Posted Nov 11, 2008
Last Updated Nov 11, 2008
This is not a scholarly and balanced study. It is an honest examination and presentation of some aspects of health care in America. And it looks at some political slogans and mottos that are passed off as self-evident political wisdom.
Health Care Plans
So you think private health insurance is more economical than single-payer universal health care? Let's look at that — while keeping in mind that I'm no financial expert, and have neither a medical education nor any peripheral experience, beyond on-the-job training (!) as an army medic. (I did not sleep in a Holiday Inn, but I do tend to be analytical.)
One howl from the free-market advocates is that a single-payer universal system would create the largest (or most inefficient, or both) bureaucracy in government. But what about corporate bureacracies?
The present system is an enormous — and enormously complicated and ill-coordinated — combination of individual corporate bueaucracies.
A few specifics: I'm 82 years old, and I've been on Medicare for 17 years. One problem with Medicare is, it addresses only parts of the need: it's designed for the elderly, and even for them it covers only part (a much appreciated part) of their expenses. Many conservative politicians call this "having a choice"; a cynical slogan in the service of "Free Market" ideology, commonly recited with true sincerity!
Many elderly people still find themselves wrecked, or wracked — or racked! — by medical bills. They're supposed to deal with this by subscribing to supplemental insurance. Like Medicare, supplemental insurance slights the month to month routine needs, pays a (blessed) fraction of the costs, and leaves the rest for the "insured" to pay out of pocket — maybe by mortgaging their home.
I'm fortunate to be healthy for my age.
Despite its faults, many of us oldtimers, perhaps most, buy supplemental insurance to cover what Medicare does not. Except that supplemental insurance doesn't either. As medical costs rise, our insurance premiums go up, and at the same time our out-of-pockets fees also get higher. Which results in putting off going to the doctor — or skipping it entirely, unless it's for something major.
(On the other hand, some, perhaps many, trips to the doctor are needless. Which leaves a person with the question, "is this major?" You have to go to the doctor to find out!)
And some (not all) health insurers are "for profit" companies, whose central objective is not medical care. In fact, many states have laws requiring corporations to operate for maximum profits, unless they've been awarded "not for profit" status.. (Of course, even non-profit companies need to finance their operations somehow.) In either case, shareholder profits are important. And bonuses for executives, based on those profits: meaningful but not extravagant appreciation of exceptional services.
One can argue that in health care — health care, not profit, should be the primary goal. And in some cases it no doubt is.
Speaking of complexity (we were, you know), my supplemental insurance initially was part of a group plan, obtained through my wife's employer. Pretty good deal. But apparently not a good enough deal for Medical Service Corporation's management, so they got out of the business, and another company took over their accounts. This was followed by, as I recall, at least one more transfer of ownership. At any rate, Premera Blue Cross ended up with it. And the ownership transfers seemed pretty seamless from this policy holders' point of view.
Eventually my wife's health declined drastically, and our son urged us to move to be near them, a 2,400-mile move from Spokane Washington to central Ohio. Premera Blue Cross kept collecting our monthly premiums electronically from our new bank — but the doctors, therapists, and hospital started billing us. Anthem, they explained, refused to pay, saying they had no record of us.
"Anthem? Who or what is Anthem?"
"Your ensurer, Anthem Blue Cross.
"Our ensurer is Premera Blue Cross."
"Never heard of them."
Another change of hands? I phoned Anthem. We weren't in their computer, and my bank statements, from my Ohio bank, still showed Premera extracting monthly premiums from my account. Anthem said they'd never heard of Premera either.
Premera said they'd never heard of Anthem.
Actually they had, higher up in the corporate bureaucracy, but the people who answered my calls didn't have a clue. Both are Blue Cross "franchises," but Premera's franchise is only for Washington state, while Anthem covers Ohio and assorted other areas. With that sorted out, Anthem now handles my expenses (those parts covered), but Premera still collects my premiums(!), and sends me summary print-outs (which are a mystery to me). This is called efficiency, and choice, the great advantages of the corporate medical insurance system. Do politicians not know these things? Or do they know them, but for political reasons pretend they don't? Some of them, I'm sure, have never actually thought about it; they simply recite slogans.
