Health Care in America

Great Debates
21

I don’t think its the generically evil “Special Interests” that ruin it.

I live in Tennessee. About 20 years back (about when I was born :slight_smile: ), the governer got it into his pretty liddle head he wassa gonna have free healthcare for anyone who couldna afford it. It wassa gonna be effient-like.

Cut to modern day. This GIGANTIC LEECH called TENNCARE is sucking every dime out of our budget, which has grown to something like 10 TIMES what it was last decade.

There isn’t a single Tennessee representative who will cut the program, so they all keep turning to tax-increasing schemes to get more cash. I’m not goig into them, but they all involve either massively reducing everything but road-building and Tenncare or installing the Income Tax from Hell. That last one would probably reduce the payment by most people, but is less fair, is far too easy for the legislature to raise, and results in less money going to the federal government (yes, most people think this is a bad thing). Its also deeply umpopular. There have been a number of major impromptu rallys and such when people found out the legislature was in secret sessions called to propose the Income Taxes.

22

Reprise - health insurance is a common employee benefit in the US, along with pensions and the like.

Because the US doesn’t have a national health service, they have developed other mechanisms for delivering healthcare. Health insurance is the main mechanism, and health insurance is cheaper to provide when it is done on a group basis. Where people individuall choose to insure themselves, insurers assume - correctly - that, the sicker they are, the more likely they are to buy health insurance, and the more they will claim on it. However where an entire group gets health insurance, the sick and the healthy are included alike, and the claims experience of the group is better, and the premiums are lower.

In the absence of a national health service, employment-based health insurance has attractions. It covers most workers and their dependents. It usually extends to retirees as well. However it fails to cover the unemployed, or those who work in low-grade jobs which don’t carry health insurance. Other mechanisms have to be found to provide healthcare for them, or they just have to go without.

I am amused by the discussion of the term “socialised medicine”. I think the term is used only in the US to describe a national health service, but it is only in the US that the word “socialised” would be considered pejorative.

23

Reprise - health insurance is a common employee benefit in the US, along with pensions and the like.

Because the US doesn’t have a national health service, they have developed other mechanisms for delivering healthcare. Health insurance is the main mechanism, and health insurance is cheaper to provide when it is done on a group basis. Where people individuall choose to insure themselves, insurers assume - correctly - that, the sicker they are, the more likely they are to buy health insurance, and the more they will claim on it. However where an entire group gets health insurance, the sick and the healthy are included alike, and the claims experience of the group is better, and the premiums are lower.

In the absence of a national health service, employment-based health insurance has attractions. It covers most workers and their dependents. It usually extends to retirees as well. However it fails to cover the unemployed, or those who work in low-grade jobs which don’t carry health insurance. Other mechanisms have to be found to provide healthcare for them, or they just have to go without.

I am amused by the discussion of the term “socialised medicine”. I think the term is used only in the US to describe a national health service, but it is only in the US that the word “socialised” would be considered pejorative.

24

Reprise - health insurance is a common employee benefit in the US, along with pensions and the like.

Because the US doesn’t have a national health service, they have developed other mechanisms for delivering healthcare. Health insurance is the main mechanism, and health insurance is cheaper to provide when it is done on a group basis. Where people individuall choose to insure themselves, insurers assume - correctly - that, the sicker they are, the more likely they are to buy health insurance, and the more they will claim on it. However where an entire group gets health insurance, the sick and the healthy are included alike, and the claims experience of the group is better, and the premiums are lower.

In the absence of a national health service, employment-based health insurance has attractions. It covers most workers and their dependents. It usually extends to retirees as well. However it fails to cover the unemployed, or those who work in low-grade jobs which don’t carry health insurance. Other mechanisms have to be found to provide healthcare for them, or they just have to go without.

I am amused by the discussion of the term “socialised medicine”. I think the term is used only in the US to describe a national health service, but it is only in the US that the word “socialised” would be considered pejorative.

25

How are those “Socialised Firefighting Services” in your area? Unless of course, in the US you manage to call that a “profitable industry” too.

I’m sure those in small-business, a major force for economic growth in your country, might feel a reason to shed tears over the collapse of their livelihoods, whether it be too small to deserve your pity or not.

**Sailor:

**Pah. I can afford private health care. However, at my current state of youthful healthiness I choose not to take it up. If I’m feeling sick tommorrow morning, I’ll go to my doctor and see him free-of-charge. If I’m hit by a bus tommorrow, I’ll walk (ok, drag) myself into a public hospital and they’ll take piece me back together WITHOUT first asking whether I have insurance or not.

