Sometimes it's a good idea, when debating policy, to go back and try to define, as best you can, the exact nature of the problem you are attempting to alleviate. In health care, it seems to me the problem is that most people, most of the time, have a substantial risk, too high to be ignored, of requiring medical care that is so expensive that paying for it out of pocket would ruin their financial life permanently. I should say, my research is old, and may be inaccurate; it's possible that the problem really is that most people regularly require more medical care than they can afford, but I hope not. I think if there was no insurance, most people, most years, would be able to pay for what they needed. But some people every year would need far more, and there is no real way to tell who.
Digression, already: This state of affairs is, of course, the inevitable and happy result of medical advances and our national ideals. People who used to die quickly and cheaply are given years or decades of unimaginably expensive life, and not just the people with wealth and power, either. We don't assume that the newest, most beneficial treatments will be kept for the sole benefit of an autocracy, but expect that poor people, too, will get the care they need to stay alive, and will pay for it, too. I don't mean to suggest that there is a real and observable equality of resources in this country, but there is a laudable belief in equality of resources, which tends to break down some of the walls around the upper classes. At any rate, the one solution that nobody seems to be seriously arguing for is the one that would be the easiest to implement; letting the middle-classes bleed to death from car crashes and cough their lungs out from pneumonia, so they won't cost so much to keep alive when they come down with something really expensive. End digression.
Anyway, the way we have managed to distribute health care to the people who require it is a hotchpotch system of private insurance, public assistance and charity. It's kind of a fun system, where nobody really knows what care is available, and what it costs. Still, as I see it, there are three current problems. First, there are a lot of people who, for whatever reason, are uninsured. Some number of these will be bankrupted by their medical needs every year; some number of health care providers will not be paid for their services to these impoverished people. And, of course, because some of these people, logically enough, will take substantial risks with their health (rather than with their financial future), there will be public health hazards involved. I don't want to overestimate this; most of the uninsured are healthy and won't need much, if any, medical care while they are uninsured. But it's a matter of statistics; the larger this group is, the more people within that group that need medical care will be, and the greater the public health risk is. It's likely there is some acceptable size for that group, but however big it is, it remains a problem.
The second problem is that a lot of people are insured, but can't really afford the insurance they have. They manage to keep paying the premiums (through their employer, usually) at the expense of, oh, fixing the roof, saving for their children's education, buying healthy and fresh food, starting a new business, air-conditioning the house, buying books. I saw in a recent AP article that the "average" family policy costs $11,500 a year. At the moment, that money is, for most people, money that their employer is not paying them, rather than money they are paying from their checking account. I'm not sure that makes a difference. And y'all know, Gentle Readers, how much I hate averages. Still, when I think of what ten thousand dollars a year would mean to our household budget, our relatively affluent household's budget, I find it hard to believe that people aren't being squeezed out of some pretty major purchases by that cost.
The third problem is that there is a group of people who are insured, but who are not getting their money's worth from it, because the care they need is denied or delayed. It's hard for me to tell how big this problem is, because of course their insurance companies are unlikely to keep statistics on this sort of thing. I suspect that it's a big problem, but not quite as big a problem in actuality as it is in the culture. Every case of this (and there certainly are many of them) gets talked about a lot, so everybody knows somebody who was screwed by their insurer somehow. Just by virtue of that, however, the problem of this group is likely to be larger than their actual numbers, because people will perceive their insurance to be less valuable than it is, and be more likely to risk a time without insurance. And, of course, the people in this group, however many of them there are, are either doing without health care or being ruined by the cost, so they might as well be counted as uninsured, as far as public health policy goes.