Meanwhile our doctors etc had had major delays in getting paid. Still do. The corporate wheels turn slowly.
Meanwhile Gail died, and there were adminstrative details to deal with. The hospice system (bless their souls) took care of many of them. But at least one further matter fell through the cracks.
Lots of us authorize our regular creditors — the electric company, the mortgage holder, our insurance companies…to withdraw our periodic debits electronically from our checking account. Our banks then list these withdrawals on our monthly statements. It's quick, organized, convenient, and generally accurate. I rarely use my bank card as a credit card. I do use it as a debit card though, punching in my code each time. So I have a considerable monthy list of electronic withdrawals. And on that list, each withdrawal is identified by some exotic-looking alpha-numeric code. Most of which aren't so hard to figure out. But a few were too exotic for my brain.
Still, I trusted. None of them smelled felonious, and I trusted the system.
Then, just recently, I checked two of them. They were taken out every month on the same day. So I stopped in at the bank. One was my health insurance premium. The other was Gail's. She'd died last year, but Premera didn't know that. Nobody (meaning me) had thought to tell them. Mea culpa; my fault. I suspect that Hospice would have taken care of notifying Premera if I'd mentioned it. As it stands, when I phoned Premera, they plugged the hole right away. Then I faxed them a copy of the death certificate, and by the end of the year, I'm to be reimbursed for Gail's premiums, for me a large sum.
There are two points to this story: (1) the existing "free market" system of health care is complex, inefficient, and expensive, a pieced-together patchwork; and (2) that humans and human institutions on either side of the equation make mistakes.
Are you old enough to recall when most doctors had either one or no secretary? Now they may have more clerical staff than medical. And that clerical staff is larger than you see. For example, billing involves various venders and agencies, and is commonly farmed out to a billing agent. And if you phone that agent with a billing question, you may find her harassed and uncertain, and afraid of (and unhappy with) your questions. One I phoned said she didn't know either! (Now that was reassuring.)
And we haven't even considered the (blessed) technical support staffs, a result not of bureaucracy, but of the many welcome scientific and technical advances from which we benefit via those tech folks.
As much as anything, we need a system in which profits and executive bonuses don't compete with health care. We need to shift their focus to the health care mission: which, extreme as it may seem, should be health care. That's what President Truman had in mind when he proposed national health insurance. He was ahead of his time.
On the other hand, how have federal agencies done in actually operating health care operations? The Veterans Health Administration for example. Actually pretty well, given the demands made on it, and tight budgets. In the late 20th Century, Congress closed some VA hospitals in the name of economy, citing genuine problems. The results have included some innovative improvements in veterans' health care. But particularly in the west, where distances between VA hospitals are large, to shut one down can be a blow to veterans, many with service-related health problems. Montana, the "Big Sky State," is the fourth largest state in the country, as you noticed if you ever drove across it. And it has no VA hospital at all. This problem has been eased but not eliminated by "health centers" and outpatient clinics.
Bad reputations from the past can be hard to live down, but how about this piece by Phillip Longman,, excerpted from the Jan/Feb 2005 issue of Washington Monthly online magazine?
….If the debate is over health-care reform, it won't be long before some free-market conservative will jump up and say that the sorry shape of the nation's veterans hospitals just proves what happens when government gets into the health-care business. And if he's a true believer, he'll then probably go on to suggest, quoting William Safire and other free marketers, that the government should just shut down the whole miserable system and provide veterans with health-care vouchers.
