Friday, July 06, 2007

More Solutions, Long Post

Free health care isn't free. The money has to come from somewhere; the question is how to get it into a bucket, and then how most effectively to get it back out, to where it's needed. People frame it in all sorts of ways, depending on their political persuasions. Andrew Sullivan says that in arguing for government to pay, liberals would have us all be permanent supplicants. Brilliant. And it fits nicely onto a bumper sticker. But it's fatuous. If the ultimate virtue is the taking of money out of one's own pocket and paying directly for one's health premiums, then probably less than 10% of Americans are virtuous. (No comment.) Premiums are paid by employers, by governments, but by only a few individuals themselves (I'm among them.) We're already supplicants. (Well, not me.) If there were universal coverage, taxes would go up somewhere, but premium expenses would go down. The money that goes into the bucket, in other words, would be mostly a wash. Left hand or right hand, it comes and goes. My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over. That would be good, by whatever method the money is taken from us, and by whichever agency it's given back in the form of health care. Package it with a name that makes you happy. Money comes from us one way or another, gets centralized somewhere, and returned in the form of plaster and penicillin. In what way does having insurers in the middle help that happen?

The always-thoughtful Eric worries: "The problem I have with single-payer systems is that I fear a serious erosion in innovation - what compels a single-payer to add coverage for a new-but-expensive lifesaving modality? If your choices are "take what you're given" or "pack sand and pay for it yourself", new technology won't be deployed to save people's lives nearly as quickly." He makes an important point, but, like my concern about monolithic control of reimbursement, it can be addressed (so says me, the non-politician, non-economist, non-systems-wonk) by having at the top panels of consumers and providers making reality-based (remember that bygone concept?) decisions. If such a structure were in place, given that we're now talking about a single entity instead of hundreds, it would be possible for providers and consumers actually to have control. This makes a strong argument for single-payor, as opposed to our current situation, wherein we're divided and conquered. How should such panels be constituted, by whom, with what feedback loop attached to the citizenry? I'm thinking, I'm thinking! But I'm guessing people much smarter than I could figure it out.

I haven't seen "Sicko" yet, but I've seen M. Moore's other movies, so I'm guessing that at its center, he has the problem right, and that in examples and solutions he's overplayed his hand with anecdotes and shot himself in the foot with hyperbole. Speaking of which, in a review of the film James Christopher of the London Times says, "What he hasn’t done is lie in a corridor all night at the Royal Free watching his severed toe disintegrate in a plastic cup of melted ice. I have." Interesting: in my opinion, universal health care has no business covering the re-implantation of toes. Fingers, yes (depending on which ones). Toes, unh-uh. If surgeons use big toes to replace thumbs, -- and they do, they do -- that they are otherwise dispensible, foot-wise, is spoken to. A thing to which it is spoken.

And that gets us to the nitty-gritty. The bucket isn't bottomless. We can decide how much it holds, but at some point we also have to decide for what kinds of care the contents will be doled out; unless we want to make it bottomless, which we could in theory, but won't and can't in fact. Keep the costs down, we all say, except (you know what's coming) when the care in question is for us or our loved ones. "Spend a little as possible on them, and as much as needed on me" is a plan, all right, but is hardly a workable one. (Less so in the minds of one political party than the other). But let me be clear (since I've given myself the soapbox): I'm OK with tiers in the system. Not tiers of joy, to be sure. But this is America; plus I've said in my previous post that I think payments to providers ought to reflect quality of work: if I'm asking for rewards for the quality of my work, I can't begrudge it elsewhere. It's not without moral unclarity (if health care is a right, it doesn't automatically follow that people should be barred from obtaining different levels thereof), but the idea that there might be a difference between basic coverage given to all, and that available to those willing and able to spend more is one I can accept. It's just the way it is: a system that is the same for everyone with no avenue for opting up won't fly, pragmatically, at this point in the US; but one that provided everything for everyone under all circumstances will bankrupt us, absolutely, eventually. Heck, we're heading there (bankruptcy) already, on more than one track.

