No Matter What it Costs

Here in the land of the free, medical care is not. Most of us can’t figure out what it costs, and some of us don’t care. No wonder it doesn’t work very well.

The symbol you see here is a Caduceus which is an icon adopted by most commercial interests in the health care industry.  The Asclepius, which is pretty much the same except for it’s derivation and the fact that it only has one snake, is representative of most health care professionals…doctors, nurses, etc.  Interestingly there is no symbol that represents the most important constituency of the health care industry…the consumers…me and you.  The derivation of each symbol, and how it came to represent the various factions (which I will not bore you with) makes about as much sense as how we consume and pay for health care in the United States today.

Can we all agree at the outset that health care in America is a mess, and no one knows for sure whether the most recent health care legislation (Obamacare to some of you) will make it better or worse.  Let me give you some facts:

1. According to George Will, who normally gets his facts right, individual consumers of health care pay only 12% of total costs for services provided.  Someone else, insurers, government, employers, etc, pay the other 88%.  Twenty-five years ago individuals paid 47%.  Granted, it cost a lot less then, but you get my point.

2. The US leads the world in health expenditures per person at approximately $4500, but is last of all developed countries in life expectancy.

3.  We are second in the league tables for MRI machines per million of population after Japan, but we’re last in number of deaths per 1000 live births for all developed countries.

4.  US health care costs as a per cent of GDP are the highest in the world by a wide margin at 17%, but the per cent of health care costs paid by the government is the lowest at 45% compared to other developed countries who range from 67-82%.

5.  And finally, while it’s widely agreed that if one has enough money, one can get the best care in the world here, that care is not accessible for most of our fellow citizens.  To wit:  life expectancy in the US, in spite of spending over $2 trillion dollars a year (about twice as much as any other developed country), is dead last of all developed countries.

Something just ain’t right.  And it’s going to take us to the poor house, if it hasn’t already.  Like the Caduceus and the Asclepius, the reasons for all this are complicated, and even if you understood it all, it still probably wouldn’t make much sense.  If the facts stated above are a surprise to you, you’re in good company.  In the recent debates about health care reform, I recall no discussion in which the parties started with a clear statement of the problem before launching in to their particular brand of political rhetoric.  Let me take a crack at what they didn’t do…clearly describe the problem succinctly without political polemic.

 WE ARE SPENDING TOO MUCH AND GETTING TOO LITTLE FOR TOO FEW.

The $64,000 question….no, the $2 trillion question is…whyzzat?  Let me give you a clue.  We are part of the problem.  Of the three major constituencies who consume health care, two of them don’t care what it costs.  The fully insured (those with private insurance provided by their companies or medicare), and those who rely on public institutions at no cost to them, have no motivation to question the cost of their care.  The cost of care is someone else’s problem.  The third constituency, those with high deductible, limited coverage insurance care a lot about cost, and they behave as very well educated consumers should behave.  They shop around, they ask about costs, they ask about alternatives, they ask about medical necessity, and they ask about outcomes.  Most of you reading this piece will belong to the first (fully insured) group.  Be honest.  Can you tell me the last time you had a conversation with your health providers about costs.  And if you did ask about cost, could they tell you.  I thought so.

Those of us who are willing to face the fact that the system is broken know that there are many reasons. I’ll name but a few:

1. Too much bad government regulation

2. Not enough effective government regulation

3. Fraud and abuse by unscrupulous providers

4. Defensive medicine

5. Runaway legal costs for medical malpractice torts

6. Rapid proliferation of new medical technologies

7. High development and marketing cost for new pharmaceutical products

8. Fee for service billing practices not tied to outcomes

9. Inefficient private insurers

10. Inefficient public plans (medicare and medicaid)

11. Misalignment of financial incentives of medical care providers

12.Lack of individual accountability

13.Poor consumer behavior

14. Too much use of emergency facilities for the primary care of uninsured consumers

The odd thing is that most knowledgeable people would agree on most of these causal factors, but still can’t agree on a course of action to address the underlying problems.

The harsh reality is that about one in six (slightly over fifty million) of our citizens have no form of health insurance either because they don’t think they need it or because they can’t afford it and don’t qualify for an existing government plan.  Mostly the latter.  It’s pretty clear that these one in six are going to get sick and need care at some point.  Some of them won’t get care when they desperately need it, some won’t get timely care, and some won’t get the quality of care they need.  Hence, the US has the highest mortality rate in live births per thousand of all developed countries and the shortest life expectancy.  Is this crazy or what?  And to compound the craziness, the care that is provided for this group through city and county hospital emergency rooms is the least efficient and most costly.

There is no evidence available yet that the most recent health care reform legislation (The Affordable Health Care Act)  will help, but I have to believe that problems caused by man can be solved by man.  I’m pretty sure, though, that name calling won’t help.  Let’s keep working on it until we get it right.

Health Care: Socialized (Or Not)

America’s struggle to provide universal access to affordable health care has proceeded in fits and starts. The only constant has been vitriolic opposition and misinformation

This discussion must start with an affirmation of fundamental belief.  Do the citizens of the United States have a right to affordable health care or not?  I believe the answer is yes, but my belief is more rooted in a moral than legal point of view.

