Wednesday, January 27, 2010

Real stuff

I am the worst blogger ever, I know. I owe you things from like a month ago I think...and several from last week, at least.

So, here goes on some real issues:

During my election preview post last week, I made a flippant comment about the asinine health care proposal that the House and Senate were working out, and Ys asked why it was so asinine. Pretty fair question, so here is my criticism of the current proposal (in as much as any of us know what it actually says right now...whole other issue).

The debate started because most Americans have decided that our health care system is broken. The quality of care is outstanding, and access remains better than virtually any other place in the world, but that access is diminishing and the costs are ballooning at an alarming rate. As such, people are looking to reform the system with two basic goals: 1) increase coverage, 2) reduce costs. As a third goal, many more-liberal citizens would like to see a government-insurer that will compete with private insurers where competition is lacking or collusive.

The proposed plan does pretty well with #1: it extends health insurance to many people that don't have it. Unfortunately, the mechanism is poor (and likely unconstitutional): it simply requires everyone who doesn't have health insurance to buy it. All of those people have decided that the benefits of health care do not justify the costs (or else they would have bought it already...duh), so simply requiring them by law to buy into the system seems a little...I dunno...dumb?

On goal #2, the plan is a total failure. While some proponents have made the totally absurd argument that this will cut costs, common sense says that it will cost a fortune (short version: a lot more people will be using a lot more health care.) Various sources put the cost of the plan at somewhere near a trillion dollars. I know that the President is a big fan of unsustainable spending aimed at getting more and more people to feel reliant on the Federal Government, but even by his standards, this is ridiculous.

Side note: any time you hear a politician use the phrase "deficit neutral", you should never vote for them again. You are smarter than that.

Also, for those who support goal #3, this proposal gives you a big middle finger, too. I am not fan of Nancy Pelosi (or of a public insurance company), but she was right on when she called out the President on this two weeks ago...her supporters should have been ecstatic at her doing that.

Here is my question...if the system is broken, then why are we trying to make it much, much bigger? There is very little "reform" in this bill, and a whole lot of expanding a system that we are trying to fix. Anyone who can explain how that works to me will get a cookie...

There are several competing dynamics here:
1) The quality of care (quality of doctors, of equipment, of medicines and of innovation)
2) The availability of care (how long do you have to wait for a doctor? What type and level of care are you entitled to?)
3) Cost

You can maximize any one of them easily, and you can probably maximize two of them easily...but you simply can not have all three. Medical care, like any other good or service, is a limited resource and it is subject to the immutable laws of economics. If we decide that it is in our social interest to have unlimited access for everyone to incredibly high-quality care, then we have to accept that the costs will be astronomical. If we want cheap care, then we have to accept that it will either be limited in its availability or in its quality. Claiming otherwise is akin to arguing against gravity.

I have a lot more on this, and will be happy to discuss it further either here, or via email or gchat, but this is already getting really long, and I also owe you an explanation of why, despite what you read, this was really not the reason that the Republican won the Senate seat last week. That will wait until tomorrow:-)


Ys said...

I still don't get it... I know I'm spoilt here in the UK we get free healthcare FOR ALL so you don't have "afford" to get treated if you're sick, you just go to the doctor and get fixed. Only very few things are private-healthcare-only. In Wales we also get ALL our prescriptions for free too (not sure if they rolled this out in England yet...). So you don't even need to pay for the medicine that you need to fix you.

I suppose to me it just seems dumb that there's millions of people not getting health care because they can't afford it in a country that's supposedly the best country in the world. We pay taxes to get free health care and it works. The NHS wasn't always great but it's something you've got to continually manage. It's back on track again now.

I saw a programme about this new US health care bill and the overall feeling was "Why should I pay for other people to get health care?" That seems like one hell of a selfish way to view the world. Only one woman in the entire show said that she'd rather pay a little extra if it meant people not dying. The reason why I asked the question was to understand why a NHS-style system is seen as such a terrible idea in America.

WOW this comment is way too long! I'm just so interested in it. I feel like I've missed a vital piece of the puzzle cos I just don't get it :/

SG said...

I admit I don't follow politics real close so I don't know all the ins and outs of the health care plan but my feeling is that health care is a right not a privilege and everyone should have access to it. When my fiance was out of work for 4 months he didn't have health insurance because he couldn't afford to pay for it on his own. Thank God nothing happened or he could have ended up with enormous medical bills.