It's either/or. Either we decide as a nation that we're happy spending whatever it takes on health care, or we address the issue of rationing (ok, let's call it "prioritizing.") Some countries do it openly: in England, on "the National" it was true at least at one time that, for example, a person of a certain age with a certain percentage of body burn got supportive care only: pain medication, comfort. Some do it de-facto and maybe even cynically: in Canada you have to wait a long time for certain procedures, which means some don't get them, even though it's not specifically proscribed. A few years back a British orthopedic surgeon responded to outcry over long waits for hip replacement by saying that the line wasn't as long as it looked, since some people die while waiting for the operation. Probably the hardest thing any health care worker does is deciding when further care is inappropriate. It goes on all the time; it's just not formalized. Somehow, sometime, on paper and in public, it needs to be. A comatose hundred-year-old in kidney failure doesn't get dialyzed. A ninety-five year old? Not him, either. Sixty? Sixty-five? OK, eighty-five? And if the idea is repulsive -- which it is -- and if it simply can't be addressed (certainly Congress never will), then let's just agree that the best we'll ever do is nibble at the edges. Which, to date, has pretty much meant nothing more than continually lowering reimbursement to doctors and hospitals. Turnip. Blood.

Outraged comments on posts such as this notwithstanding, people willing to work extremely hard under lots of stress to provide an excellent product have a natural inclination to expect some sort of commensurate reward. Certainly no doctor expects to get as much as a mid-level executive for Healthcom, or as much as a second-string second baseman. But something that reflects work and which doesn't continually drop would be nice. The price for the current approach has been, and will continue to be, burnout of the best, and the looking elsewhere than medicine by the sorts of people you'd like to see choosing it as a profession. The problem with us goddamn doctors is that we're also human beings. Tell me what you think a colon resection is worth, then stop lowering the amount every year. And if you won't let me charge more on my own because I do a better job (every other professional does), then show me a way you'll try to figure out if I'm better and slip me a little something. If not, don't expect everyone to keep striving. It doesn't work that way anywhere else; increasingly, it's not working that way in medicine, either. Which makes the next paragraph, probably, wishful thinking.

There's one thing to do before playing the rationing card. Doctors, as a group, have a hard time with it; but it's coming, and it needs to arrive. To the extent that it has arroven (yes, I know), so far it's pathetic. I refer to finding out what works, why some doctors get better results than others, why some can get the same results as others at half the cost. Determining, in other words, "best practices." Finding that out and putting in place methods to encourage the good and eliminate the bad. Care, that is. What we have so far, referred to by the much unloved acronym "P4P" -- which stands for "pay for performance" -- is, at best, silly; and at worst, counterproductive, because it's so stupid. An example of bureaucracy at its worst, the list of parameters seems to have been generated by a committee with little input from actual practitioners. Big surprise. I know medical quality is hard to quantify, to solidify into a checklist. But for surgeons, for example, the archetype is getting pre-op antibiotics into the patient no longer than an hour before surgery. Funny. In training, we were told to get it infused at least an hour ahead of time, so tissue levels could rise and equilibrate. Yeah, you can measure it and write it down. But what goes on much before that -- in terms of selecting and planning an operation -- and after that -- in terms of carrying it out and in providing post op care -- has volcanically more impact that the ticks of the antibiotic clock. Everyone knows that. Getting a handle on it is where the action is; but if it's possible at all, it'll take a hell of a lot of work. Thousands of records will need to be reviewed, outcomes compared, methods dissected. Necessarily, judgment will be called into question, egos will be threatened. Worse, errors in data collection and analysis will be made; conclusions may be wrong sometimes, or tainted. The various specialty societies and colleges will need to be at the helm, and it'll take time and will generate lots of heat (with good planning, maybe enough to reduce oil imports), but in my opinion it has to be done. All doctors and nurses know it: there are good ones, and better ones. And some bad ones. Crazy maybe, but I think most docs -- given the right incentives and handled in constructive ways -- will respond to information that allows them to do a better job, even if it means admitting that they may not have been in the past. Scream, yell, get pissed off, feel insulted. Then lie awake at night and think it over, look yourself in the mirror when you get up. And make some changes. Been there. Done that.