Although our Declaration of Independence assures us that “life, liberty and the pursuit of happiness” are inalienable rights, there are more than a few American who would disagree that the right to affordable health care is not embraced in this statement of fundamental rights.  I’m not going to mount an argument against them on this point, although I think they are wrong.  I will simply say that all of our fellow human beings and citizens have this right because it is the right, the moral position to take.  Others disagree.

Every attempt to achieve universal coverage and health care reform beginning with FDR and continuing through the current administration’s attempt has been met with ferocious opposition.  Indeed, the negative fervor has often approached hysteria.  The epithet of choice has been “socialized medicine” as if invoking this now pejorative term would evoke visions of Lennin, Kruschev, and even, god forbid, that rascal, communist, Castro.  Indeed,  as early as 1953 when Harry Truman thought to propose a form of National Health Insurance, Senator Robert Taft (R) Ohio characterized the initiative as a “socialized plan”.  The American Medical Association, recognizing a threat to America, assessed each of their members $25.00 to fight the plan, speculating whether “socialized medicine might lead to socialization (sic) in other forms of American life”.  In 1961 as battle lines were being drawn in the fight of what would become Medicare, Ronald Reagan, then on the payroll of General Electric, recorded a speech wherein he weighed in on the threats of  “socialized medicine” intoning that it was “antithetical to freedom”, and added that “… the easiest way of imposing socialism on people is thru medicine.”

In 1965 LBJ continued to implement his version of The Great Society with the passage of PL 89-97 Health Insurance for the Aged and Medical Assistance, but it had firm resistance from guess who?  Ah you got it.  The American Medical Association and the Republican Party.  In the Senate, the Republicans voted against it 17-13 and their colleagues in the House had 68 nays out of 138.  As for that paragon of progressive thought, the AMA, Dr. Edward Annis, their president at the time of passage, cried in despair on public television when the favorable vote was announced.  This, of course, is the same guardian of public health that strenuously opposed putting warning labels on cigarette packages.

Let’s think about this a minute.  Socialized medicine, hmmm.  What exactly does that mean?   Let’s parse it down.  Socialism:  an economic organization characterized by state, public, or common worker ownership and administration of the means of production and distribution.  You know, like public libraries, public schools, or highways.  Now that’s socialism.

It follows then that socialized medicine is a system in which the government, acting on behalf of the people, owns and operates health care facilities and employes directly health care professionals.  Examples would be the National Health Service in the United Kingdom and the health care systems in such socialist places as Spain, Israel, and Finland.  We also already have socialized medicine right here in the good old US of A.  The Veteran’s Administration, the Indian Health Service, and yes the Army, Navy and Air Force Medical Systems each practice a pure form of socialized medicine.  In each of these, we, the government, own the facilities, operate the system and employ the health care professionals, and delivers care to their constituents.  I think it’s at least a little odd that the AMA and conservatives in general aren’t clamoring to turn these elements of socialism over to the free enterprise system.  But, of course, they’re not clamoring for any such thing.

What about Medicare?  Well it’s a little different.  It’s called a single payer system, and the single payer is Uncle Sam.  But Uncle Sam does more than just pay.  It sets the terms of coverage and reimbursement much like private insurers do for the plans they sell.  Those covered by Medicare pay premiums based in part on their ability to pay and the difference is subsidized by the government.  It’s actually more complicated than that, but the details aren’t central to my point.  Yet many refer to the Medicare system as socialized medicine.  Certainly the AMA did in 1965 when they were opposing it.  So did George H.W. Bush who referred to it repeatedly as “socialized medicine” and Bob Dole (who now gets his Viagra through Medicare) who said, “I was there fighting it, voting against it….because it was socialized medicine, and I knew it wouldn’t work.”  Yet no one today is suggesting we should get rid of Medicare.  OK, maybe neanderthal Newt is, but even the AMA now loves Medicare…..even though it is by their definition “socialized medicine”.

As a result the term socialized medicine has come to mean any type of publicly funded health care program……that doesn’t currently exist.  You can see what they’ve done though.  They’ve hijacked the term, wrapped it in a negative connotation and now use it to frighten the bejesus out of anyone and everyone.  And it’s working.  That’s actually pretty clever.  Pick a negative word, attach it to something you don’t like, say it over, and over, and over again until it has the meaning you wish it to have.  OED be damned.

So what’s the problem?  This is not a semantic exercise. Lemme cut to the chase.  There’s two big problems.  First, not everyone can get health care when they need it, and second, the cost of health care is going to bankrupt us all if we don’t fix it.  What, you ask,  do I think?  I think the nay sayers are always going to oppose change that benefits anyone other than themselves,  and Obama and his minions haven’t done a very good job at putting forth a simple, straightforward framework for revising the system to solve the critical problems.  They’ve thrown in everything but the kitchen sink, and we’ve wound up talking about death panels rather than universal coverage.  We need a plan that:

1. Provides for universal coverage of all citizens that is affordable

2. Reduces the total cost of providing health care to our nation to a level that is manageable

3. Improves the quality of health care outcomes achieved (We ought to at least be better than Slovakia, for cryin’ out loud)

4. Demands accountability from all constituents of the system including consumers of care, providers of care, administrators of care and government policy makers.

You can call it whatever you want.  I call it common sense and self interest.