So. Having done all of that, if you will kindly wake up and pay attention to this next bit. Everyone? Yes? OK. I'm coming to my point, now. Yes? Do you need some more time? No? OK, here we go:
Politically and rhetorically, it's very important for our Party and its representatives to face any new proposal with the explicit question of how it will help with the basic problem and (even more important politically) how it will help the three groups I meantion above. I think the paramount issue, from the point of view of persuasion, is the second group, the people who have insurance they can't quite afford. So, when Our Only President suggests his nonsense proposition which he claims would save a typical family a few hundred dollars a year, the Democrats have to go on television (and the floor of the Senate) and say Will this really help the working family who is sweating their health care now? Will this mean more money in your paycheck every other week? Will this keep your employer from increasing your premium? Are you getting off the treadmill, or are we just increasing the speed?
In terms of actual policy, I'd be suspicious of any attempt to make health care cheaper, in the aggregate. We could, I suppose, institute some sort of price freeze, but other than that, I think the reason health care is expensive is because health care is expensive, and while it doesn't have to be quite as expensive as it is now, it does have to be expensive enough that the main problem, that most people are at risk for incurring more medical expenses than they can ever pay off, will remain. The simplest solution to protecting against that risk is (it seems to me) a inclusive single-payer system, relying on the fact that most people at risk in any given year do not, fortunately, really incur those costs. I'd like to see that argued forcefully, in the national conversation. But it isn't the only way to deal with the risk.
My point, though, is that any policy proposal that doesn't address the current problems does not actually address the current problems, and it's a good idea to point that out, clearly and in detail. Make it clear that you understand that people are going bankrupt, and that Our Only President's proposal would do nothing at all to help them. Make it clear that people are being squeezed by premium increases that have the same effect as cutting their wages, and that Our Only President's proposal will do very little to help them. And make it clear that people are getting screwed by unscrupulous insurers who went into the business of health care to make a profit out of people's need, and that Our Only President's proposal is a proposal to help those insurers.
Tolerabimus quod tolerare debemus,
-Vardibidian.
One argument against a single-payer system — or at least I think this argues against it, although I could be confused about what a single-payer system means — is that when those who benefit from something are highly insulated from the costs of the thing, they tend not to mind much if the thing is expensive. Health care and higher education are two common examples I hear mentioned along these lines.
Another argument I’ve heard is that “health care” and “health insurance” are not the same thing. In particular, I have the sense that a lot of health care money is spent treating conditions that are entirely predictable and happen to everyone, and are not rare or catastrophic at all — but which are expensive to treat, and which it’s very distasteful to consider doing away with. Elder Care, for example: If putting grandma in a nursing home costs $10K per month, just because she’s old and frail and needs lots of attention and assistance and medication, that’s something that will happen to everyone lucky enough to survive that long without suffering a catastrophic illness, and no one wants to say “enh, she’s had a long enough life, kick her to the curb”. But the flip side of that is that if you want to say that everyone should live in a nursing home, at $10K per month, for several years, then you need to figure out some way to come up with that money, and simply saying that you want it to happen isn’t good enough.
Oh, and where I was going with that was: You can’t pay for those sorts of costs with a traditional insurance model, where a million people pay $10 and the one person who gets hit by the million-to-one bad luck gets the $10M to pay for it. Those sorts of costs are nothing like insurance, and calling them “insurance” is misleading and confusing when you start trying to figure out how to pay for them.
On the first point, when I was reading studies (and this was more than ten years ago, and things might well have changed) there was very little empirical evidence that people with good insurance “bought” more health care than they would have without. That included, by the way, the health care they were supposed to buy more of, such as annual physicals, flu shots, and preventive and maintenance measures of various kinds, which were “free” with the insurance they had already bought. The theory said they should, but they didn’t. The bastards.
As for your second point, if we have indeed got to the point where most people really do need more health care than they can afford, then insurance will of course fail. I should add that we have a separate Medicare program specifically so that Elder Care does not come into the equation, but then Medicare is … incomplete. Anyway, I haven’t done any real research into this for ten years or so, and during that time costs have continued to rise, I suspect.