To the extent that people running for president are addressing health care at all, keeping the money-changers between consumers and providers seems to be a given, which strikes me as feckless and crazy. Why should a national health-plan include a layer which provides no care, is clearly dispensable, and which serves to suck huge amounts of money out of the system? It's like paying someone to put the key in your car before you start it.

So my thoughts distill to three things, needed in this order: a single-payor system that includes real and actual control at the top by providers and consumers; a no-holds-barred effort to find and encourage (enforce) best practices, which recognizes and rewards excellence; and, when all the money that's possible to save has been saved, the toughest of them all: prioritizing care; deciding which expenses make sense, and which don't -- rationing. (Alternative to number three: stop complaining about costs of health care.)

(I suppose it's not trivial that if the insurers were really to go away, there'd be lots of decent people without jobs. But that's hardly a reason to keep a useless system going. Maybe some of those displaced would be willing to do those jobs that, you know, Americans don't want to do. That way we could solve immigration, too.)


Hildy Gottlieb said...

You state that the solution is an either/or. In my experience, that is only true when we confront this as a problem-to-be-solved. The decision becomes "Which hole in the dam shall we plug?" rather than "How do we keep the town dry?"

My experience in the world of healthcare is in asking that bigger question - the one that starts at the place of agreement: "What would it look like if our community / country were healthy? And how do we establish the conditions for that to happen?"

If we continue to see our nation's health as a problem-to-be-solved, we will never be healthy. The very best we could hope for under that scenario is to be "not sick."

Sid Schwab said...

Hildy: it's a good point. But I think it's on a separate track: achieving maximum good health is, I agree, a major goal. Still, until perfection, paying for health care will still be needed. So it seems that whereas the costs and savings are intertwined, I think we still need people addressing each problem, separately. (Interestingly, I just read an article showing that all the efforts to get kids to eat healthy are failing.)

Pursey Tuttweiler said...

Good Lord, lots of food for thought. I will have to take more time to read this thoroughly and check back, but I do like what you are saying about the politicians views of this. The thing that is so incredibly frightening is that the economic disaster that would follow a single payor system is enough to keep the money makers from ever letting this happen and a politician who truly pushes for this will find their career cut unexpectedly short. Ann Richards took on the insurance giants, and i cannot fathom how she could have lost to G.W. for Governor when she ran for her second term, but she did. Hildy, the huge corporate giants would not survive if folks were healthy. What would happen to pharmaceutical companies if cancer were cured or diabetes disappeared? What is the incentive for health and who gains, except of course the healthy person? And these initiatives for healthy diets, how can they succeed when the fast food giants have private contracts in schools. Oh, and I live near a very wealthy high school and there is a Pizza Hut, a McDonalds, a Taco Bell, a Sonic, etc. within a stones throw. The lovely high school young women, even the athletes and cheerleaders have the cutest figures and huge guts. They have middle aged spread in their teens. What is up with that? It cannot be healthy to be a size 4 with a beer gut at age 18. It has to be the diet. Oh well, as you can see, I have a lot to say. Sid, I stopped by to let you know that I tagged you to post 8 random things about yourself. If you don't want to, that is fine, but it can be fun.

Anonymous said...

Thank you Dr. Schwab.

Eric, AKA The Pragmatic Caregiver said...

"always-thoughtful" - cripes, I'm in deep dung now.

Not that I'm employing a divide-and-conquer strategy here, but I want to go back to the part about single-payor being necessary.