Yet here's a curious fact that few conservatives or liberals know. Who do you think receives higher-quality health care. Medicare patients who are free to pick their own doctors and specialists? Or aging veterans stuck in those presumably filthy VA hospitals with their antiquated equipment, uncaring administrators, and incompetent staff? An answer came in 2003, when the prestigious New England Journal of Medicine published a study that compared veterans health facilities on 11 measures of quality with fee-for-service Medicare. On all 11 measures, the quality of care in veterans facilities proved to be "significantly better."
Here's another curious fact. The Annals of Internal Medicine recently published a study that compared veterans health facilities with commercial managed-care systems in their treatment of diabetes patients. In seven out of seven measures of quality, the VA provided better care.
It gets stranger. Pushed by large employers who are eager to know what they are buying when they purchase health care for their employees, an outfit called the National Committee for Quality Assurance today ranks health-care plans on 17 different performance measures. These include how well the plans manage high blood pressure or how precisely they adhere to standard protocols of evidence-based medicine such as prescribing beta blockers for patients recovering from a heart attack. Winning NCQA's seal of approval is the gold standard in the health-care industry. And who do you suppose this year's winner is: Johns Hopkins? Mayo Clinic? Massachusetts General? Nope. In every single category, the VHA system outperforms the highest rated non-VHA hospitals.
Thank you, Phillip Longman, you really opened my eyes. Clearly there's been a lot of change in the Veterans Health Administration, its organization, facilities, staffing and standards, since the Bad Old Days.
At any rate, the health-care issues are broader and more basic than a national, one-payer health system versus the Free Market. We're in the process of getting more computer innovations in everything from monitoring physiological readouts; to digital — and legible! — prescriptions that would reduce errors in medication; to permitting medical records transfers that permit someone's records to be updated in something like real time among the different labs and specialists working with that patient. And no doubt to things I've never heard of.
But meanwhile we need more doctors. We need more nurses. And to have them will require years of education and training, and/or importing them. And to import them as a means of getting them more cheaply looks an awful lot like exporting good-paying jobs.
And nestled in there somewhere lies another problem: Doctors and nurses are reputedly overworked, overscheduled, and overstressed — not a life-style to tempt college freshmen. And internships are said to be a holdover from 18th century bond slavery. Meanwhile, medical school is highy expensive. (Though there are various entirely legal ways of financing a medical education, if your grades are good enough. A good high school counselor should be able to get you started.) And doctors do make a lot more money than most of us. If they live long enough, they can enjoy a high quality retirement. But if we want enough doctors, we need either to find a lot of highly dedicated candidates, or else make the physician life-style (and the nurse life-style) friendlier to pursue.
Both would be good.
A Long Hard Look— The overall problem is a lot bigger and tougher than all of the above combined, although they are part of it. There are innumerable "medical" disorders, almost all of them unpleasant in one respect or another. And there are more and more approaches to their treatments, with still more on the production line. At the same time, people don't want to suffer or be inconvenienced — and certainly not to die (shudder).
"Quick-freeze me, so I can be thawed out when they have a cure!" (Talk about culture shock — waking up in a society you can't understand, with no sense of the technology, perhaps to live on in a museum — or a 22nd-century freak show.
Eventually, each of us will die, in my case probably sooner than you, unless you hang around really tough neighborhoods. You and I are going to experience death in one form or another. (There's something to be said for getting used to the idea.) And unless you die young, you'll undergo a period of decline before that.
I experienced my father's rather quick death when he was 54 and I was 6. My mother's long slow decline came when I was middle-aged. My sweetheart/wife's death, at age 78, was relatively easy and painless, and we'd had several years to get used to what was closing in on us. Getting used to it. Reviewing inwardly. Growing in love and understanding.
None of those are typical; there is no "typical." Circumstances differ.
People differ; some may never get used to it; to some, that may be beyond contemplating. But those who do get used to it are part of the solution, a locus of balance and sanity on the issue. I have several degenerated disks that sort of hamper me — except they don't, really, because I've long since learned how to live with them, actively and comfortably. (Lucky me.) In fact I'm at least as happy now as I was at any previous time in my life. Lucky again. And finally, my Advance Directive stipulates that when only being "plugged in" keeps me alive, they're to pull the plug.
