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Monday, August 10, 2009

Thoughts on Health Care in the US

Graphic from Johnny Crow's Garden, 1903, by Leslie Brooke. Public Domain.

There's a lot of concern about possible changes to the US healthcare system. I don't have the answers, and I don't know what, if anything, Congress will come up with.

Are there problems with healthcare in the US? Yes.
There certainly are problems with the US healthcare "system." What are they? Here are some of them:
1) About 1 in 10 of us don't have health insurance. Such people usually get health care, but it's not done efficiently. They use emergency rooms, which is an expensive type of care, and makes it more difficult for emergency rooms to handle real emergencies. It also means that such people usually don't visit health professionals for preventive care, which would save money, as well as keeping people without insurance from having some of the worst problems. It is likely that about two-thirds as many people die in the US each month, because they don't have health insurance, than were killed on September 11, 2001. (See here.)
2) Healthcare costs are rising quite a bit faster than national income or production. If this continues, we will be spending all of our money on healthcare. Obviously, that's impossible.
What causes this? Part of it is that the medical establishment is afraid of being sued, so they order tests and treatments that don't really help, but cost money and other resources. Most or all of the items in this list contribute to cost increase.
3) We have come to put more value on life than we really ought to. Is anybody really better off when a person who is really dying, and dying soon, is given yet another treatment, just to buy a few more hours or days? We are all going to die, and sometimes we just need to accept that. Unfortunately, some people don't. The culture of the medical establishment is to keep alive no matter what. That doesn't always make sense.
4) The way most of us get health insurance causes serious distortions in other things.
US manufacturers must include health insurance for their employees in their costs. Manufacturers from other countries don't have this expense, at least not directly. So US manufacturers have a competitive disadvantage.
Small businesses often feel they can't afford health insurance, which means that it's harder to get and keep good employees.
There is a big incentive to keep people from working full-time, because hiring them full-time often means the added expense of health insurance. Employers and employees would often both be better off if more employees were hired for full-time work.
Losing your job means that you not only lose a pay check, but, often, your health insurance, too, and, perhaps, your family's health insurance. Getting a divorce may mean that you lose health insurance.
5) The current private insurance system creates a private bureaucracy of its own, plus the additional help (bureacracy) that doctors and hospitals have to hire to file claims, or, in all too many cases, to re-file them, because the insurance company has "lost" the first one.
Private insurers do not have healthcare as their primary goal -- it's profit. That means that they often do everything they can to avoid paying for legitimate treatment, even to the point of sometimes denying it. They are reluctant to cover people with pre-existing conditions, or people in certain hazardous occupations. In other words, they want to cover well people, not sick ones.
6) The current fee-for-service arrangement is an incentive for healthcare providers to recommend more expensive treatment. Just as selling a big SUV means more profit for auto companies than selling a compact car, selling coronary by-pass surgery means more income for healthcare providers than recommending exercise or other preventive care.
This type of payment plan is also an incentive for doctors to become specialists, as opposed to practicing family care, child care, or care for the aged. Cardiac surgeons make more money than family doctors. So generalists are rarer. This means that it is harder for isolated communities to get doctors, and that most people have several doctors, who probably aren't communicating very well with each other.
7) We aren't doing much, as a nation, to encourage good habits, such as exercise and getting enough sleep, and to discourage bad habits, such as excess alcohol consumption, excess exposure to the sun or use of tanning beds, eating too much of the wrong foods, and smoking.

Doesn't the US have the best healthcare in the world? Not really.
To hear some politicians talk, we do. But:
1) The US life expectancy is 45th best in the world. Canadians live an average of over two years longer than we do, and Japanese live over four years longer.
2) The US has the 33rd best infant mortality rate in the world, which means that Brunei, Cuba, Slovenia, and 29 other countries, have a lower infant death rate. Iceland and Singapore have less than half our infant death rate. The infant death rate in Canada is about 76% of ours, which means that for every three babies dying in Canada, we have almost four. (Added September 1, 2009: A friend sent me a link to an Associated Press article which gives further indication that US care for infants, and pre-school children, is not well at all.)
3) As a nation, we are paying almost twice as much per person on healthcare as Canada does.
4) I don't know how these statistics compare to other countries, but a recent report by CNN says that nearly 100,000 people a year die from medical errors while they are hospitalized, and nearly 100,000 additional people die from infections caught while they were in the hospital, in the US. The same report also says that 1 in 15 hospitalized children is harmed by medical errors.
5) I love our country, with all of its faults. If I moved to another country, and kept my US citizenship, the most important reason I did would not be that I didn't want to lose my right to the US healthcare "system," or because I love Blue Cross, or Aetna. I have known Canadians living in the US for which that did seem to be a main reason for keeping their Canadian citizenship -- they didn't want to lose their right to the Canadian healthcare system.

Note, added December 14, 2012: This post was, in part, written as a comment on "Obamacare," which became law on June 8, 2010, although many of the provisions have not yet gone into effect. I haven't changed the post, other than to add this note. The material above is still mostly pertinent on this date. Here's the Wikipedia article on the Patient Protection and Affordable Care Act.

Shouldn't we avoid socializing medicine, or preventing government bureaucrats from determining who gets what care?
There may be some dangers here, but they don't seem to be nearly as great as we are often told.
We now have insurance company bureaucrats determining who gets what care. It is not at all clear that "government bureaucrats" would do any worse. Based on the experience of almost every other industrialized country in the world, including our neighbors to the North, health care would be better under a national government payer (i. e., socialized medicine), at least by the important measures given in the previous section.
Most of the health care that I currently receive is through a government-run system, namely Medicare. I have had no problems with it. Granted, the expense of Medicare is ballooning, and there will be problems down the road, if something isn't done, but this isn't because of who is running it, it's because more people are coming under Medicare. The overhead cost of Medicare is said to be considerably lower than that of private insurance companies.

