Monday, July 6, 2009

National Health Care - Pros & Cons

It's no secret that health care costs are spiraling out of control in this country. On average, we now spend more per person on health care than both food and housing. Insurance premiums are multiplying much faster than inflation, which prevents economic growth and leaves businesses with less money to give raises or hire more workers. While the quality and availability of medical care in the United States remains among the best in the world, many wonder whether we'd be better off adopting a universal government-controlled health care system like the one used in Canada.

The number of uninsured citizens has grown to over 40 million. Since health care premiums continue to grow at several times the rate of inflation, many businesses are simply choosing to not offer a health plan, or if they do, to pass on more of the cost to employees. Employees facing higher costs themselves are often choosing to go without health coverage. No health insurance doesn't necessarily mean no health care since there are many clinics and services that are free to indigent individuals. However, any costs not covered by insurance must be absorbed by all the rest of us, which means even higher premiums.

Health care has become increasingly unaffordable for businesses and individuals. Businesses and individuals that choose to keep their health plans still must pay a much higher amount. Remember, businesses only have a certain amount of money they can spend on labor. If they must spend more on health insurance premiums, they will have less money to spend on raises, new hires, investment, and so on. Individuals who must pay more for premiums have less money to spend on rent, food, and consumer goods; in other words, less money is pumped back into the economy. Thus, health care prevents the country from making a robust economic recovery. A simpler government-controlled system that reduces costs would go a long way in helping that recovery.

Medical professionals can concentrate on healing the patient rather than on insurance procedures, malpractice liability, etc. Doctors have to take classes now simply to understand all the insurance plans out there; they are often restricted by insurance practices, such as what tests can be ordered. Doctors must practice defensive medicine to avoid getting sued. Some physicians are even leaving the profession rather than deal with all these non-medical headaches. A simplified universal health system would allow doctors, nurses, and other medical professions to simply focus on doing what's best for the patient. Medicine is a complex enough subject as it is. Our current system just adds to an already mentally-draining profession.

There isn't a single government agency or division that runs efficiently; do we really want an organization that developed the U.S. Tax Code handling something as complex as health care? Quick, try to think of one government office that runs efficiently. Fannie Mae and Freddie Mac? The Department of Transportation? Social Security Administration? Department of Education? There isn't a single government office that squeezes efficiency out of every dollar the way the private sector can. We've all heard stories of government waste such as million-dollar cow flatulence studies or the Pentagon's 14 billion dollar Bradley design project that resulted in a transport vehicle which when struck by a mortar produced a gas that killed every man inside. How about the U.S. income tax system? When originally implemented, it collected 1 percent from the highest income citizens. Look at it today. A few years back to government published a "Tax Simplification Guide", and the guide itself was over 1,000 pages long! This is what happens when politicians mess with something that should be simple. Think about the Department of Motor Vehicles. This isn't rocket science--they have to keep track of licenses and basic database information for state residents. However, the costs to support the department are enormous, and when was the last time you went to the DMV and didn't have to stand in line? If it can't handle things this simple, how can we expect the government to handle all the complex nuances of the medical system? If any private business failed year after year to achieve its objectives and satisfy its customers, it would go out of business or be passed up by competitors.

Government-controlled health care would lead to a decrease in patient flexibility. At first glance, it would appear universal health care would increase flexibility. After all, if government paid for everything under one plan, you could in theory go to any doctor. However, some controls are going to have to be put in to keep costs from exploding. For example, would "elective" surgeries such as breast implants, wart removal, hair restoration, and lasik eye surgery be covered? Then you may say, that's easy, make patients pay for elective surgery. Although some procedures are obviously not needed, who decides what is elective and what is required? What about a breast reduction for back problems? What about a hysterectomy for fibroid problems? What about a nose job to fix a septum problem caused in an accident? Whenever you have government control of something, you have one item added to the equation that will most definitely screw things up--politics. Suddenly, every medical procedure and situation is going to come down to a political battle. The compromises that result will put in controls that limit patient options. The universal system in Canada forces patients to wait over 6 months for a routine pap smear. Canada residents will often go to the U.S. or offer additional money to get their health care needs taken care of.

Patients aren't likely to curb their drug costs and doctor visits if health care is free; thus, total costs will be several times what they are now. Co-pays and deductibles were put in place because there are medical problems that are more minor annoyances than anything else. Sure, it would be nice if we had the medical staff and resources to treat every ache and pain experienced by an American, but we don't. For example, what if a patient is having trouble sleeping? What if a patient has a minor cold, flu, or headache? There are scores of problems that we wouldn't go to a doctor to solve if we had to pay for it; however, if everything is free, why not go? The result is that doctors must spend more time on non-critical care, and the patients that really need immediate help must wait. In fact, for a number of problems, it's better if no medical care is given whatsoever. The body's immune system is designed to fight off infections and other illnesses. It becomes stronger when it can fight things off on its own. Treating the symptoms can prolong the underlying problem, in addition to the societal side effects such as the growing antibiotic resistance of certain infections.