I wouldn't try to convince anyone; those are very personal issues. But those, broadly, are the facts as I see them, for you to examine if you wish.
Dealing with the Costs— The biggest knocks on single-payer government health care systems are the cost in taxes, and the waiting lists for major surgeries. But if you don't pay for it in taxes, you'll pay for it in insurance premiums, or out of pocket. TANSTAAFL (there ain't no such thing as a free lunch); someone pays.)
Which brings up another point regarding our vaunted "Free Market" health care system. (A "Free Market" system heavily and crudely shored up by governments and other non-free market entities.) In the past, churches built and operated many many hospitals in the USA, many (most?) of which, in this high-cost time, are now operated by non-church entities. There are also county and municipal hospitals. Horrors!
And of course there is Medicare, which is federal. And Medicaide, which is a state program, to some degree under local authority. In some states Medicaid is subcontracted to private health insurance companies. Getting approval can be complicated and difficult. And if you lose your apartment, move three blocks, then discover there's a county line inbetween, you're likely to lose your coverage and need to go through the approval procedure again, with no guarantee, because the requirements may be different. Some people in poor health live in their car, to keep their medicaid eligibility.
Approximately 60 percent of poor Americans are not covered by Medicaid.
Who are those medicaid-eligible folks, anyway? They're people with too little money to be worthwhile(!) and too young for Medicare. (Although some conservative legislators fought the program anyway. To quote Ebenezar Scrooge: "Let them die then, and reduce the surplus population.")
(On the other hand, Republican senator Orin Hatch, an epitomal conservative, co-authored the State Children's Health Insurance Program [SCHIP] in the Senate).
Congressional Health Care
(not ready to post yet)
All health care, whether via a government bureaucracy or multiple corporate bureaucracies, grows more expensive as more and more pharmaceuticals are developed. And more sophisticated — and expensive — equipment is developed for more and more conditions, some of them a matter more of cosmetics or convenience than anything else. It can be somewhat self-indulgent. A treatment or apparatus enabling you to walk is one thing; but "I need an operation to improve my golf swing"; or "I need a prescription, or surgery, to improve my sex life…" And inbetween, many things more problematic. There's nothing wrong with any of those, but urgent? Can they wait a few months?
A new perspective could help a lot, but new perspectives can be hard to examine.
Do you read the Bible? Even some of we heathens read the Bible from time to time. It's an interesting book, and thought-provoking. Notable, in this regard, is the book of Ecclesiastes: "Vanity, vanity, all is vanity!" And further on down the page: "For all things there is a season, and a time for every matter under heaven…. A time for living and a time for dying…." That's pretty obvious, if you actually look at it, but today's culture tends to be greed-oriented and impatient: "I want it all, and I want it now!" Not everyone, but those are the values that marketers work so hard at instilling, with considerable success.
Want. That can mean: "I'd like to have…" or "I could use…" or "I demand…!"
Golf swing. Sex life. Tummy tuck. Colder beer… I could use a tummy tuck. Recently I lost about 20 pounds, but my durn skin didn't shrink. On the other hand...what the heck. No one expects me to be pretty.
Back to the cost and efficiency of health care systems. Sweden's national health care system seems to be the favorite example of a successful program. But just how successful has it been, actually? American politicians often claim we have the best health care in the world. People (most of them wealthy, I assume) come here from many countries for medical treatment.
In a BBC on-line article, "How the NHS [British National Health Service] could Learn from Sweden," health reporter Nick Triggle compares Sweden's with other health care systems in Europe. "Whenever health systems are ranked," he tells us, "Sweden's always seems to come top or at the very least a close runner-up…. Cancer survival rates, infant mortality and life expectancy figures all outstrip many of its European neighbours. So how does Sweden do it and what can [Britain's] National Health Service learn?... Sweden has a long history of spending lots of money on health."