Of course, before I hit 30 I’ll take up private health insurance. With an income tax rebate, it’s certainly an option encouraged by the government. But an option it remains.

26

A few scattered points:

–Most health care economists who talk about this issue will bring up “the triangle” of quality, access, and cost. You need to pick two. It’s possible to have top-notch care immediately available for everyone, but it’s going to cost an assload of money. If you have cheap care available for everyone, it’s not going to be of the highest quality. If you want inexpensive, top-quality care, you either have to limit who gets it or how much access people have to it.

In America, we want everyone to be able to have top-quality care where and when they want it, and it shouldn’t cost anything. The first thing we’re going to have to realize, socialized medicine or not, is that we can’t have it all.

–One problem, in my opinion, is the huge buffer zone between the doctors and the patients when it comes to money. Most doctors at the institution I just came from think nothing of ordering a CT scan or an MRI, with no idea how much it’s going to cost or how the patient is going to pay for it.

There’s an attitude at places like this that the doctors shouldn’t have to think about costs. For instance, I once had a patient who the team was considering switching to colloid fluids from crystalloid, despite at best equivocal evidence for it doing any good in his case. (I forget the specifics.) “It can’t hurt,” was the reasoning. In the discussion, I brought up that the albumin used for colloid fluid was ridiculously expensive, and that it would cost a couple thousand dollars a day for this gentleman who wasn’t going anywhere anytime soon. They looked at me with some disdain and ignored my comments; the resident later took me aside and said that one shouldn’t bring up cost issues on rounds.

I smiled and agreed, but I think they were kidding themselves. If it were a life-or-death intervention, or if there were any solid evidence that it would benefit the patient, it would be one thing. If it were a cheap plus/minus intervention, it would be yet another thing. But doctors are going to have to become less resentful of the idea that costs have to be considered.

–Similarly, patients will have to accept the same thing. I think everyone is entitled to medical care, but it has to be on medicine’s terms. Tests have indications. If someone doesn’t have the indications, he or she shouldn’t have the test. If something gets missed that would have been picked up by a test that wasn’t indicated, that’s an unfortunate happenstance, not a mistake.

If people want to pay for their own full-body MRI, they should knock themselves out. Look for a push in the next few years, though, for insurance companies and the like to cover such things, despite the lack of evidence (outside the anecdote) that they do any good.

–I’m generally wary of any attempts at “tort reform”, since I don’t want to make it even easier for those with money and good lawyers to screw those who have neither. I agree that some is warranted in this case.

What is happening, though, is that hospitals and professional societies are developing more rigid, evidence-based guidelines for doctors to follow for certain diseases. Doctors decry this as “cookie-cutter medicine”, but there’s a reason you use a cookie cutter instead of cutting each cookie by hand. No one is saying that a doctor can’t deviate from the guidelines, it’s just that he should have a good reason for doing so, since the guidelines lay out the best course of action based on the available evidence. It is hard to sustain a malpractice case against a doctor who followed such a protocol.

Sorry for rambling–it’s early.

Dr. J

27

It’s worth pointing out, though, for the benefit of reprise and other non-U.S. citizens, that many jobs don’t come with health insurance attached. Large corporations frequently provide health insurance. Many retailers do not, many temp agencies do not, etc. Waiters, for example, seldom get covered by the employer. It’s entirely possible to be a sterling full-time employee and not be covered by your employer’s health insurance. Moreover, not all plans cover preventative treatment. I’m talking basic stuff here, like a yearly gynecological exam. It’s a little frustrating. I think it’s easy for people who are safely ensconced in the corporate world to forget how hard it can be to find a job in another field with health insurance.

28

That’s not an argument against “socialized” medicine, but against the british socialized medicine. There are no waiting list here (France) , nor, AFAIK, in Germany, for instance. It simply falls down, as usual, to how much money a country is willing to spend on healthcare.

Totally false. Here, usually, people who can afford it usually
pick a private hospital when they have some small ailment, because rooms are prettier or things like that. But people who have something serious would go to the public hospitals because they have a better equipment, better trained medical teams, etc…I wouldn’t put a feet in a private hospital if my life was at stake, here. There are some exceptions, though. There are some top notch private hospitals but they’re rare, and anyway not better (from the medical point of view, not the size of the TV set point of view, of course) than their public counterparts.

