Monday, September 22, 2008
I am in Washington attending "The National Congress on Health Reform," so I am liable to commit some serious off-topic blogging over the next couple of days. Apologies in advance. It is a subject that interests me both professionally and as a blogger, and I even agree with the lefties on this key point: We ought to reform the system in a fairly comprehensive way. However, I also ask questions that the progressives rarely discuss, but should.
As the son of a doctor who has uncles that are a dentist and a biochemist and cousins who are nurses, I laughed at the American Prospects list of the 10 reasons American health care is so bad.
Any list like that which doesn't include the current state of American tort law is lying. My father was paying his nurses more than he made in the last year he practiced medicine. He was only sued once, wrongly in the 1970's, but that didn't save him. He gave up his license too soon because he couldn't afford to pay the insurance premiums, in large part due to John Edwards style "making wealth through lawsuits" kind of law.
That is the criminal part of the current "debate" on health care. Very few people are willing to treat the disease, they just patch up the symptoms. We have too many elected officials who are lawyers who will not admit their profession is a part of the problem, so they point the fingers at the insurance companies, the doctors and their administration.
Way to go. As someone who has lived overseas for several years, had a couple kids there, and otherwise received care from one of the world's best health care systems, I've reached a few conclusions about how the American system must be changed in order to be successful.
First, the notion that employers should be responsible for one's healthcare, by paying premiums and such, is a poor idea. Perhaps in a previous era this might have made sense, but the relationship between employer and employee is inherently antagnostic and giving employers this power does not empower workers, it undermines them, by increasing the hazard that occurs when an employee changes jobs to improve their situation.
Second, there is only one institution in whose financial interest it is for American citizens to be healthy throughout their entire lives, and that is the United States government. Therefore, it is the government which should be actively providing certain preventative health care, such as vaccines, for which no other institution has a particular interest in providing. On certain days in my town overseas, for example, all young children are periodically examined and immunized by a row of doctors for free at the city hall.
Third, Americans have two cultural issues with respect to health care that must be addressed in some fashion. One is the low regard and understanding of "customer service" held by office staff and even doctors themselves. This is not about being "nice", but rather allowing patients to make appointments in a timely fashion (among other things) and ensuring that the information patients and other caregivers need to know is properly handled from start to finish. Second, and this is probably related, the notion that patients must be their own advocates (asking questions of their doctor, getting second opinions, checking their bills, making appointments, etc., etc.) is a poor approach that allows doctors and other care providers to disown responsibility for the patient. I'm not saying these attitudes can be changed, but rather, there must be some attempt to mitigate their negative effects, perhaps through the improved use of informatics, insurance handling, etc.
So squealer, you feel those things are provided in the socialized setting? Customer service in England/Canada and appointments in a timely fashion? US doctors to provide an extra hour of service per your requests for the same $45 reimbursement? The US government is here to help you and will make your doctors to so, until they close their doors in perhaps 30 days inorder to avoid obvious bankruptcy. Canada, England, Cuba? The reward there is to see as few patients as possible. Get real.
Anon, there are a lot of solutions that take into account the points that Squealer makes that do not involve "socialism," per se. The ugly truth is that we pay far more for our healthcare in this country and get worse results. That is dumb, and we can fix it without socialism.
The "worse results" claim is 100% bogus. The way that claim is arrived at is so dishonest even a 5 year old could rip the argument up. Canada's system is in financial trouble! And of course if you let people die before their care, it will bring down costs dramatically. Ted Kennedy if an average person would be dead if he were in England, Canada or Cuba.
But, hey, if you want that, go for it. The average wait time for an MRI in Canada is 10 weeks, if you are able to get a referral which is doubtful. The average time for surgery after a diagnosis of cancer in Canada is beyond what US oncologists say is standard care. In almost every case of cancer care in Canada, considered the best socialized system, every cancer patient and subsequent would be a winnable malpractice case in the USA.
So do you plan to go to Canada or England for your care? And why are Canadians flocking to the USA for their care? It's great for colds and you need only to see a nurse. And why did Ted Kennedy choose substandard American care?
There will be a mass retirement. Why are 90% of England's doctors FMGs? Why are there no English national doctors? Good luck with that.
Ezra Klein calls Rudy Giuliani's claim that his survival rate for prostate cancer was double that of in England's a "straight lie". Maybe Giuliani's numbers aren't exactly right, but I think it is clear the UK NHS does statistically poorly compared to other countries when treating particular diseases. A close family friend got cancer recently and (I helped in the research) found that the best survival rates for that disease were highest in the US, but Australia was so close behind as to make no difference. But the UK survival rates were at a significantly lower level. This is an issue even in Britain. Maybe the differences aren't as big as Rudy claims, but there are real and undeniable problems in the UK.
But even though treatments were generally good within the country (Australia) there are variations in quality of treatment internally. Because the friend had private health insurance to supplement the standard Medicare coverage that person could get surgery from a doctor reckoned to be one the best in the country. Of course, survival rates are only a statistic. Where you fall in the distribution is an individual outcome: even where survival rates are 99%, you may still be in the 1% that dies. But it is only natural to stack the odds in your favor. At any rate, the treatment was probably good and the total out of pocket, including a week's stay in the hospital, came to about $600 after insurance reimbursements, which was pretty reasonable considering.
Two observations may be in order. In Australia you can get (and are encouraged to get) private health cover in addition to the system funded through taxes. This has the effect of giving the individual the choice of adjusting his health cover to conform to his risk/preference profile. If you don't like the basic menu, you can get extras. Second, private insurance unloads the public system and leaves it to the relatively poor, which is good. Because from what I can see anecdotally the Australian public health system has no real margins. ER rooms can take hours to clear patients, even those clearly in distress. And some hospitals have shut down wards to save money. I remember thinking that if a truck bomb went off in Sydney and 500 seriously injured people needed simultaneous treatment then the true cost of "just enough" would soon become apparent.
Why do people get private cover in a country with a universal public system? They want choice. They may not care if a government provided doctor treats them for broken arms, but would sell the house to find the absolute best man for pancreatic cancer.
With regards pharmaceuticals the situation is more complex. There is a list of subsidized drugs. And this helps pensioners and the poor who quite happily pop their heart medication and maintenance drugs without it costing them too much. Of course, none of this is "free" because taxes make up the difference in the end.
I think there is no "free lunch". But there are relative efficiencies. A good health care system allocates resources well without destroying essential consumer choice. Some societies may also find it desirable to put a kind of floor to ensure everyone gets at least some level of care. But the hard reality is that an inefficient system collapses on itself in the end. The key problem is to find the inefficiencies and try to get the market to solve them, intervening only if the market simply can't. Of course, the social context matters too. Australia which is a relatively small, culturally homogenous, comparatively fully-employed place without a land border doesn't have (I think) a very large free rider problem which more diverse and wide-open societies might have. Therefore things may work in Oz simply because it is Oz.
Here in California a single law firm has sued 400 businesses in a year for $5,000 each because they are not in compliance with the Americans with Disabilities act. No proof that their businesses do not comply has been offered, just an allegation. The businesses have to hire lawyers and fight, which is expensive, or pay up, which is expensive. That expense is passed on to consumers.
In the same way abuses by the lawsuit industry have added to the cost practicing medicine in the US since at least the 1970's, when my father's insurance premiums doubled a few times. Treating the symptom and not the disease is bad medicine, and bad public policy.
Let's start with California and eliminate all possibility of suing a doctor. Let's see what happens in four years to the price of malpractice insurance and the quality of medical care. Whatever we do, let's be very careful, because once we institute government forced medical care for all, we can never go back.