Health Care Reform
Mar 26th, 2009 | 15 responses
I had previously opened up a discussion on this important topic but had not revisited it in a while and since it is likely to be a major issue in the coming months I thought it was worth addressing again. I presume it goes without saying that we all agree that there is a problem, that our current health care system is incredibly messed up and that unless we make some major reforms in the coming years we will experience a major meltdown.
Speaking for myself I am open to any solution from pure free market to single payer nationalized, the key issue is that the proposed system will actually work rather than simply create new problems or just make us feel better for a while. For me the issue is not how we solve it but simply that they solve it.
On first glance I am not hopeful that a pure free market setup will work. While we don’t really have such a system now we did in the past and things didn’t work very well in terms of providing full coverage. For profit systems do have their advantages in terms of pushing innovations and also in enabling hospitals to obtain the newest equipment.
But they have the flaw of being for profit and thus being unable to provide services to everyone. If you are trying to make a profit then you can’t really care for those who need tons of free services. This leads to the problem we currently have where many people are forced into long waits at the emergency room which tends to cost the government more but helps with the bottom line of the hospital.
Looking at my own case for example, I am self employed and thus have to pay for my own insurance. Because I am single and reasonably healthy I have pretty basic ‘hit by a truck’ coverage for health and equally basic vision and dental coverage that costs me about $ 2,000-$ 2,500 a year in premiums.
It’s great coverage when I need basic checkups or exams but when I recently had to go to a specialist for some tests I had to pay about $ 1,000 or so out of pocket. The expense was well worth it since it involved my health and I was quite pleased when all the results came out perfect. It took me a while to pay off the extra bills and I had to give up plans for a trip to visit friends in LA.
Of course in my case it was hardly a major sacrifice, I do not have a family to support and the costs are relatively low compared to what many people pay. But it was a minor burden and something that could have caused a bigger problem had the test results not gone well and had I needed further treatment.
At the same time it does demonstrate that it is possible for most people to obtain basic coverage, though in the long run that coverage is not always sufficient.
On the opposite end of the scale I am also doubtful about a full blown nationalized single payer solution to the problem. Like the free market idea the single payer program has both good and bad points. On the good side it provides coverage to everyone, so people do not fall through the cracks.
But on the bad side because they are basically in the business of rationing health care the coverage provided to everyone is not always the best. We’ve all seen stories about long waiting lists in places like Canada and Europe where people with non life threatening conditions have to wait months on end to have pretty important procedures.
There is also the risk of abuse of the system in the sense that when something is free we are far more likely to take advantage of the benefit. For example I recently had a minor bout with athlete’s foot like symptoms (sorry if this is TMI) and so I naturally began to channel my inner hypocondriac. I went on the internet to do research and began to get images of all kinds of major infections and problems I could have.
Of course deep down I knew it was just a litttle fungus and if I went to the doctor he’d tell me to get something at the drug store and use it for a few weeks. Because I would have had to pay to see the doctor I decided to just do what he was going to tell me anyway and see what happened. Of course in just a few days things began to clear up and now everything is just fine. I saved myself the cost of the doctor and prevented wasting his time.
But had it been free under a national system, I probably would have gone to the doctor and had him tell me to do just what I did. I would not have solved anything but it would have cost money to the system for me to go in. If you factor in millions of other people with colds, flu and other conditions that basically cannot be solved by a doctor visit you could see where a lot of waste could be built in.
Indeed in the days before health insurance (it didn’t really become a work benefit until during WW2 when wage/price controls prevented wage hikes) people did engage in what you might call reasonable rationing. If you really needed to see the doctor you did, but if it was something you could solve your self, you also did that. I’m not saying we need to go back all the way to such a system as there were clearly problems. But we do need to make a balance to prevent people from abusing the system
Because both extremes provide both good and bad soliutions, my guess is that the ultimate solution to the problem will probably be some mix of both free market and government and that the real question will be what kind of mix.