Triggle then proceeds to review, briefly, key aspects of the Swedish system.
Meanwhile, how does the American "system" compare, in terms of health and cost?
The World Health Organization summaries include many different measures for each of the 100+ member nations. Because the published tables didn't fit on website pages, they were broken up and awkward to use, so I arbitrarily used data for 7 "first-world" nations (Sweden, Switzerland, Canada, the UK, Germany, the Czech Republic, and the USA); also 2 ex-USSR nations (Russia and the Ukraine); and 3 nations in the process of becoming first-world nations, (China, India, and Mexico).
I selected four straight-forward, readily understood measures: Life expectancies for males and females. The USA ranked below five of the other six first-world states I've included. In infant mortality, we ranked the worst of the seven first-world nations used. We also ranked worst in deaths of women in childbirth, among the seven first-world nations...and below both ex-Soviet states.
Those are the measures used in most comparisons.
(You don't suppose the bulk of US deaths in childbirth could be largely of women who couldn't afford regular medical examinations, do you? Surely not.)
In deaths per 100,000 population between ages 15 and 60, we ranked #6, between Germany and China. (Between ages 15 and 60 eliminates the statistical effects of childhood deaths, and deaths from "old age"). For the most part, the first-world nations, including the U.S., did substantially better than "third-world nations."
Not bad, but nothing to brag about. Certainly not grounds to claim the best health care in the world. Sweden led the nations I used, followed very closely by Switzerland, but Iceland was up there with them, in a cluster that also included Denmark, Finland and Norway.
So. Sweden was either the best or very near it. Our only real claims for best, I suspect, is in prestige specialists and research. Clearly we're not the best for health care in general.
Ah! But we're supreme in cost efficiency and effectiveness. Right?
Far from it. According to the Congressional Research Service, in 2004 we had the highest health care costs in the world, at $6,102 per person. Other nations of particular interest were Canada, at $3,650; Sweden at $2,825, and the Czech Republic at $1,362.
More efficient then? We must be: we hold more closely to Free Market principles, and we have more billionaires than any other country. No?
Breaking down those costs (again for 2004), the number of doctor visits per capita in the United States was well below the OECD average, yet the United States spent $2,668 per capita on outpatient care alone, three-and-a-half times the OECD average and twice as much as the second-highest spender, Luxumbourg, in this category. (OECD stands for Organisation for Economic Co-operation and Development, which archives the records.)
In fact, assessing what drives the difference between health care spending in the U.S. and the rest of the world, some leading health economists responded this way: “It’s the prices, stupid.” Put more formally, a report from the OECD declared that << there is no doubt that U.S. prices for medical care commodities and services are significantly higher than in other countries, and serve as a key determinant of higher overall spending. >> (That's an edited version of the original, to make it more clear.)
Note the word "commodity"; health care as a commodity. To me that suggests a skewed emphasis. Or screwed emphasis, if you prefer.
Closer examination uncovers all kinds of complex interactions in cost accounting. Whatever health plan our next federal administration comes up with, there is no way in heck it will be perfect, let alone please everyone. And "outpatient" has a somewhat different meaning in the USA than in other countries. For example, a patient in a U.S. hospital, who is under the care of an outside physician rather than a staff physician, is reported as an outpatient, even though he's staying in the hospital, and being charged by the hospital for hospital facilities.
There's probably a sensible reason for that, but it complicates comparisons.
And now, back to Sweden: if the Swedish system is so great, why do they reform it so often? If it's so damned good, why don't they leave it alone? (Hmm. And why aren't we driving 1930 Packards? There was a good car! I learned to drive in one.) First the Swedes work from a different viewpoint, treating their system as a system in the making. From time to time they adjust it to fit changing circumstances and growing understanding.