I agree that for-profit insurers are eeeeeeevillll. I know - my mom (she of the looming lifetime cap) and I are insured by (the same) one. I don't think they have efficient business process, I don't think they have a Calvinist approach to internal costs, and I agree that they make their money by denying payment as frequently as legally possible and as long as permitted, plus two weeks. They are tools, and I actively dislike them as an organization and everyone I deal with there as subhuman beings.

Fortunately, they've shot themselves in the collective feet so many times that they are a topic of humorous conversation, or, when they somehow screw up the orthopedist's charges, humerus conversation.

The thing is, we're stuck with them - because our group is headed for actuarial death spiral (older, sicker, underserved area), we can't effectively change carriers. They can't dump us, but by god they can uprate us the most the state will allow every year, and see if we'll drop of our own accord. We're too stubborn to do so; mom's continued living is, in part, a giant eff ewe to our insurer, which makes it all the more delicious.

I think the local nonprofit Blue would be a stellar choice for our health care brokerage. In fact, the very same nonprofit Blue paid Sid's fee in 1983, without much managed care involvement - it was one of their traditional indemnity plans. Now they won't take our group for love nor money. That's not right; one sick person out of 120 shouldn't make a firm uninsurable. The prudent thing would be to fire my mom, COBRAing her coverage to the current carrier, and then changing the 119 other less-dead members to the Blue, whose computers will suddenly recognize us as less of a ticking time bomb. Until someone else gets sick and the cycle starts anew. In a company our size, *one* employee with something like metastatic breast cancer, relapsing-remitting MS treated with one of the biotech drugs, or a kid born with a bad heart, and we teeter on being branded untouchable.

Listen to what I'm saying: we should fire a woman with advanced cancer. My *mom*. The idea is reprehensible, but the reality is, without familial ties, people do get shitcanned by small businesses to control healthcare costs. It's never so tackily overt - usually, if they're that sick, their work performance suffers, they run out of sick leave, etc, etc, etc. It happens, though - and so long as the rules allow carriers to cherry-pick groups that are statistically unlikely to actually use all the healthcare they paid for, it's gonna keep happening.

Community rating is more important than single-payor. When everybody's in the pool, sick moms get paid for by well young men. That's how the Blues worked for decades. Everybody of a certain age and gender paid the same price, and I believe the doctors were pretty happy about it, because reimbursement levels started slipping when upstart companies figured out how to use statistical modeling to keep the premiums low to attract the healthy ones who would never use it while keeping those who might use what they paid for either out of the pool (refusal to write) or kick 'em out when they got there - (adjusting next year's premium based on claims experience).

To keep well young men in the pool, there's got to be some incentives and some disincentives for failure to pay and play. Otherwise, anomalous deathspirals occur - PacifiCare and QualMed are good examples in the Pacific Northwest of carriers whose models broke under the strain when those subscribers fled and only the truly-desperate remained.

Yes, single-payor is one way to handle this. It's not the only way, though. Medicare isn't *really* single-payor; yes, CMMS nee HCFA determines with broad brush what gets paid for, and it's better than it used to be (with the separate Part A intermediaries and Part B insurers), but when the rubber meets the road, it's still a federation of independent (profit-making) entities issuing local coverage decisions, and that makes me nervous. Aunt Sadie in Boca and Aunt Lizella in Scottsdale shouldn't be treated differently for the same diagnosis because of which government contractor is paying the bills, but they can be as it stands now. Independent for-profit entities making coverage decisions seems to be a tradition we've created with Medicare.

Sid: here's a direct question for you....

"If the marketplace was truly level for all carriers through enforced community rating, mandatory coverage and true portability (ie, you could switch at will, and your employer/the government (choose one) gave you a pile of money to go buy coverage in the individual market), why couldn't companies compete on customer service, coverages, provider networks or any other set of benchmarks?"

What's so wrong with some healthy competition if it drives down costs? By moving the incentives away from "make the most money through statistical arbitrage" to "compete for customers through quality", you change the game.