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15 Responses to “Health Care Reform”
One of my frustrations when this subject is discussed is the concept that health-care rationing occurs only in government health care systems. In fact, every insurance company rations health care as well. My insurance says that I can get coverage for one bone density scan every two years, for example. My only option if my doctor thinks a second scan is helpful, is to pay 100% of a bloated retail price for a scan every year. Why? Because doctors and hospitals have a retail/insurance price schedule. And, because so many of them incur huge costs providing services for those who can neither pay the retail price nor have insurance, they are constantly on the verge of going broke. The only variable they have to work with is to continue to raise the retail price. Those of us who aren't destitute, and who need services beyond those our insurance companies cover, must pay premium prices for them.
I don't see how this is different from a single-payer system which would also presumably decide that a bone density scan is appropriate only every two years. Again, if my doctor recommended one before the 2 year anniversary, I could have one by paying retail. The question is how bloated that retail price would be. If much of our population didn't get all their health care in trauma centers–even for a routine sore throat–that retail price wouldn't have to be so large.
To some degree, rationing is an dirty little secret of both single-payer systems and insurance companies. And, for good reason. Minus some cost-containment, we would all consume health care at incredible levels, and levels which we know will not actually improve outcomes. If my cancer is terminal, should I be receive a new drug which costs an extra $100,000 annually, but which might give me 30 extra days? I don't know, but I do know that these decisions are being made by insurance companies every single day. But they're being made in private offices where they aren't subject to public debate. With a single-payer system, these subjects could be debated openly. And, with rigorous utilization reviews such as Obama is proposing, my doctor and I would know whether the claims that drug reps are touting, and which are being advertised so heavily, actually have merit.
Janjanjan is right. For profit systems are full of rationing as well. They also just drop people who cost them money if they can find a loophole to allow them to do so. In addition they interfere with doctor decisions in other ways, like their lists of approved drugs. I think the government should create a non-profit organization with a sliding fee scale that is available to everyone. This is purely an alternative for those who can afford private companies but a life saver for those who can't. Businesses can sign up for it for their employees and cover the payments as a benefit if they want, just like they can (If they can afford it.) with private insurance. They can compete if they can in any way they want while a system exists for those who they have no interest in dealing with.
It's not that anyone thinks that there isn't rationing now, it's the degree of it. When you look at a system like Britain or Canada, the only way the govt is able to control cost is to drastically limit access to certain procedures or radically deviate from wait times that we are accustomed to. It's a far cry from the situation Janjanjan describes- limits to bone scans- and the reports coming out of Britain about people yanking out all of their own rotting teeth because they can't get in to see a dentist.
The question is how far are you willing to go with the rationing, and will the decisions made on which things to ration be in accordance with what you and your doctor now can decide to do under the current system? When you look at the nationalized systems we now have in the US- VA and Medicaid- there are already much stricter limits on what is covered than in the private system.
Private insurance doesn't do squat for dental care in this country, CS. And why is it that conservatives always refer to Britain and Canada? There's never any mention of any of the other industrialized countries that have government systems of varying kinds.
Depends how comprehensive your coverage is, Jim- and the point is that when the whole system is nationalized, the govt decides how to compensate for specialties.
Besides, I only threw out the dental example because it's the most graphic. There are scores of other examples in regular medical issues- cancer patients dying before they can get surgery, people living with back pain for a year or more, etc.
And I figured someone would say that about Britain/Canada vs other countries. I didn't mean to imply that those are the only kinds of systems- I was just responding to the general idea that 'we have rationing right now, so why worry about that?” We do in fact have to 'worry about it' in the sense that we should figure out how rationing will occur under any proposed system, and whether it will get to a degree that is intolerable once costs start to rise. That's one of my main concerns- that we start off and everyone's relatively happy so the system becomes closer to a nationalized one because people feel it's 'working'- but then the rationing becomes more and more evident over time as costs explode and the status quo is unsustainable.
And, with rigorous utilization reviews such as Obama is proposing, my doctor and I would know whether the claims that drug reps are touting, and which are being advertised so heavily, actually have merit.
No I'm afraid you wouldn't. Go look at the VA drug formulary – do you really think those drugs are chosen on the basis of merit? They're chosen on the basis of how much money the VA has to pay for them. Not to mention many medications are used for off-label indications which the government will lag way behind approving.
And why do you want bone densitometry more often than every two years? Bone density doesn't change that fast, it'd just be a waste of money.