This paragraph added on Aug 14, 2009. I listened to President Obama at a "town meeting" on this subject, in Montana. He expanded my understanding of this issue. Canada and the United Kingdom have socialized medicine, in the sense that their governments not only pay for healthcare expenses, but also run the hospitals and other medical facilities, and hire the medical personnel. He said that there are other options, and mentioned the system of the Netherlands, where apparently there are privately owned medical facilities, and where doctors can decide to go into practice without being hired by the government. The government does pay the bills. That system would be less socialistic than the Canadian system. No doubt there are other possibilities.

President Obama has never proposed doing away with the current insurance-based system, although there are other politicians who want to do away with it. It appears unlikely that that will happen any time soon, if ever, in spite of its faults.

Under the healthcare plan currently proposed, disasters X, Y, and Z will come upon us.
(Whatever X, Y and Z are, such as government access to our financial data, doing away with medicare, or government promotion of euthanasia.) Maybe such disasters will come, if there are changes in healthcare. But most likely not. These, and other serious problems, are mostly scare tactics by people with a vested interest in the system the way it is, or a vested interest in fighting Democrats. (This is not the same thing as principled, civil opposition to change in healthcare, or even to Democrats. But no one should call people who are trying to fix the problems Nazis, even if they don't like the proposals.)
I wouldn't worry too much about these supposed coming disasters. In the first place, vested interests (such as the insurance companies and others) are doing everything they can to discourage change, including lobbying on a massive scale, and putting out information, or misinformation.
In the second place, at this point, we have no idea what sort of plan, if any, will be adopted by Congress. The House has adopted a plan, but the Senate isn't going to do so until September, at the earliest, and almost certainly there will be big differences between the two, which will require lots of conference committee work. And, as I say, it is possible that there will not even be a new health care plan adopted by Congress during this session.
In the third place, although our Congress is not the most popular institution in the US, it does have some sense, and even if it did want to do away with medicare, it knows full well that there would be a massive outcry, perhaps even a revolt. The same response would be expected with the other disasters mentioned at the beginning of this section. They aren't going to happen.

What about the cost?
Aye, there's the rub. We seem unlikely to change much from our private insurance-based "system." Although there are some who want to do so, President Obama has not advocated that, instead, he seems to be favoring providing more people with access to private insurance, but with a public insurance option. One way in which this might be done would be to subsidize small businesses, so that they could afford to offer health plans for employees.

Providing health insurance for the many millions that don't have it now will be expensive, indeed. No wonder some in Congress are balking.

What's the solution? I don't see one. We lack political will to change from private insurance to public, in spite of the generally good experience of other countries. Keeping the "system" we have now won't stop escalating costs. They are going to continue to go up. As with financial institutions, and auto makers, we have decided, in effect, that private health insurance companies are too big to fail.

If a new plan is adopted, it doesn't seem that it will attack any of the problems listed in the first section, except the first one, and maybe a small part of the fourth. The most promising way to deal with all of those problems would seem to be if a public option were included, did well enough, and was allowed to grow at the expense of private health insurance, over several years. We'll see.

I offer, only half in jest, my plan.

Thanks for reading.

Graphic added on Aug 11, 2009. Note added above, December 14, 2012.


Hamster said...

I just thought I'd mention what my wife and I have done to cut the cost of health care.
We are in our 60's and self of the most unfortunate groups of all. Our Blue Shield premiums are $920 per month. Our deductible is $4000 for me and $4000 for my wife.
(I understand that is pretty standard for folks at our age and with our health conditions)
So before I can get a dime of help from my insurance policy I have to spend $15,000 per year out of pocket on medical bills and premiums.
Needless to say we try not to use the medical system in the US unless we have to.
Over the last 5 years we've started going to Thailand for our medical checkups, dental care and medical needs.
Almost every November we hop on a plane and head to Bangkok where we check in a private hospital called Vejthani. Airfare can vary from $800-$1200 round trip depending on what class you fly. But even taking that into consideration...we really save a lot
There are a lot of hospitals in Bangkok that cater to Americans..the best known is called Bumrungrad Hospital which was featured in the "60 minutes" episode. (more expensive but still cheap by us standards)
Many Private hospitals in Thailand put my local US hospital to shame.
The care is excellent, equipment brand new and the cost...just a fraction of what I would have to pay out of pocket in the US. For example, last November I had an Endoscopic balloon dilation for a condition known as dysphagia. The specialist in the US said the operation would cost me $2500. (His bill for the 15 minute consultation was $250.) I decided to wait until I got to Thailand
This time I had it done at a public hospital in Bangkok called Chulalongkorn Hospital...cost $100 including biopsy, (all I needed for ID was my US passport. No questions asked!!)

I have to keep my US insurance in case I have a heart attack or get hit by a bus. Otherwise I would like to drop my health insurance here and just rely on the Thai medical system.

Anyway, that's my solution to the health care problem.

Martin LaBar said...

Thanks, Hamster.

This seems to work for you, and shows yet more reason why saying that the US "system" is the best in the world is either lying or delusion.

Unfortunately, this won't work for everyone. Not everyone in your age and employment group can pay for health insurance, and not everyone needing care can spare the money, or the time, to go to Thailand.

Thanks for commenting!

FancyHorse said...

May I send this post to some of my friends, and/or put it on another website?

Thanks, Nancy

Martin LaBar said...

Help yourself!


Technology said...

It seems like people are understanding what they want from the proposed health plan then getting upset over nothing.

Martin LaBar said...

Thanks, Technology. I guess.

Much of the upset is over nothing. There are also genuine fears of features people like now, if there is change, and of how we're going to pay for all of this.