Eric, Who Is Really Fired Up About This At The Moment

Anonymous said...

Why do think that a single payer system-as it would be sewed together in this country by the usual suspect special interests groups-would not be "administered" by the same group of insurers much to their profit?

Sid Schwab said...

Eric: I guess they could, and maybe they would. I doubt they'd subject themselves to those sort of controls -- they pretty much make the legislation, don't they? If it were to come to pass, the customer would benefit in terms of service, in theory. But still: the service they provide, at best, is answering phones and emails, and maybe helping with forms. It's not really of unique value. It's brokering (emphasis on "broke.") I admit my perspective is heavily influenced by watching the numbers of people employed by my clinic, just to deal with insurance companies, steadily increase to the point of taking over an entire former bank building (perfect). Two floors of cubicles, and I'm sure it's way more now. That's a lotta dough, especially when multiplied by thousands of hospitals, clinics, offices. And that's just on the provider side... And think how much easier it would be for you and your mother if there were one system, one set of rules, no need to plead for coverage. Input some data, get covered. Put a tooth under your pillow....

Richard said...

Sid, your post is strangely similar to where the Canadian health system is going.

Public discontent over the infamous "wait-lists" ignored by Michael Moore in Sicko has led towards a move to allow private companies to provide health care.

The real stickler is whether such care is paid for by the government (keeping to the single-payor model) or by the patient. Privately provided but publicly funded care is what just about every family doctor is. When it comes to elective surgeries and care beyond the primary care physician, private provision seems to provide some competition to encourage the public system to innovate and improve, but also ends up putting public tax dollars into a few private pockets. However, given the conservative nature of most western governments, "public-private partnerships" are here to stay for the near future and will increasingly be a mainstay of Canadian health for elective and outpatient care.

The main argument against privately funded and provided care in Canada is that such a "second tier" would draw on the resources of the public system (doctors, nurses, and other health care professionals trained at such a high public cost). The workaround has been demonstrated at the False Creek Clinic in Vancouver, where patients can consult an ER physician for a (hefty) fee. The physicians employed under at this urgent care clinic do not participate in the public system (and I also believe that some of them are foreign-trained). Nevertheless, technically this clinic is a violation of Canadian laws on health provisions, and it will be interesting to see how the Canadian government reacts and whether this business model will succeed.

rlbates said...

Good post Dr Schwab. Good comments. But I know from trying to have reasonable discussions with family and friends that when it comes to rationing care, it can get heated real fast. For example, why should most of the infertility procedures be paid for by health insurances? When has having a baby ever been important for physical health (yes, I could argue for emotional health)? Notice how many more premies there are with the multiple births from insemination procedures? We cover these, but how much mental health coverage do these same insurances provide? It gets tough real quick, but I agree it is needed. The pie is only so large. Too bad we can't do the same as Jesus did with the fishes and loaves.

jb said...

Sorry, Sid, I'm not buying. The only way to get single payer is for the govt to be the payer. I want to see the govt run any other system efficiently and humanely before they get their hands on the profession that I have dedicated my life to and everyone depends on to stay alive and well. The only reason the post office works as well as it does is that it has some competition in FedEx, UPS, DHL, and it takes more and more $ to do less every year. Let the govt run a basic clinic system if it wants to try, but it's mandatory to have some private competition.

The only way to get young healthy guys to join the insurance pool is for there to be serious consequence for not joining. These guys are unlikely to get colon cancer, but they do crash their motorbikes and fall down skiing. We may have to leave them lying there until they get up if want to motivate them to buy a basic Blue Cross policy.

I do agree that P4P is a joke- an excuse for some people to say they are doing something, anything, to look busy.

Cathy said...

Dr. Schwab, I did read all of this post but I have not read every one of these comments, so if I am repeating someone please forgive me.