I don't know what the answer is but I would like to think if I lost my job tomorrow I could still get medical care without having to go into severe debt. I think even mediocre care is better than no care.

With all the great minds in this country you would think someone could come up with a valid solution to the problem.

DSS said...

I couldn't have said it better myself! I hope you don't mind if I link to you from my blog. I've been trying to explain to people why this isn't a good idea...but they just can't seem to grasp it. I think that perhaps I'm a bit too emotional about it when I attempt to explain.

Thanks for doing a stellar job!

Accidentally Me said...

Americans are, as it turns out, unwilling to accept the level of care that is delivered in the UK, or in Canada. Published wait times (and since they are published by the government, they are dubious to begin with) for emergency rooms, for doctors visits and for surgeries are between two and ten times longer than they are here. Do we need that level of access? Maybe not...but for now, no one is willing to accept it, even for cheaper care.

We use WAY too much medicine... every time someone has an ache, they want an MRI and three prescpriptions and they want to see a specialist. And since the cost is paid by someone else (usually an insurance company) there is no one to tell you not to do it. Hence, spiraling costs.

Also...we are super fat...and that doesn't help at all.

Krishna said...

Excellent post, AM! Love your blog.

Ys, I believe that healthcare system in UK works great for a good number of uncomplicated problems. But not so much for terminal or life-threatening illnesses. I'm talking heart attacks that require emergency angioplasty (very time sensitive procedure). I'm talking chemo patients that die from sepsis because of pure negligence.

So, as far as you paying extra so that "people don't die", well, I'm not so sure that's helping.

Speaking of which, its not so much that all opponents of the current health care bill don't want to pay for the less fortunate. Its just that we don't want to pay more taxes to give more power to the insurance companies and their evil monopolies.

The current health care system is not good. I will give you that, my liberal friends. But just because it needs to be reformed, doesn't mean that we ought to approve whatever solution either party tries to force down our gullets. The whole Ben Nelson thing?! Disgusting politics, democrats.

Our Happy Married Life... said...

have you tried reading the damn health care proposal? that's what's asinine! 1,000 something pages that needs to be translated?
I do fear what healthcare might come to. I agree with you 100%. This whole subject raises my blood pressure. :)

Kari said...

Actually the wait lists aren't that much longer in Canada than the US -- it's all about how you do the math (I work in Health Policy Research north of the border). However, I don't think our style of health care would ever work in the US. I work with a number of MDs who are originally from the US and they are always amazed at the things Canadians will say regarding lab tests, "extraordinary care" etc (eg: an 98 year old gramma saying that she doesn't feel that she should see a specialist because she's already used up enough of society's money -- that would likely not be uttered by an American according to these MDs). Having lived in the US (and had the best of the best possible health coverage), all I can say is that the systems are so different that you can't take one and put it in the other's country. IEven though the two countries share a border there are many subtle difference between the countries that require solutions to be home grown -- not transplanted. I would say that in a country like the US, one solution can not be applied to the entire country -- there are just too many differences.
Anyhow -- that's my loonie worth of opinions.


Anonymous said...


I am an often reader and only very sporadic commenter. While our politics often diverge, I agree with a lot of this post. And I am honestly no where near as well versed in the subject as you are, but I do have issue with one thing you say. Namely that people who do not buy health care have decided that the benefits of it do not justify the cost.

I work in the service industry in NYC and am currently in graduate school (with massive loans used for tuition and health coverage while in school, but that is a different issue) Prior to being in school, while working in theatre and for a time only working in a restaurant, I had insurance through a program in ny for low income people (which I was only able to have because I luckily fell into the small income level bracket that allowed for this type of coverage) My cost per month was about $250 and provided generally ok to good coverage (though no dental or optical) Because I am the way I am with money,I was able to cover this cost, though at times it made things hard for me.

I work with people, quite a few people actually, for whom this amount of money per month is just not an option. And they are no less thrifty and no less careful with their money than I am. Circumstances have made their everyday needs of housing and food, and commuting the only things they can cover.

So I would just say that it's not a question of benefits not justifying costs. These people I know, know the benefits and desperately want health coverage, for some, it is just an impossibility. And for this reason, while this bill does not/might not/can not work, I am glad that it is something that is being worked


Anonymous said...

Wow...I have just begun reading your blog and I love it!! I have yet to comment on anything but, I must say..BRAVO on this last post. Way to sum it up.

