Thursday, September 24, 2009

Healthcare: America Needs an Enema

We are currently witnessing the strongest push for reformed healthcare since President Clinton attempted it in 1994. There are strong opinions on both sides of the table with the Democrats pushing what they see as necessary reform and the Republicans digging in their heels in order to defend capitalism against the scourge of “socialized medicine.” I, like most Americans, simply digested the word “socialize medicine” and associated it with a form of medicinal communism that would stifle innovation and cripple our financially-ailing federal government; and to be sure, I think all Americans can agree that our bureaucracies are unparalleled in their ability to misallocate tax-payer funding. With that in mind, the fear of an inefficient, poorly-managed government healthcare infrastructure is certainly not unfounded and perhaps even likely. However, I am equally as frightened of allowing healthcare insurance to remain a profit-driven enterprise where the number of patients receiving care inversely impacts the profits of that company’s shareholders. Simply stated, the more treatment you receive, the less money they make; and I have no illusions that my personal wellness is powerless against handsome yearly dividends.

So we find ourselves trapped between an existing system that forces 700,000 American citizens a year into bankruptcy for the misfortune of simply getting sick, and an untested government-regulated path that would become the largest overhaul of a healthcare system the world has ever known. As T.R. Reid pointed out in his book “The Healing of America,” there is one pivotal moral question that must come before all others: Should every citizen have the right to receive medical care regardless of employment or economic status? This question is and has been the driving force behind every successful healthcare reform movement of the past 200 years, because without a consensus amongst the populous concerning this issue, failure is assured. When I pressed myself for an answer, I had to elevate healthcare above a privilege and recognize it as a right. When I visualize a privilege I see home ownership, having a car, and even attending college; for these, to an extent, function as capitalist “spoils of war” and are not guaranteed.

Despite their intrinsic philosophical differences, both parties can agree on a simple fact: our current system is bloated, unfair, and dramatically ineffective. As Americans we pay more for health care than any industrialized nation on earth, spending around 16% of our gross-domestic product on healthcare and watching an average of 20% of that money finance advertising, administrative overhead, and profit for out private insurers. As a comparison, France spends less than 8% of their GDP on healthcare and their administrative costs run about 5%.

Now it is easy to dismiss a comparison like this by relying on the idea that “you get what you pay for” and sure we pay more, because we have access to the greatest physicians and hospitals in the world, right? Unfortunately for us, the comparison cannot be nullified that easily. In 2000, The World Health Organization ranked wealthy industrialized nations on the fairness and quality of their healthcare infrastructures. France was ranked number one, and the United States came in at thirty-seven.

So maybe we cannot tell ourselves that we have the fairest or cheapest system, but don’t we at least have the most innovative and effective? Again, the statistics are sobering:

· America ranks 19th in preventing death from curable diseases in people under the age of 75.

· America has the highest infant mortality rate out of the 23 industrialized nations surveyed and more than double that of Japan and Sweden.

· America was tied for dead last out of 23 nations in the category of “healthy life expectancy after age 60.”

· American diabetics have a shorter life span than diabetics in any of the other 23 industrialized nations.

The problem is not the training or skill of our medical community, it is the fact that the number of people financially able to reach that community is rapidly shrinking due to exponentially increasing cost. So does this mean we have to institute the dreaded “socialized medicine” in order to see the kind of results Europeans have gotten? Let’s look at how they do it:

· The Bismark Model – Providers of both insurance and medical treatment are private with employers and employees paying a portion of the cost. The government does negotiate fees for treatment with the medical community so that fees are standardized and costs can be adequately controlled. It is basically the same system that we use except the insurance companies operate as a non-profit entity and the fees are standardized. This is the model used in France, Germany, Japan, Belgium, and Switzerland.

· The Beveridge Model – There are no medical bills or fees and the doctors, hospitals, and treatment are all paid for and provided by the government through taxes. In this system, medical treatment is a sort of taxpayer funded community service like the Fire or Police Department. This is what most of us think of as “socialized medicine” and it used by Great Brittan, Italy, Spain, Scandinavia, and (gasp) the Unites States Department of Veterans Affairs.

· National Health Insurance Model – The providers are still all private, but instead of several private competing insurance companies, there is one big government insurance pool that everyone pays into. This gives the government incredible bargaining power (which explains why they can buy the exact same drugs as us for 70% less) but they still do not own or pay the doctors or hospitals. This is used in Canada, Taiwan, South Korea, and (double gasp) the United States as Medicare (we even stole the name from the Canadians.)