Of all the posts I have read pertaining to this topic(and there has been a lot of them) your's makes more sense than any thing else I have seen. Most just whine about it without offering any type solution at all.

I do worry though about a tier system being doable. If we have an NHS for everyone, but at the same time allow private pay for those who want it, won't that just be more of a continuance of what the entire medicaid system has been? Won't the majority of Doc's then just refuse to accept the NHS patients and only see the private pay? Isn't Canada having alot of problem because of that very thing with their NHS? Or, would all Drs. be required to treat NHS patients? I don't know how all this would work, but unless they have to see some, then I think the majority won't.

Also, This is not my personal opinion because thankfully, from reading these medical blogs, I have gotten more educated about this. but, people seem to not have a lot of compassion for Physicians when it comes to their pay and it is because they don't understand exactly where all the money goes.

When we go to the ER and then get a bill for $4,500.00 for very little work done, we sometimes imagine that this money is going to the Dr.s. People think..."Why are they whining about money when I just paid this guy $4,500.00. my opinion is that Dr.s need to begin educating the public about just where all this money goes. the majority of the public do not read medical blogs on a daily basis, and don't understand all this. Until you guys make them understand they are going to think you are paid far more than what you actually are.

Also, what is that OS talking about people dying while waiting for hip replacement? An arthritic or damaged knee or hip is not a terminal illness. How is this happening? If it is because of some other chronic illness they have that caused them to die in the interim, then maybe they should not have been waiting to have joint replacement anyway.

I do think most of what you say is doable. And I absolutely believe an NHS is coming to America.

Sid Schwab said...

cathy: when I talk about tiers, I don't mean differing levels of compensation for providers; there should be no difference, which would mean there'd be no reason for physicians not to see those patients. I mean -- and it's not entirely fair -- that some things would be covered for those who pay extra, that aren't covered for those who don't. Private rooms. And certain care: maybe national health care won't cover dialysis if you're over 65; but if you want to pay for it, you can get it. Such things are clearly onerous; in Canada, as I understand it, if a thing isn't covered, you can't get it, no matter what (although it seems that may change.) What I'm saying is that -- problematic as it may be -- there ought to be a level of care guaranteed for all, but people who are willing and able to pay more, can get more; until or unless we can get to a point where we control costs and can afford funding everything for everyone. Which is even less likely to happen than having some sort of NHS, I'd say.

Anonymous said...

Sid, you've overlooked the no-free-lunch reality. You complain that commercial insurers administrative overheads consume premium dollars that could be spent on healthcare. but, you've forgotten that running the Medicare program also involves overheads, something of the order of 20%, that are not included within the Medicare budget but are nonetheless real. Those dollars, too, could be spent on healthcare if they had not been first taken as taxes. In my view, the overheads are a wash. What's important is maintaining freedom of choice.

Sid Schwab said...

anon: the data I've seen show that in fact medicare administrative costs are far lower than those of insurance companies. Plus, medicare siphons no money to investors, to multimillionaire CEOs; in addition to which, the fact that there are dozens and dozens of companies with differing rules and plans adds hugely to the overheads of the providers having to deal with them.

Anonymous said...

Sid, this is quite well thought out. But you seem to have a stubborn and completely unwarranted optimism towards the way single payer would be run. In one paragraph you refer to how great single payer will be when providers set priorities and determine how to allot care. Then in the very next paragraph you talk about the utter bureaucratic, pointless idiocy that is P4P without seeming to connect the two!

Single payer will be exactly what P4P is, exactly what JCAHO is, exactly what EMTALA is, exactly what every single government mandate is - completely unworkable mandates issued by faceless bureaucrats who have never touched a patient in their lives. It doesn't matter if the regulation would shut down 75% of America's ERs like one JCAHO issued recently, they'll still do it. And why shouldn't they? It's hardly like it's going to inconvenience them. P4P is an even better example; the measures are almost all irrelevant and everyone acknowledges this. Everyone acknowledges that outcome measures, the only reliable ones, will result in system gaming and hurting sick patients. And yet despite all this, the march of P4P continues unstoppable under the weight of its own bureaucracy.