I work and am insured via my employer, but, my husband is self-employed with no medical coverage at this time. We are STILL against the Obamasurance.

Brian said...

Long time reader and not as frequent a contributor as I should be ...

To echo the statements of your UK reader above and to add my two cents in.

I am a Canadian living in the United States, thus I am a US resident. It makes absolutely no sense to me that people have to pick and choose their medical care based on how much money they have. To take it a step further, nobody should ever be forced to lose their savings, their home or what not because they are sick. For Canadians and most Europeans this just seems so incredibly wrong yet that's the system here in the US.

As for published wait times - I agree there are some levels of care that have longer wait times than here in the United States. For example, if you have a rash on your arm and your GP doesn't think it's serious but would like a dermatologist to look at it, yeah you might wait a month or two. Your finger hurts when you bend it a certain way? If your GP doesn't think it will negatively impact your life this very moment they will refer you to a specialist and yes you might wait a while. However, if you are sick in the ER with a major issue or have a life threatening situation, you do not take your place at the back of the line.

Five years ago my mother was diagnosed with two different types of cancer. From her GP visit, to an oncologist to surgery and radiation/chemo ... all a matter of days. There was never any compromise on the care she received and never, ever did she face long wait times. Unfortunately she lost her battle and I can't say enough about the doctors, nurses and other medical staff we came in contact with back home in Ontario over the two years. My father is still alive and through it all never received a single bill/invoice and nobody ever asked him for a dollar. It wasn't her fault she got sick, and in a way the country and the system took care of her.

One of the major reasons universal health care will never work in the US is because of the crazy notion that the government shouldn't interfere with certain things, like health care. "Let the free market run the course" people will say, but some things should be the responsibility of the government.

Rice said...

I read your blog all the time and don't think I've ever commented but I loved this post and had to put my two cents in!

I agree with DSS, couldn't have said it better myself! I too have tried to explain my feelings on the whole matter but it never comes out this well versed! I also agree that our healthcare system could use some serious work but I am never a fan of the government controlling more in my life than they already do...

Trigger said...

I currently work in healthcare. And I am going to medical school next year. The majority of my friends are also employed in healthcare, or are physicians or other mid-level practitioners already. I have yet to come across someone working in healthcare who is not in support of healthcare reform.

This current proposal is not the ideal fix these people (and myself) would like. Honestly, we would like single-payer coverage, even though it would mean that my eventual salary as a physician would be less than it is projected to be under our current system.

To me, healthcare is a right. I volunteer at a free clinic weekly. The patients I see are DEVASTATED when we can't treat their acute needs and have to send them to the ER. As a clinic assistant there, I have yet to leave a clinic without at least one of the patients I work with on a given night winding up in tears due to the cost of the care they are about to need.

These people are the WORKING poor. If they qualify for our state-based indigent healthcare plan, they are not eligible for services at our clinic. We see people who have full time jobs with employers who don't offer healthcare benefits. We see people who are in between jobs that were lost due to the recession, who lost healthcare coverage with that job. Many of these people have never been uninsured before. They show up and wait in line for 2 hours hoping to get one of the 20 or so spots that our volunteer healthcare providers can see at each clinic.

Most people are one major medical illness away from bankruptcy. My parents have what is considered excellent insurance, and when my dad got a kidney stone that needed treatment (I use this example because this is not an instance of Americans being over-medicated, this is a true medical necessity to prevent kidney damage, so I don't think you can argue about the importance of him seeking this care), his treatment cost $9,000. Covered at 80%, that still left a bill of $1,800. My middle class parents were able to afford that, but what uninsured person could come up with $9,000 out of pocket? A very wealthy person could, but chances are they are able to afford to buy private insurance or have chosen not to buy insurance because they can afford the out of pocket costs.

Trigger said...

The other example I think of often was a 20 year old man who came into our clinic. He was a Type I diabetic - since childhood, not a result of poor diet or lack of exercise or any other behavioral cause. Treating his disease is expensive; it requires insulin, syringes, glucometer test strips, etc. As an acute care clinic, we do not carry supplies to treat ongoing conditions such as his, and we had to refer him to a county run clinic, with a wait time of 5-6 weeks. He was out of insulin right then, and when he burst into tears after I told him we had nothing to give him, we discovered that he truly felt like he would not last the next month and a half of waiting to be seen by the other clinic. He was probably right. We scrounged together a way to fill an insulin prescription for him in hopes of keeping his disease barely in check over the coming weeks. He is 20. He is applying for jobs. My state has the second highest unemployment rate currently, and someone like him, who was working his way through community college until he got laid off, is not a desirable applicant for the few job opportunities that do remain.