But yes, it is very important to distinguish between health care and health insurance. We do not, for instance, have a health care crisis in this country, although we do have a health insurance crisis. Well, crisis still seems strong. Furthermore, while it makes sense to claim that everybody should have a basic right to health care, it is obviously nonsense to claim that everybody has a basic right to health insurance. To me, this is one of the great advantages of the single-payer concept; it removes the entire concept of insurance and insurers from health care.
Thanks,
-V.
I’d say we do have a health care crisis. Medication errors injure 1.5 million people a year in this country. Millions of people do not live within 100 miles of any abortion provider. Hundreds of hospitals have been closed in the past decade, and new ones do not open up to take their place. Emergency rooms in many areas do not have critical staff on call, such as neurosurgeons or orthopedic surgeons. It’s nice that if you get hit by a car, an ambulance will take you somewhere and they have to treat you whether or not you can pay. But if you die anyway because they can’t get you to a hospital fast enough because the closest two closed, or they have no neurosurgeon on call to stop the swelling in your brain, or they accidentally give you the wrong meds and destroy your heart or your liver or your kidneys, then the adequate parts don’t matter so much.
On the first point: The problem with someone else paying for your stuff isn’t that it inclines you to use more stuff, it’s that it inclines to you take fewer measures to keep costs down. One of those measures is using less stuff, but others include shopping around, looking for other options, and so on. Think about the way you shop for groceries compared to the way you shop for health care. If your grocery store says “the product you want is 30% more expensive this week”, there’s at least some chance that you’d check another store, or consider waiting another week and seeing if the price fell, or try another product. Sometimes you can’t do that — if you need that particular product, right now, then you buy it, and grumble about the cost. But if the price goes up on something that someone else pays for, you’re much less likely to do any of those cost saving things, or even to grumble about the cost, when you can get what you want and someone else will pay for it, when your share of the price is fixed no matter how much it costs.
On the second: I’m actually a little unclear now on where the crisis is. I thought the problem was that that health care costs were rising unsustainably quickly. The cost of the Medicare expansion went up by like 50% between when the law was passed and when it went into effect, and the surplus used to fund it is predicted to run out in ten years. It sounds like you’re saying that the crisis is people who suffer catastrophic injury or illness; has there been a sudden increase in the number of such people who don’t have health insurance? It’s possible, but it’s not something I’ve heard much about.
Michael,
Well, and I’m not suggesting that our health care is perfect, but it is awfully damned good. It would be better if it were, you know, better, and there are lots of ways it could be better, but comparing the availability of very good care to either a generation in the past or the current status almost anywhere in the world, I think things are astonishingly good. I am willing to be persuaded that the real problem is not financial but practical, but it seems to me that the financial problem is much larger.
Now, irilyth, on your first point, I understand the theory of moral hazard, what I am saying is that at least as of the early nineties there was no evidence for its actual existence in the health care arena. Without such evidence, and pretty compelling evidence, too, I don’t see that we should be making policy based on the theory. On your second, well, this is why it’s so useful to try to go back and describe the problem we’re trying to remedy. If the problem is that health care costs in the aggregate are rising to the point where most people really will require more health care than they can afford over their lifetimes, then it’s true that insurance will certainly fail (we could set up some system like Social Security, where people would be compelled to spend their lives paying for the health care they will eventually need, so that when the need comes, the money is mostly there, but this is not insurance). It’s not true that the projected cost of the Medicare drug program rose 50% between its passage and when it went into effect; Our Only President and his cabal of crooks and incompetents deliberately lied about the projected cost of the plan. Other projections were more in line with the actual costs, although of course the plan isn’t fully in effect yet, so those could be wrong, too. As I understand it, the crisis (and I still maintain that crisis is too strong a word) is that there has been a substantial increase in the number of people bankrupted by medical costs, and that real wages are decreasing (by some measures) because the share of employers’ costs that go to health insurance (as opposed to care) is going up, without any increased benefit to the employee.
