Wednesday, January 27, 2010

Healthcare, II

Some really good comments yesterday, and I don't really take issue with any of them, nor do I want to get involved in a specific-case discussion, which doesn't serve a whole lot of purpose. Some of the disagreement is really just semantic anyway...most everyone agrees that there is plenty of room for reform, and plenty of room to improve the way we deliver health care.

There were some good defenses of the British NIH and of the Canadian system...but those systems work where they are for a couple of reasons, most notably that England and Canada are not the United States. Americans are fatter than most every other country (and therefore have more obesity-related diseases), more demanding (prescription drug use and doctors visits are higher among Americans than anyone else) and much more litigious (which leads to what many doctors refer to as "defensive medicine" - it is easier to order a test or prescribe a drug than to run the risk of being sued for missing something). Ally did a really good job yesterday of explaining why a lot of our problems are not the fault of government or insurance companies or hospital operators but rather of the American people

The NIH is a total no-go, I think, because I am pretty sure it would require at least one Constitutional Amendment. The Federal Government does not have the authority to nationalize an entire industry, take all of the assets (hospitals, ambulances, equipment, etc.) by edict or by eminent domain, and them inform all of the doctors and nurses that they now have to work for the government. I know that Constitutional limits are flaunted by Congress and the President all the time, but this would be a stretch.

[Here is another dirty little secret: Americans subsidize the health care of everyone else in the world. We end up paying for most of the innovation, and everyone else piggy-backs on the profitability model here. So, for the rest of the world, you should be rooting against single-payer care in the US that would force innovation to either disappear or have its costs shared internationally.]

We have a totally perverted system whereby we pay as socialists, but we still consume as capitalists. As Trigger points out, we do NOT have "market based" health care. Markets involve people making consumptions decisions based on costs and benefits. Cost is nowhere in our health care decision-tree. Imagine that, when buying a car, everyone paid the average price of a car, but you could pick any car you wanted off of the lot. What happens? Everyone drives Bentleys, and the cost of a car rises to $185,000.

Our system of "insurance" is part of the problem as well. Insurance is the spreading of the risk of unusual or catastrophic events...what he do is pay communally for everything. To keep with car analogies: you pay for your gas, tires, oil changes and other routine maintenance out of your pocket, but you have insurance that covers accidents and whatnot. Just a random question...if everything was included in your auto insurance, how much do you think an oil change would cost? Certainly not $19.

We share everything, including routine costs and the costs of self-inflicted disorders, with no allowance for the behaviors of the person involved (except smoking). Because of the way that Americans consume routine care, the costs of that care are astronomical, which then trickles down into the difficulties of obtaining care for the truly catastrophic (and a couple people told good stories about cancer and organ failure and whatnot.)

And that all sort of gets me back to the initial point from yesterday...not that we do not need or could not benefit from Health care reform, just that this current proposal is a disaster. There are certainly some positives (wider insurance coverage, better accommodations for people who are truly just the victims of bad luck), but the overall premise of the bill is flawed. It addresses none of the root causes of our soaring health care costs, it simply promises that the government will pick up the tab for more people. Our government already refuses to live within its means, and this will just do more to continue with our pressing bankruptcy.

In the interest of not being a total negative-nancy, I will throw out the following as a potential solution that would probably work in the US, and would dramatically lower overall costs. I would propose that we go back to an actual insurance model, whereby routine and expected costs are paid out of pocket by the user (or, there is just some limit...say your first $1,000, or $2,500 a year or something) and insurance exists to cover the unexpected and the catastrophic.

Whether that insurance is provided by private companies or by the government is really not as important so long as the principle is preserved: patients and doctors interact directly on most care, without the need for an insurance company or a bureaucrat to determine what should be paid for and how much it should cost. (There is a role for government, as well...most notably for people with serious, genetic pre-existing conditions). However, we do not bankrupt people or families because of an unforeseen and unlikely illness.



Dawn said...

I'm really on the fence about this, being that I'm Canadian, but living in the U.S.

So I see the U.S. healthcare system and I wonder why it can't be as "easy" (never mind the tax issue) as it was in Canada.

I haven't commented here in a while (although I've been reading) and I'd like to stay on-topic so...

In terms of healthcare (kinda):

How's Munchkin's foot feeling??? :)

Ys said...

I know this is a serious issue but you saying a lot of american's are fat and that's part of the problem gave me an attack of very non-PC giggles. I just wasn't expecting to read that! ;)

You've helped clear my poor frazzled mind a bit over it so thanks for that. I wanted to bug you cos you always seem up on the politics ;)

Can I just defend the British waiting lists attacks though: I had to have major surgery and had it within a month, no waiting, got it done, and I had an expert in the field who probably saved my life. My mother-in-law had cancer she was treated fast and well and has fully recovered. And my mother has recently been sick and she was treated fast and well also. I know the waiting times in A&E are not ideal (I recently sat for two hours with my granny-in-law) but if time-wasters would stop coming in for snotty noses then that would help. But I agree something does have to be done there. And I am not happy with this ring-up-and-get-an-appointment-on-the-day nonsense with the doctors surgeries.

Thanks again AM for dumbing it down for me, the US system is just so bloody confusing! I thought our system was bad enough ;)

Brian said...

Two comments in two days, I am on my way to becoming a regular perhaps :)

Another insightful and honest post - it's what I love about your blog!

Just to piggyback one more point and in no way am I trying to attack any particular group of professionals here.

I neglected to point out yesterday two more thoughts on why the system is messed up here in the US. Again, like everyone else I don't have a solution but I can sure point out the problems :)

1. Medical professionals make A LOT of money. When I was in college I worked in a Radiology department and got to know a lot of the doctors pretty well. Since it was a public hospital the salaries of the doctors were disclosed once a year. Many of them had private clinics on the side but I know a few Radiologists made in the $135-150 a year range. I have to imagine doctors here in the US make at least twice that given the for-profit system that exists. I know there is a massive 'brain drain' from Canada to the US where many professionals, particularly doctors and nurses, flee to the US because of the big time money that is available. So what's the point? I guess if medical professionals in the US weren't making two and three times that of their colleagues in the US than in theory overall costs should be lower on the front end. So why do they make so much money ....
2. Americans love to sue one another. Malpractice insurance has to be so high because people in the US will sue at the drop of a hat. This then leads to greater overall costs to the patient as doctors and hospitals need to protect themselves.

Just a few other things to ponder.

It would be so much easier just to wipe the slate clean and start from the beginning here in the US. Of course that isn't possible :(

Ally said...

I like the idea of consumers paying for more routine costs simply because this would encourage us to acquire health care services just like we do a television or vehicle. My last employer offered high-deductible insurance similar to what you described, and I became much more conscious of the unnecessary lab work, tests, etc. that my physicians wanted to perform because I had to pay for the first $2,000 out of pocket (from my HSA). I found that a CVS minute clinic could handle some routine illnesses, that I could refuse to allow my gynecologist to perform a pregnancy test I didn't need, and that I could shop around for cheaper office visits among general practitioners. Americans simply have to understand that we have to accept some responsibility here.

Rice said...

Have to comment on what Brian said here, really quick...

2. Americans love to sue one another. Malpractice insurance has to be so high because people in the US will sue at the drop of a hat. This then leads to greater overall costs to the patient as doctors and hospitals need to protect themselves.

I personally think this is a HUGE problem with the costs of health care. An OBGYN that I know told me the other day that 40% of his practice overhead goes towards medical malpractice insurance. 40 PERCENT!! That's insane! No wonder things cost so much when doctors basically can't practice medicine for fear of being sued, it's ridiculous!