Government-mandated procedures will likely reduce doctor flexibility and lead to poor patient care. When government controls things, politics always seep into the decision-making. Steps will have to be taken to keep costs under control. Rules will be put in place as to when doctors can perform certain expensive tests or when drugs can be given. Insurance companies are already tying the hands of doctors somewhat. Government influence will only make things worse, leading to decreased doctor flexibility and poor patient care.

Health care equipment, drugs, and services may end up being rationed by the government. In other words, politics, lifestyle of patients, and philosophical differences of those in power, could determine who gets what. Any time you have politicians making health care decisions instead of medical or economics professions, you open a whole group of potential rationing issues. As costs inevitably get out of control and have to be curtailed, some ways will be needed to cut costs. Care will have to be rationed. How do you determine what to do with limited resources? How much of "experimental" treatments will have to be eliminated? If you're over 80, will the government pay for the same services as people under 30? Would you be able to get something as expensive as a pacemaker or an organ transplant if you're old? Would your political party affiliation or group membership determine if you received certain treatments? What if you acquire AIDS through drug use or homosexual activity, would you still receive medical services? What if you get liver disease through alcoholism, or diabetes from being overweight, or lung cancer from smoking--will the government still help you? You may or may not trust the current president & Congress to make reasonable decisions, but what about future presidents and congressional members?

Removing the medical sector from the free enterprise system tends to reduce the overall quality of health care. Study-upon-study has shown the quality of health care is typically higher in the U.S. than in any other nation, including those with nationalized health insurance. The United States has lower breast and prostate cancer mortality rates than New Zealand, the United Kingdom, Germany, Canada, France and Australia.

In short... there are good arguments for, and good arguments against a nationalized (or socialized) healthcare plan. And, as I tend to believe in most things, I feel that the truth lies somewhere in the middle. I don't know where in the middle it lies on this issue... I just know that both sides are wrong, and blatantly mis-representing both the pros and cons of this issue in their own favor. It's as if Americans have become incapable of independent, rational thought, and rely solely on what political or religious leaders tell them to believe or say. Stop it! Use your brain!

11 comments:

Ronni said...

I just want something. I make too much to qualify for indigent care, but not enough to afford even the most minimal of personal coverage. The alternative is to sign up for the Williamson County plan that gives me discounts at certain clinics, on a sliding scale. Better than nothing, but I will still feel as if I have a giant sign around my neck that says, "CHARITY!"

Marsha said...

I consider a good middle ground to be a government-sponsored medical insurance open to everyone- similar to medicare-and a boutique industry of private medical insurers that people with the means can purchase into. Everyone gets the basics, if you can afford more, great.

I already spend $300 plus a month on heath care premiums, I wouldn't mind at all sending my money to a public insurer rather than a private one if it means all my friends and family that don't work for corporations could be insured as well. I would sleep better at night.

Grant said...

Sorry about this... but this is going to be rather long. Welcome to part I:

The truth falls considerably further from the middle than your post suggests. Mainly because you got an awful lot of those facts in it completely wrong.

First, although I suspect this was less in the way of an intended argument than just a casual comment to open things up that you didn't fully think through... quality and availability of care in the US among the best in the world?

You cannot possibly seriously make that statement within a single sentence of pointing out that there are 40 million uninsured people in the US. That's patently absurd. Availability of care in the US is atrocious compared to most other nations.

Moving on to something that you clearly did mean as an argument... "there isn't a single government agency or division that runs efficiently"... except that the last study I saw said medicare was outstripping private insurers efficiencies by absurd amounts. Please say you have more basis for making that statement than an appeal to "common knowledge" that the government just never does anything right. Because you know... that's why we only trust them with trivial unimportant things, like the national infrastructure that keeps the entire nation running, or the military with enough nuclear capability to extinguish all life on the planet. Look, congress ticks me off about 6 times a day too, but let's try not to confuse that with the entire national govenment. Legislators are legislators and they exist to get elected and play stupid political games... then you have the civil servants who exist to perform a function. They latter generally serve that function pretty well once you get past the legislators and the politics getting in their way, all snark directed against them on a regular basis aside.