I have no idea whether the actual costs of medical care are rising unmanageably these days, or what would constitute unmanagability. I haven’t been paying enough attention–have HCA and Blue Cross and United and Aetna been losing a lot of money recently?
Thanks,
-V.
http://www.washingtonpost.com/wp-dyn/content/article/2006/06/14/AR2006061402166.html
“Emergency medical care in the United States is on the verge of collapse, with the nation’s declining number of emergency rooms dangerously overcrowded and often unable to provide the expertise needed to treat seriously ill people in a safe and efficient manner.”
http://www.bmj.com/cgi/content/full/327/7424/1129
Our disability-adjusted life expectancy is worse than Japan, Australia, France, Sweden, Spain, Italy, Greece, Netherlands, Canada, UK, Norway, Austria, Finland, and Germany.
If we rerank based on conditions amenable to medical care, we fall further.
http://www.geographyiq.com/ranking/ranking_Infant_Mortality_Rate_aall.htm
In infant mortality, we are worse than 35 other countries.
Our health care is better than almost anywhere in the world? Based on what?
Our assessment of health care should take into account differences in available resources and knowledge. We know more now than we used to, and we have wonderful new drugs and tools, but if we don’t apply what we know and have to sick people as well as we used to, then our quality of health care has gone down. And a number of doctors (who should be well-informed about the fact that we have wonderful knew drugs and tools and knowledge) who I’ve talked with recently have said that they believe our health care has gone way down in quality over the past generation. Not a conversation I started or wanted to participate in, but they all want to proactively apologize for the numerous failures built into our current system. Similarly, we should compare delivery of health care today between countries who have similar established standards of living for their citizenry. Compare the US to Canada and France and Norway, and compare Ghana and Kenya and Nepal, but don’t mix up those groups.
health care. let’s say we have five problems.
(1) health care resources and staff are distributed badly.
(2) insurance coverage is spotty and unreliable.
(3) public health programs are seriously underfunded.
(4) insurance overhead and medical costs are both rising.
(5) more people than usual are about to get old and die.
well, (6), because we have to factor in increased natural disaster expenses for a couple generations.
the moral hazard thing doesn’t float with me, either, and the biggest reason isn’t that it’s hard for me to imagine americans doing less about their physical health, though that’s true, it is. where the moral hazard is lacking is we’re paying for our current system through multiple avenues that have nothing to do with health.
federal taxes pay for a lot, state taxes pay for some, things we buy at the store pay for some, and then there’s the actual bills and co-pays. if it were broken out as a separate element of your taxes (it’d have to be), or an entirely different bill, and then with no co-pays for the preventive visits, people would not only do it right/better, they’d push each other to do it. i think that’s one of the weaknesses of our “i got mine” system — it’s hard to help people. we don’t like to talk about money and talking about the doctor is always talking about money.
I’m perplexed, Michael. If I say that health care in the US is better than almost anywhere in the world, why would you think I was not talking about Ghana and Kenya and Nepal, and China and Brazil and, well, most other places in the world? I am perfectly happy to accept that healthcare in the US is not as good as in Norway or France, and include them in the handful of places-fifteen or sixteen countries, most of them smallish-where healthcare is even better than it is here. That doesn’t indicate a crisis to me; far from it.
I do find the numbers in the Washington Post article (about reports from the Institute of Medicine troubling; evidently since I last did much serious reading on the topic, emergency room visits have gone up 27%. That does include two very large disasters, but then we should be (as hibiscus points out) prepared for very large disasters in the next few decades. Now, other than large disasters, we probably shouldn’t be getting much of our health care in emergency rooms, but should isn’t is.
Oh, and if I can venture to disagree with hibiscus’ point number 5, the problem from the point of view of insurance/Medicare is not that they will die. The problem is that an unprecedented number of people will get old before they die.
Thanks,
-V.