29

By the way, I do agree with one of the first posters. Regardless of what system (public or private) is dominant, western countries are spending more and more money on health, due to more and more costly equipments being needed, more and more costly cure invented, etc…Health expenses already represent an incredible part of western countries GNP, and this percentage is growing (no figures out of my head…but possibly someone will know).

There’s a risk that at some point, we’ll be in a situation where we know how to cure something but plainly won’t be able to afford the treatments for everybody. So, indeed, it could be necessary at some point to ration (and rationalize…that also is strongly needed) health care…

30

I think this is a pretty contentious statement. According to this site www.kingsfund.org.uk/eKingsfund/ assets/applets/ebint-10.PDF the UK spends 6.8% of its Gross Domestic Product on healthcare (counting both public and private expenditure) while the US spends 13.9% of its (much larger) GDP on healthcare. Expenditure per head is probably three times what it is in the UK, if not more. But if we use life expectancy as an (admittedly crude) measure of public health, the UK is a healthier place than the US. In fact, of seven major economies (UK, US, France, German, Japan, Canada, Italy) the US has the highest health expenditure but the lowest life expectancy. It also has the worst infant mortality. Signficantly - or perhaps not - the US is also the only country in the list where private expenditure on healthcare exceeds public expenditure.

Of course, quality of healthcare is not the only determinant of life expectancy and infant mortality, and no doubt other and perhaps better measures of the effectiveness of healthcare could be devised. I’m sure this research has already been done, but I’m not familiar with it. But it’s very far from proven that the US system is a more efficient or effective deliverer of healthcare than the more or less socialised systems of other countries.

31

Some anecdotal evidence which proves nothing but explains my sentiments on the whole issue.
As a student in the UK I dislocated my knee playing soccer. I din’t have a car at the time, so an ambulance came and took me to an emergency ward (casualty). I had to wait for over an hour, but then I was seen by a doctor, who drained the blood from my kneecap and sent me to get some Xrays. I was given some painkillers and anti inflammatories and went home. This was in Sheffield - a big city in the nidustrial north of England ( I guess you could compare it to Detroit).
I went home to my parents, transferred my case and had arthoroscopic surgery on the knee 3 weeks later (I could walk on it). I Received physical therapy and painkillers for the knee. It’s fine. All of this was free - normally there would be a nominal fee for the prescription medicine but it was waived as I was a full time student.

I moved to the US a year later. I managed to dislocate my shoulder playing Rugby. The emergency room in a small eastern town (in Delaware) took 2 hours to process my paperwork. I saw a specialist later who referred me to another specialist. His five minutes cost me $700. My surgery was scheduled and cost me $1500 personally - my health insurance paid the rest. Physical therapy was covered.

The argument that a national health service is bloated and inneficient may hold some water, but a totally private service is just as inneficient as it ends up being a monopoly and will bill to maximize profits.
We’v all heard of the $60 aspirin. Another personal observation:
My father is a Radiologist in the UK - he does very well for himself. Nice house, fun car, nice vacations, plenty of golf…etc.
I have a friend over here who’s father is a radiologist. He owns three houses, a boat, a number of cars including his own silver side bus! He bought his son a ferrari when he got into med school. I’m not making this up.
The medical profession in the US will never support moving towards a state provided service - they make too much money at the moment by controlling the supply.
I’m employed by a small business - 20 people. I have to pay about $240 a month for health insurance, half of what the plan costs, the company picks up the other half. I’m in my mid 20’s,don’t smoke and don’t have any history of medical problems (except for managing to twist my limbs at odd angles on occasion).
It’s crap I tell you.

32

Yes, some companies and some doctors are greedy and should be whipped to peices. Nevertheless, the majority of health services in America is certainly as fast, effective, and efficient as anything you’ll find anywhere else.

BTW, Keith, without knowing more about the exact work (even fields like radiology can be subdivided by where and how good peole are) those two do, its hard for us to get a true sense of how exact it is.

"If I’m hit by a bus tommorrow, I’ll walk (ok, drag) myself into a public hospital and they’ll take piece me back together WITHOUT first asking whether I have insurance or not. "

I believe it is the public law practically everywhere if not everywhere that you must be treated in an emergency situation. Regardless of your ability to pay. If you can afford you, you are expected to repay the hospital for the health services rendered.