Bottom line, the free market is a wonderful system for a lot of things. It really is. If I'm looking to build a society and I want it supplied with steel, or lumber, or produce, or rubber duckies, or cars, or computers, or name your regular old consumer good...the free market is the system I want set up to deliver it. BUT, some things the government DOES do better because the free market is simply not geared for it. A national military is one, large scale national infrastructure is another, postal service (make all the jokes you want, you try setting up a system that can deliver a letter from any part of the nation to any other part of the nation, no matter where, no matter how backwoods or isolated, for a few lousy cents and almost *always* get it where it needs to be going. Fed ex is great at delivering packages to major population centers, there's not as much profit in providing regular penny packet carrier service to Joe Woodsman who lives 50 miles from the nearest town unless you're going to charge him prohibitive fees for each pickup and delivery.. and thus the post office exists, to spread that cost across the population and make universal access to the nation's mail system far more accessible. Which is good for the whole... not something private enterprise is built to take into account anywhere very high on it's priority list.)

And finally... insurance. The private sector absolutely SUCKS at providing health insurance. And it should be painfully obvious why to anyone who stops and thinks about it for even 5 minutes. Imagine you sell any of those consumer goods I listed above. Who do you want as a customer? You want people who need your product the most. Because they'll use lots of it. And the more they use, the more they buy, in direct proportion. and the more they buy, the more money you make. So they get what they need, you make a profit providing it, and everyone is happy and society ticks along smoothly with it's needs getting met.

Grant said...

Part II:

What happens if you're selling insurance? Assuming you aren't, you know, insane... the LAST people you want as customers are the people who need your product the most. Also known as the sick and injured... or the illness and injury prone. Because see, the more of your service they use the more money you LOSE. The profit motive is upside down and backwards. Insurance companies can of course still be ridiculously successful and profitable in free market economies... the problem is they do it by avoiding as much as they possibly can providing the services they sell to the people who actually need to use them, instead directing all their efforts at selling to the people they're betting don't need them at all, or need them very little, but will pay for them anyway just to be safe. This presents a bit of a problem for society as a whole.

And when the profit motive isn't structured to society's benefit you NEED to have a non profit government agency step in and intervene to either force them to operate in a manner which is more beneficial to the functioning of that society, or simply step in and perform the function directly. Every other industrialized nation on the planet gets this. Which is why EVERY other industrialized nation uses far more public sector involvement in their health care systems and, by totally wild coincidence, ALL of them run health care systems that are far and away more cost effective that the one in the US. And the actual real world hard data from dozens of nations covering hundreds of millions of people for decades rather trumps your "I don't think government can do it better" theory based on your dislike of the DMV.

Moving, on… no, it would not appear “at first glance” that universal coverage would increase flexibility. It would appear after looking at it for half a century being implemented across the globe that it would increase patient flexibility. Putting your list of “what about” hypotheticals aside as irrelevant, since they’re actually NOT hypotheticals considering we have the rest of the industrialized world to look at to give us the answer…patient flexibility is clearly greater under a universal system. There is no such thing as “in network”. No such thing as “pre-authorization” to see a doctor or risk not having the care be paid for. There is no team of accountants and lawyers lurking over your shoulder whose reason for existence is to try to screw you out of being covered for something or just plain get you dumped from your coverage completely as soon as it becomes expensive for your insurance plan. There is no need to carefully weigh just how risky it is for you to be without health insurance while changing jobs or starting your own business since it doesn’t happen. And as for “what about” things the government plan doesn’t cover? Well, how about we look at those other nations? Like, oh, Canada. They allow private supplemental insurance packages to cover anything the government doesn’t. But since the government covers everything that would be considered a really big ticket necessary item the supplemental plans can be had on the cheap since they don’t have to worry about anyone they’re covering suddenly needing a half million dollars in exotic treatments for some rare debilitating brain disease or something, They KNOW that’s already taken care of. Most employers have no problem providing them for their employees fully paid for as an employment perk, and if you can’t get it there they’re easily within the reach of the majority of the population to purchase directly.

And you’re acting like your “what about” scenarios aren’t already exactly the problem you’re worrying they will be if you make the system more public sector. What do you think happens every time you send a claim in to your insurance company and their claims department gets their hands on it? Thousands of times a day across the nation those people reject the kinds of procedures you’re talking about here… and they do it because [i]it’s their job[/i] to protect the bottom line for the shareholders.

Grant said...

Part III:

And for the love of God, would people stop getting their information about the Canadian health care system from internet rumors? That “makes them wait 6 months for a pap smear” number probably came from isolated reports that in one province in Canada (Quebec) some women were having waits of UP TO 6 months… worst case. For one thing, the system in Quebec is widely acknowledged to be the worst administered provincial system in Canada by a good margin (btw, the health insurance systems are run by the provinces in Canada, not the federal government… they’re actually like 13 different systems, one in each province). For another, that was hardly what the average woman was looking at even in Quebec. And for ANOTHER, it had nothing to do with the government *forcing* anyone to do anything.