Each approach has its pros and cons, but many are not as different from our current system as some would have us believe. While these models can be an excellent stepping stone toward a fairer and more efficient system, we must also remain aware that our challenge is unprecedented in size and scope since we are attempting to cover a population of over 300 million people (by comparison, the populations of France and Great Brittan combined barely cracks 125 million.)

So what have our Washington friends come up with to alleviate this problem? Several days ago I began searching for the similarities and differences between the Democratic offerings and the Republican offerings. Since most of the GOP offerings are similar in scope and approach, I will use the Patients Choice Act (helmed by Wisconsin Republican Paul Ryan) to compare to the Obama / Biden policy of the Democrats.

My initial impression was shock at how many components they both shared:

· Both call for a type of open-air marketplace called “The Exchange” that would theoretically stimulate competition between providers and allow better deals for the end consumer.

· Both would provide a form of “sliding-scale” tax credits that would allow greater federal tax deductions based on income and medical expenditures.

· Both plans would require guaranteed access to care for all Americans regardless of age, race, or pre-existing conditions.

· Both promise portability so that workers can take their health insurance with them if they happen to change jobs.

· Both wish to save money by digitizing all of your medical records & insurance history onto an electronic card that would be swiped at the doctor’s office to eliminate paper records.

· Both demand an increase in “transparency” concerning hospital costs, patient care figures, and percentage of premiums going to administrative overhead.

· Both promise more emphasis placed on prevention in order to reduce the number of preventable diseases killing Americans.

So at this point you might wonder what all the fighting is about. If the plans are so closely linked, why has this schism appeared between members of the two parties? The answer lies in the logistics of bringing these promised changes about:

· The GOP uncompromisingly believes that the Federal Government cannot be trusted to “deliver high quality health care to every American;” instead they believe that the necessary reforms can be made by returning the current system to “core values” through a matrix of tax incentives and non-profit insurance oversight committees, and member-owned entities.

· The Democrats believe that only the federal government has the negotiating and oversight power to implement and enforce the necessary changes and to ensure fairness and coverage for all.

What I Like:

· The digitization of medical records is long overdue and could save billions in administrative overhead and even prevent unnecessary loss of life and expensive duplication of efforts. Both plans are pushing for it, with the Republicans suggesting an independent member-owned Health Bank to house the data. My question is, if everyone is required to have digital records, who would not be a “member?” The Democrats suggest that a government branch should be established to house the records, akin to the existing social security administration. One entity will have all our health records either way, and it is disconcerting but necessary.

· The idea of transparency is a must, especially concerning the costs of rendering services. I could visit 100 different clinics, have the same tests run, and still end up with 100 different prices for the exact same service. It is like pulling in to get an oil change and instead of giving me the price, they just take my keys and tell me “We’ll just see how it goes and let you know how much the price is afterward.” In France, every doctor’s office and hospital has a posted sign with the prices for medical treatment on it, just like ordering from a restaurant.

What we need to add:

· Both plans leave the current profit-driven private insurance industry intact. No industrialized nation has successfully implemented affordable coverage for all of its citizens while maintaining a profit-driven private insurance infrastructure. Simply put, there is just not enough money to cover everyone’s medical bills and still make shareholders rich because those are two conflicting ideals.

What I am not buying:

· The GOP promises to bring about all of the changes with no tax increases or new government spending. I am certainly no economist, but I am skeptical that we can establish many of the measures, such as nationwide “Health Courts,” state based “Exchanges,” new oversight committees, and affordable healthcare of everyone, without forking out something for them. It also seems unlikely that tax incentives alone could force a profit driven industry to bring the 45 million uninsured Americans under their wing for a reasonable fee to the consumer.

· The Democrats also promise to bring about these wonderful changes without “adding a dime to the deficit” by paying for everything upfront. This is also unrealistic as the government oversight measures and entities necessary to implement their plan will have to be funded by someone. I can guarantee you that no-one in Congress (Republican or Democrat) is going to supplement funding by reducing their own salary. The money has to come from somewhere.

If we are serious about changing the way healthcare works in this country, it will be painful and we will initially spend more money than we save. However, I, like so many others, have come to the decision that the goal of fixing what is broken justifies the frustrating trial and error that will no doubt accompany an overhaul of this magnitude. We can and should learn from the example of countries like Canada, France, Great Britain, Switzerland, Germany, and Japan, but while doing so we must remember that the system likely to emerge from all this will be uniquely American and that is something that I can live with.

Everyone should read the proposed solutions to make an informed decision. Here are the links to the detailed summaries for each side’s proposal:

Obama / Biden Proposal -

GOP Patient’s Choice Act -

*Facts and statistics come from the World Health Organization and T.R. Reid’s The Healing of America

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