Beyond that: (1) the available money is limited, (2) the knowledge is limited, and (3) things change, including human values and opinions — like everywhere else. In Sweden, the biggest gripe is the waiting times for some types of surgery, in spite of their having more doctors for the number of people. (On the other hand, in Sweden there is less waiting to see a doctor, and the doctor doesn't rush you out the door with questions unanswered.)
There is a comprehensive 140-page book (in English) titled Health Systems in Transition: Profile on Sweden. I skimmed the detailed table of contents, then read very carefully the Conclusions, which paint a picture of the history of the Swedish system. A history of careful planning, five decades of experience, and a series of reforms to incorporate lessons learned, changes in medical science, practices and needs, and perceived shortcomings. It's been remarkable successful, and all in all, the Swedes like it. The major complaint has been, as already mentioned, waiting for surgery, and access to services involving expensive, late-model equipment.
There people wait. Here many people don't even "get in line," because they can't afford the service. Look at that; really look at it. If you can afford it, there's not much wait (unless you're on Medicaid).
Thinking Outside the Rhetorical Lines—
There are aspects of health care that get overlooked a lot. My physician in Spokane WA, 7 or 8 years ago, told me how healthy I was "for your age," adding that "if you keep up that power walking, you'll live to be a hundred." I answered, "don't wish that on me, doctor."
But his point was valid. Ordinarily we can improve our health to a degree by paying attention to how we live. It's remarkable what can be accomplished. And breaking dumb-ass habits can be helpful, both in regard to day-to-day bodily function, and in avoiding accidents, strokes, heart attacks, gum disease and the like. (Gum disease is no joke; I've been there, and fortunately lucked out.)
We don't know what drives other people — a lot of the time we don't know what drives ourselves — and we've got no business trying to coerce others to live any particular way. Certainly not past childhood. But we owe it to our loved ones to point out the forseeeable costs of certain practices. And within reason (which basically means not driving while under the influence, eating yourself hog fat and diabetic, and getting yourself all overwrought over something that actually doesn't amount to a pint of, uh…dog waste product.
Good advice, of course, is cheap, even if it's actually good, unless it comes from a professional. And as you may have noticed, professional advice may not be worth much either, though the odds are better. On the other hand, advice may be just what you need. Depending on whether you're receptive, and whether you're able to follow it.
Of course, if you're a total butthead, we'll have to hope you don't take down a bystander and wreck (or end) someone's life because you're irresponsible. Think about it.
Sane living is not going to end ill health, but statistically it can postpone it and alleviate it. And good advice sure as heck won't end even blatantly stupid decisions, let alone actions that seem okay at the time but end up causing you great grief.
On the other hand, decades of mild pressure and selected restrictions, plus serious increases in cigarette taxes, have produced a culture in which cigarette use is much reduced. I'm not suggesting cultural warfare, or shame campaigns — Lord preserve us from those! — but it makes sense to keep our culture trending toward healthier, and generally wiser, living. That could help importantly with health care costs.
And transparent health care costs could help move us toward healthier living.
In Scandinavia, hard liquor is very expensive, but beer is cheap, and of course about 1/8 as intoxicating. And if a driver is found with a blood alcohol content of 0.2 (first offense, no aggravating circumstances!), he or she is fined, the fine determined by income level. (Apparently they try for equality of pain!) Penalties get stiffer with increased BAC. For a blood alcohol content of .10, add a minimum of 1–2 months in jail! Cause a fatal accident with a BAC of .10 and you're looking at up to six years in jail. Most European countries have comparable sytems.
That's bound to reduce both drinking and traffic accidents.
Here's another thought: in some American constituencies, if you're convicted of headlighting deer (poaching deer from your vehicle), your vehicle as well as your gun can be confiscated. Why not confiscate the car for a second conviction of DUI? Now there's something to contemplate.
There's a limit to how much can be accomplished by laws, but laws can contribute to the evolution of personal/social/cultural responsibility, which seems to me an important element in any successful resolution of our health care situation — and the rest of our future.