When or if single payer runs, you may rest assured it will NOT be providers or anything of the sort running it, because that would be COMPLETELY UNPRECEDENTED in the history of American medicine. Let's get real here.

dr. bean said...

Who will guard the guardians? By which I mean how do we get the hypothetical steering panel of patients and doctors to stay true to their mission? In any single party--oops I mean payor system, the group in power is subject to the complacency of power which tends to corrupt their purpose and stagnate their vision. Accountability . I'm sorry, I think pie(in sky) is the most accurate of the tags for this post.

daddy stacks said...

Frankly, I don't trust doctors being in charge of a big bucket of money.

How about everyone look after themselves. That way, only money that exists in the consumers pockets will get spent.

If you want big bucks get into the NBA not the AMA.

Sid Schwab said...

anon: I don't disagree. I'm saying this is my solution, not that it's how it will be. If my solution were in place, there would be panels at the top, as I described. I'm not saying that's how it'd be; just that that's how I'd like to see it.

dr bean: I don't disagree with you, either: I've been on boards and panels of insurance companies, and I had to work hard to remind myself that I was there as a physician and not as a company advocate. But I managed, and I assume there are a few among the millions who could, also. Fact is, I have no optimism whatsoever that politicians of either party will ever get to meaningful solutions. Our system no longer is conducive to solutions for any issue, other than finding ways for a given politico to retain power by the most disingenuous means possible. Pie in the sky; no doubt. But we can dream...

Eric, AKA The Pragmatic Caregiver said...

Here's what kind of decisionmaking we have at the head of the Medicare B carrier for the state of Washington:

In short, the CEO of Noridian got busted for DUI. Yeah, he's a great humanitarian with fantastic judgment.

medrecgal said...

This kind of rationing of health care might very well help the economic crunch, but who do you suggest should be the types of people who are refused or delayed in this new system, other than the obvious ones like you describe (like the 85 year old who needs dialysis)? I don't think a lot of people would take particularly kindly to the suggestion that some conditions/situations/ages are more "worthy to be treated" than others being built into the system. Of course, I understand that these kinds of decisions are made by insurance companies and such all the time, but it would be more patently obvious under a single-payer system. This nation would have to overhaul its whole line of thinking about access to health care before anything like this would work. Can you picture the righteous indignation when someone found out they were rejected, and another person they perceive as less worthy got their procedure or service? Something strikes me very uneasily about such blatant rationing, even though I know filtering out does happen. And would universal coverage force lowered standards of care and limited access to technology? It seems to be doing so in Canada and on the NHS in Great Britain.

The other problem you mention is a primary one--Americans in general are terrible at being personally responsible for their own health, and that drives up costs for everyone. If we ate better, moved more, and spent less time whining, we'd need less insurance.

Dr. J. said...

Sid: Here in Canada te reverse discussion is happenning. We have a single payer (sort of) system, and the discussion is around whether we should broaden out private options. One issue I've not seen discussed much is the issue of wealth, health, and entitlement.

In Canada one of the underlying assumptions built into our system is that health care is not a commodity and should be insulated from 'market forces'. It's an issue much in dispute. In general, the assumption means that the type of care you get, the speed at which you get it, and where you get it are not tied to personal (or family) success, achievment or wealth. The idea is that access to healthcare should be universal, and that high quality care should be provided equally for everyone. As an idea, this means that determinents of health (insumuch as they are affected by healthcare) shouldn't be affected by wealth.

There's been a great deal of creep in privitization of elective but important procedures (joint arthroplasty in particular), where individuals pay out of pocket for care at a private hospital, and there-by skip the waiting list.

The essence of this argument is whether wealth should be able to purchase care, or if care should be for all. As a Canadian doctor I understand when patients pay to skip the line up, but I do worry that it does more than confuse the logistics of the system, perhaps it undermines the philosophy of it....
Dr. J.

emily t said...

