the answer: it's hard to reconcile realistic spending increases with...tax cuts." (and a billion dollars a week spent in Iraq).

The real lesson here is that things add up. The administration has been able to push tax cuts that mainly go to the wealthiest few Americans, because the downside seems abstract; the middle class doesn't seem to understand that those cuts will eventually starve programs that it counts on, like Medicare.

But the downside has already begun. There is a direct link between the administration's affluent-friendly tax cuts and the growing crisis of Medicare underfunding; it really is a case of their wealth versus your health.

And the pièce de résistance? -- The fact that this administration has supported a proposal to leave six million low-income seniors out of a Medicare prescription drug benefit.

And so the question is, as Democratic Presidential Candidate Howard Dean has put it, "Do you prefer the President's tax cuts, or would you like health insurance that can never be taken away."

Tomorrow morning, I would like to explore a health care model that best reflects Jewish teachings and practices, and that holds great promise for healing our health care system.

Until tomorrow, stay healthy - you can't afford not to.

October 4, 2003

On to Part Two