Rationing under a system that depends on for-profit corporations is just as capricious, just as liable to change with no notice and definitely no transparency to the public or the company's customers. Once again, you are not presenting a valid defense of the current system or any system that still depends on the corporations that currently dominate the system, CS. I know they'll drop me like a hot potato if they can get away with it if I become seriously ill. I know that I will lose my insurance under the current system if I become too ill to work. I know that if things stay anywhere close to where they are now the financial clout these companies have will guarantee that partial compromises will always leave the balance of power with them, meaning millions will suffer. After all, the only responsibility of any corporate officer is the profits of the shareholders.
Let's see, someone says that a plan that is proposed by Obama that has not taken effect yet would produce a desired result. DaGoat says that no it wouldn't because an existing program in a different government agency that the Obama administration has not had any time to influence doesn't work that way. While it may be possible, the logic fails miserably. In addition it should be pointed out that prescription formularies of private insurance companies are also based solely on their profit margin and they are known for being just as slow as the government to approve any off-label usages.
you are not presenting a valid defense of the current system
Because it wasn't my intent to do so. The current system is badly broken. If I argued otherwise, you'd blast me for that.
But on the issue of rationing, we have a long track record to examine how that works with the current system, and we can easily compare that with some of the other existing publicly funded healthcare systems. On this one issue, there's clearly an advantage in our current system as compared to certain types of nationalized systems (the UK and Canadian models.)
If we agree on that, then we can move on and examine other systems to see if they provide a more favorable model. In some cases they probably do, but there may also be other reasons why those systems aren't replicable in our country (not the least of which is the economy of scale- you can't say that a system that works in a country as small as Sweden would definitely be replicable on the scale of the US.)
I know that if things stay anywhere close to where they are now the financial clout these companies have will guarantee that partial compromises will always leave the balance of power with them, meaning millions will suffer. After all, the only responsibility of any corporate officer is the profits of the shareholders.
And if we shift that power to a government agency, the only difference is we add another middleman. It may be quaint to believe that political bodies uphold a commitment to the constituents, but in reality they sell out to the highest bidder among the lobbyists.
My bone density scan was simply an example–one that I figured would be familiar to many. Many of us know somebody whose doctor has recommended some treatment or drug which isn't available under their insurance coverage.
A statistic I found a few years ago illustrates a difference between US medicine and Swedish medicine practices. In the US, less than 15% of stereotactic biopsies of the breast result in a cancer diagnosis, while in Sweden 80%+ of such procedures result in a cancer diagnosis. However, the survival rate for diagnosed breast cancers is virtually identical. Such statistics could be used to defend two different approaches to a possible lump. And, it might appear that the Swedish approach is driven by “rationing” health care. But, if you look more closely, it becomes apparent that there are many factors at work here. For example, it turns out that Sweden has virtually universal mammogram usage. And, once diagnosed, Sweden has excellent and universally available treatment.
What this implies to me is that there are varied legitimate approaches to health care, and that our assumptions that the present US approach is always better may be wrong. To the individual woman with a diagnosed breast cancer, the Swedish approach would appear more attractive–excellent treatment is guaranteed. To the individual woman who is worried about a lump in her breast, the US approach would appear more attractive–if that woman has insurance which will pay for a stereotactic biopsy. If she lacks such insurance coverage, she has no recourse and can only hope that her lump isn't cancerous.
Very thoughtful discussion. I see two factors at work here.
First, basic access. It is true that private insurance, in effect, rations care. But with the right kind of “private” system, you could change plans if you didn't like the way your plan rations. With a government plan, such as single payer, you would have no choices; you would have to take it or leave it.
Second, it seems to me that American doctors over test and probably over treat. This may be a CYA operation to avoid being sued or otherwise chastised. It also may be because they know someone else is paying the bill.
I have Medicare, which is a government plan. It severely limits my choices and, if I could afford it, I would not use it. It also really screws the care providers and some are now refusing to accept Medicare.
Real consumer choice really needs to be a big part of any new plan. Inclusion of a government Medicare-style plan will be the death knell for private plans because the government plan will be cheaper. The government can unilaterally set prices and provide hidden subsidies. Because the government plan will be cheaper, the private plans will fade away and we will be left with a single payer plan and all of its disadvantages. I would take what we have now over a single payer plan.
Good stuff, this article will really help us specially health concerns.
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