These people need help. They need a lifeline. They should not be forced to choose between a safe place to live, and the supplies they need to manage their diabetes. The playing field is NOT equal in America, so we can't chalk this up to a lack of effort on some people's behalf leading them to the circumstances where they cannot afford healthcare.

And for all you free-market proponents out there, right on. Let's turn health insurance into a free market. I would love that. Health insurance right now is NOT a free market. Insurance companies have all of their insured parties backed into so many corners that we don't get to choose anything related to our care. In a free market, we vote with our wallets. If we don't like the coverage we're receiving, we stop paying for that service. If you do that with your insurance policy, you are dropped from receiving coverage. And if you apply to new insurance policies, but happen to have any number of "pre-existing conditions" as benign as migraines, or irregular periods, or eczema, you can be denied coverage. So we are bullied into putting up with sub-par services from our insurers.

Doctors in America are among the brightest, most talented, most caring providers world-wide. Changing the way we as a nation handle insurance will not change that. What it will do is show our fellow citizens that we don't believe healthcare should be for only the very rich or very poor.

I could go on forever. I'm sure I'm not even hitting the most important points in this comment, because it is a subject I feel SO passionately about...

Anonymous said...

Great synopsis, I agree with pretty much all of it.

I have to take issue with some of the commenters regarding nationalized healthcare elsewehre. My husband is British, and so I've witnessed the care his parents have received over the last 12 years. Reasonable wait times my foot...

My mother in law's doctor told her she needed a hysterectomy after dealing with horrible periods, intense pain, heavy bleeding, etc. for several years. The wait time? 14 months. She was hospitalized 3x due to this same issue during those 14 months, the shortest period was for 3 days, the longest for 8. She still had to wait for the surgery until it was her turn. How much more did it cost the taxpayers for those 3 interim hospitalizations versus having the surgery at the time it was decided it was necessary? No idea, but add to that the enduring pain and illness caused by her condition for over a year, and it's simply inexcusable.

My father in law's experiences with cardiac care have been better, but he had an 8 week wait for surgery related to colon cancer 3 years ago. It boggles the mind.

Medicare needs to be fixed and better funded to allow it to do what it was designed to do. Trying to impose another country's system on Americans simply won't work.

Ally said...

I think Ys mentions of "free healthcare" hit the nail on the head. Americans want free healthcare, and there's just no such thing. Someone has to pay for it. And given over half of Americans choice to be overweight or obese and suffer tremendous (and expensive) health problems as a result as well as our desire to live forever (spending exorbitant amounts of money prolonging life even when it's low quality), quality health care is going to be really expensive. It seems so ridiculous to me that we want the best doctors and pills for any little ailment (including ailments we could avoid with lifestyle changes) yet think our monthly insurance premiums should be less than the cost of a doctor visit.

While I totally agree that we need to help Americans who cannot afford essential health care and find it tragic that a fairly minor illness can bankrupt a family, this plan is making a very broken system bigger (as AM pointed out) not better.

ms. mindless said...

I believe that health care does need an overhaul and I am a supporter of universal health care in general. I am not sure that the system proposed is necessarily the best one, but will our nation EVER agree on one system that is the best? Likely not. I also find it interesting that those at the top (i.e. those with good health coverage) seem to be experts at prescribing what is best for those at the bottom with no coverage and speak for them, saying that they have "decided" not to buy health coverage. People don't decide that health coverage is not in their best interest. They don't have it because they can't afford it. So, let's not pretend that there is this large population of people who are just opting out of insurance because they want to.

Accidentally Me said...

Just to saying that people have decided not to buy it is not at odds with your saying "they can't afford it". If someone doesn't have insurance, then it is because they have decided that other things are more important (food and housing are obviously big ones).

You may think (very reasonably) that they should not have to make that choice, or that health coverage should be cheaper, such that the sacrifice is less. So, I am not saying that people make an easy choice not to buy it, in fact it may be a brutally difficult choice, but it is still a choice.

(And, just a note...there ARE a lot of people who opt out because they reasonably want to. Roughly half of the uninsured have family incomes over $75,000...not exactly destitute.)