What a heartfelt discussion here. Unfortunately I'm sure our politicians will collectively throw up their hands in frustration if even 10% of the pros and cons presented in this thread were on their plate. Predictably it will again be pushed to the back burner.

Sid Schwab said...

Dr J: Ideally, all care would be available to everyone. I'm aware of the issues in Canada, having seen many patients (I'm not far from the border) who chose to pay to come here rather than wait for care. In the US, I think a system that covered everyone equally and perfectly would be intolerably expensive, unless everyone would agree to accept restrictions. And given that such a system is highly unlikely, I think it's also true that a plan that prevented the ability to pay for "extras" would be politically impossible. I'm guessing that if it's ever addressed seriously, after a few failed attempts and after seeing the pricetag, the system will eventually look a lot more like what I suggest than what we have now. My personal plan is to not get sick.

Doggerelle said...

well, here in the land of 'universal' healthcare we seem to be really struggling with the idea that universal should include everybody...

I know that this is probably a very cynical view, but isn't it possible that is we had a public/private system that we could actually free up resources? If the insured could pay their way maybe the public system would actually have room to do more?

I know. I'm impossibly naive.

It's just that living in a community where there are *no* available family physicians/specialists within a 1+ hour radius you start to think that there's something fundamentally wrong.

Preventative healthcare is a great ultimate goal, but how can we possibly get to that point if we are unable to treat emergent issues?


A young friend of ours is sick. It's very likely that he has a serious food allergy. The wait time for an allergist consult is 12 months +. In the meantime his family are trying to eliminate possible causes, but he's making trips to the ER at least once a week for pain control. He's losing weight rapidly, and he's no longer living the life of a normal 9 year old.

How much more is it costing the system to manage his care this way?

This is a situation where both parents are doing their darndest to maintain a healthy situation for their kids, but they have no option but to watch their son get sicker and sicker. They're now in the position of working out how they can liquidate enough assets (i.e. the house) in order to 'buy' healthcare overseas.

Something's going very very wrong.

Pursey Tuttweiler said...

I found this link through blog contributor Bobby Bittman. It says that tort reform has attracted more specialists to small towns in Texas but has done nothing to improve patient care and has benefited the insurance companies, but not the consumer.

Sid Schwab said...

doggerelle: yours is an example of "de facto" rationing, by controlling the number of doctors in various specialties. And your point is a good one, in showing the adverse effects of doing it that way. I agree one solution is to allow for another tier of service. Deciding how much a nation is able/willing to spend, prioritizing it, allowing for "opt out:" it seems nearly impossible, and probably is.

pursey: thanks for that link. I'm going to go read it now. If a national health plan is impossible, tort reform is, I don't know, fantasmagorical?

DivaJood said...

My argument is, in part, that by eliminating the countless insurers and their enormous overhead (their profits, their executive pay and shareholder dividends -- not to mention countless redundant clerical no-sayers) you could fill the bucket to the same level and have lots left over.

Not just the insurance companies, but the pharmaceutical companies as well - their big-budget advertising is disgusting, and they are constantly inventing diseases and syndroms to sell their drugs at obscene profit margins.

But the bottom line is this: MOST of our tax dollars are being spent killing people in Iraq. Bring that money home, and we'd be able to provide health care for all.

Anonymous said...

I am a carpenter who works for an idiot; I am self employeed. I love my work and never take care of my health. Why?
I haven't been to a doctor in 20 or so years. Recently got yelled at by a dentist when I had to get a few teeth pulled for having 180/120 bp. Is that high? what do I know.
I have read and appreciated all of Sinclair's "Narnia", and I love your ideal government ideas.
I am pretty dumb, but, I do have government death care already taken care estate will be able to afford a 12 pack, and the city garbage men will deal with the remains...
works for me.