I do think you’re talking about Ghana and Kenya and Nepal, and I think you’re comparing us to them in an absolute sense, and I think that comparison is unfair. As a healthcare consumer, I completely understand wanting to live here rather than in Ghana. That will continue to be true for quite some time, I imagine. But we could be doing so much better with what we have, we used to do so much better with what we had then, there are a lot of other countries that are doing better with less than what we have, and it’s not clear to me how much better we’re doing than Ghana in terms of making use of available resources.
It’s the difference between gross revenues and profit margin — I think you’re talking about gross revenues being great (because of health care advances offsetting problems in quality of care and access to care), while I’m talking about profit margins going down.
One huge reason ER visits are up around here because there aren’t enough appointments available with primary docs, so patients get told to go to the ER when they normally wouldn’t have to. I suspect another contributor is that doctors are less willing or less able to do prescriptions or diagnoses over the phone for simple problems, forcing visits either to doc or to ER that didn’t used to be necessary.
part of the emergency room thing might go away with well integrated local walk-in clinics. otoh we don’t want to see evidence of lower levels of class hierarchy when we do our dailies so throwing the trash at ERs serves and validates many prejudices, i.e., people go to the doctor.
um how many health care systems do we have, by social function?
hide the infirm: poor. vets. old. crazy. disabled.
fix heroic or fashionable ailments, including aesthetics.
fix workplace….
i see a theme — “chronic” looks like a social division. do i detect a faint whiff of superman-ism?
irilyth wrote:
I’m hardly an authority, but since no one else seems to have brought up the obvious yet: under our current system, you’re not actually allowed to shop for health care. You’re nominally allowed to shop for health insurance: your employer may offer you a choice of two plans, or you may opt for a prohibitively expensive personal plan. Once you’ve picked a plan, though, there’s very little you can do to shop for health care besides accept or decline it. You can ask to be assigned to a new doctor or (under some of the more expensive plans) pick a specific doctor from their approved list, but for the most part you’re pretty locked-in.
Now, there *are* some entities who can shop for health care, but they’re not human beings, they’re institutions: hospitals and insurers. Am I wrong in remembering a statistic that, although the cost of health care has gone up dramatically, the earnings of health care professionals have stagnated or even declined against inflation?
If we’re looking for moral hazard, it’s probably more appropriate to look for it at the institutional level than at the annual checkup.
V wrote:
Okay, so I know one of those people. I don’t necessarily want to turn an anectode into a datum, but the reasons why that happened say a lot about the unintended consequences of widespread-but-not-universal insurance.
My friend wasn’t covered by insurance, but she’d planned more than adequately for the costs of her surgery. No, what got her was that there was a fault with the medical device she received that required a follow-up surgery, and the manufacturer only ended up reimbursing the hospitals who did the follow-ups for patients who *were* covered by insurance. Follow that?
Off the top of my head, some factors that went into this:
– Hospitals charge less to insurers than to private individuals.
– Hospitals often (as in this case) re-submit the last bill you incurred instead of generating a new bill, especially if the old bill was higher.
– The kind of money that can bankrupt a private individual is still small potatoes for purposes of hiring a lawyer, which leads to:
– There’s little deterrent against a large institution pulling a fast one on isolated private individuals.
Hospitals charge less to insurers than to private individuals.
Does everybody know this? I mean, I found it out when I was temping in the industry, and some friends of mine came across it later in seeking care themselves, but as I read your note I wondered if it was common knowledge. I mean, it makes sense, from a market point of view, that insurers would negotiate themselves deals with hospitals, etc, that individuals cannot. From a public policy point of view, this fact causes about a million problems of various kinds, from individual bankruptcy to hospitals closing.
Also, and in no way relevant to the conversation, Your Humble Blogger has been spending a lot of time in hospitals and doctor’s offices of late; is there an appropriate bracha or bad-luck-aversion gesture one does when one sees a pharmarep?
Thanks,
-V.
I have a gesture to suggest, although I don’t know that it actually averts bad luck or even that it’s really what you might call “approprtiate…”
peace
Matt