And no, Canadians will NOT often go to the US for treatment. I am getting really, really tired of hearing that fairy tale constantly repeated every time this subject comes up. The US health insurance lobby invented that story in the 90s to scare people the last time health reform was on the table and it just never went away.

The thing is, they STUDIED this last time they tried claiming it:

http://content.healthaffairs.org/cgi/content/full/21/3/19

The number of Canadians actually receiving care in the US is so small they had difficulty even measuring it in the study. And most of the very small number of people they actually did manage to find who had received care in the States in the previous year just happened to be travelling there when they got sick/injured and needed to go to a hospital before they could get home. And nothing has changed since then to alter that finding.

But yes, there are a very, *very* few Canadians who will go to the US for care to jump a line they don’t want to wait in. And eventually a US insurance lobbyist gets their hands on one of them, and the next thing you know they’re testifying in front of the freaking Senate and acting like they’re the average Canadian story or something. (And don’t even get me started on the magnificent work of fiction that is Shona Holmes and her deadly bran tumor that wasn’t a deadly brain tumor.)

And no patients aren’t likely to curb doctor’s visits under a universal system. That is one of the *points*. Get them in to see a doctor in a timely manner when preventative care can still cheaply prevent a serious issue instead of having millions of people deferring regular care then showing up in emergency rooms for fantastically expensive treatment someone has to pay for. How you think this makes costs go up when it keeps costs down in EVERY other nation using this system escapes my comprehension.

And where in the world are you getting this idea of “government mandated treatment” in a universal insurance system? In Canada doctors determine treatment. The government just deals with the insurance. And that is the case in most nations with universal coverage systems run by the public sector.

Grant said...

Part IV:

And oh cripes… rationing again. You are the same person who just mentioned tens of millions of uninsured people in the US right? What the heck do you think THAT is? An example of a whole lot of people who think having no medical coverage is really just an awesome way to live?

EVERY system rations care. All of them. No exceptions. Unless you are aware of a country somewhere that has escaped my notice that has unlimited amounts of doctors and nurses and facilities and medical supplies and hands them out like candy to anyone who asks for them. The difference between the United States and most other nations on this issue is merely the method used to perform that rationing. In most nations it is done based on an evaluation of the urgency of medical need of the patient, performed by a doctor. In the United States it is done largely based on an evaluation of the size of the patient’s bank balance performed by an insurance corporation’s accountant. And I’m not talking about just the uninsured, there are probably something like double that many people on top of that who HAVE some kind of insurance but it’s completely inadequate to meet their needs if they become seriously ill and they likely don’t even realize it and never will until the day comes they ask their plan to pay for something and it gets rejected because of the fine print on page 47, paragraph 13 subparagraph 2 of their policy.

And then people all over the country pretend none of this happens, point at other nations, and exclaim “Rationing!” with round eyed horror because some person had to wait a while for a treatment their doctor said they could wait for while someone more seriously ill went first, like they can’t fathom how such a terrifying thing could possibly be occurring.

And finally, you close with this:

“Study-upon-study has shown the quality of health care is typically higher in the U.S. than in any other nation,”

I have never seen ANY study that said that, ever. Let alone “study upon study”. I have seen people wave around isolated statistics of mortality rates for a single condition like certain types of cancers that showed in one study they were better in the US then pretend like that was representative of system wide performance. I have seen the numbers on MRIs and CT scanners per capita which look really good for the US. But I have NEVER, not one single solitary time, seen any reputable study claim the US *system* was superior or produced superior results.

The WHO ranked the US health care system 37th in the world the last time it performed a ranking.

The commonwealth fund just looked at health care amenable mortality rates in industrialized nations… as in how many people die each year who *would not have* if given adequate medical care:

http://www.commonwealthfund.org/Content/Charts/Testimony/Insurance-Design-Matters-Underinsured-Trends-Health-and-Financial-Risks-and-Principles-for-Reform/Mortality-Amenable-to-Health-Care.aspx

The United States ranked dead last in preventing those deaths despite spending far and away the most money.

This is a systematic review of dozens of studies of comparative health outcomes between the US and Canada on everything from cancer, to coronary artery disease, to chronic illnesses to various surgical procedures:

http://www.openmedicine.ca/article/view/8/1

Canada came out on top.

So where exactly are these studies you speak of that say the US *system* produces superior results? Have you ever actually read one yourself, or were you just told they exist?

And yes… I appreciate I just wrote a small novel to respond to a month old blog post… but this particular subject gets under my skin.

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