There is one more diff to be presented: Size.
European health care emergres over a far more homogoneous population than in America. Aside from that, but administering healthcare to 60 millions is a heck of a lot different than 280+ millions. Aside from which, there are likely to be more hsopitals and clinics per person in America per person due to the spread out nmature of population.

33

I’m not sure we can, but some of this thread actually gives me some hope. For despite some significant differents spins, most posters seem to agree that these are the choices.

smiling bandit’s concern is that “new” treatments may only be available to those with resources to suplement the public system. While we’d need to work on getting people to understand the analogy to public education and policing, that sure you can have more if you want to pay for it but that society will cover the basics, at least there is an understanding that such would occur.

CK and DoctorJ both understand that you can’t have everything for everybody inexpensively, though they differ about who’s to blame and what would be prefered.

The difficulty in making it happen in America is that it goes against two seperate foundations of the American mindset: democratic principles and liberterian ones … so both ends dislike it for different reasons.

Those who trumpet democratic principles are unwilling to accept that those with more money can get different healthcare than those without. All things for all people as a right! Ignore cost considerations. Put a price on a human life? Too crass; a life is priceless. If it costs three mill to extend this gals life two years then so be it. (They’d prefer to close their eyes to issues of cost)

Those who trumpet liberterian principles refuse to accept that healthcare should be a business of government at all. Let the market deal with it. Any governmental interference will eliminate all incentive for innovation and force poor care on all.

And I’ve got to comment on CK’s and keithnmick’s blame the rich doc mentality. I’m a doc, I love my job. Got a nice roof over my head. Will be able to pay for my kids college educations (if the market recovers). Drive a nice 5 year old Honda Civic. No complaints. I’m not rich but I aint poor. I know that my job is secure and I get to go to work doing something that I love and feel is worthwhile. But rewind twenty something years. There I am: top grades, tests well, could go into any field I want. Have freinds who went MBA and with three years of graduate school are pulling in the big bucks. Same with my engineering buddies. Similar with my lawyer brother (who still makes more than I do). I am deciding to go on for an additional four years of expensive education and then at least three more years of indentured servitude. Now tell me that at the end of that I’ll make no more money than the average college grad and will have to deal with governmental paperwork more than with patients. Hey, I was young and idealistic and still I’d have said where do I sign up for the MBA program. Make my salary contigent on what a government bueracrat facing a budget crisis says it should be, and you’ll not see medicine populated by many of the best and brightest (not me, but I want to school with them! ;)) Our experiences with government payors is abysmal. In our office we take our share of public aid because we feel it our duty to do so (we also do some freebie work). But we don’t get paid what it costs to keep our offices running, when they eventually get around to paying us half a year later, and after more paperwork then even many HMO’s require.

And DoctorJ’s evidence based medicine comment can’t go unchallenged. These guidelines are often consensus statements in evidenced based clothing. Often the evidence is poorly reviewed and chosen to support the conclusion that the members had in mind before they began. Rarely is cost a consideration. Not their job. Insurance companies don’t mind - the guideline says that monoclonal antibody for RSV shoulod be given monthly through winter to every former premie at a cost of a thousand per shot, because it was shown to reduce hospitalizations by a day and despite that there was no evidence that it prevented any mortality and that the cost of preventing that day of hospital stay was far, far exceeded by the cost of preventing it - okay as long as all the insurance companies are in same boat and still at a fair competition - then they can pass the costs on with competitive disadvantage.

No one is willing to watch the costs and willing to say that there should be, must be a dollar value on a year of human life.

34

Here is an interesting history of the defeat of the Clinton health care proposal, and any alternative health care plans offered at the time. It has some well known names:

I remember when Cheney reappeared in 1993 and started saying “no health care crisis.” I guess if you are the CEO of Halliburton that would be true, no matter what kind of super high tech pacemaker you need.

Here is another article on the same subject.

I have an anecdote- My SO has lupus, and takes plaquenil daily. It is a mild case, almost non-symptomatic with the drug, but she does require regular checkups and eye exams. She has been through hell with her insurance in New York- they regularly change doctors on her- they just recently took her lupus doctor, to whom she had been going for 20 years, off her plan. She picked that plan because he was on it. It’s very bad.
Anyway, she came over to St. Petersburg for a year last year. She had to keep paying her insurance in New York so she wouldn’t lose it, but of course it didn’t cover anything in Europe. It’s $340- a month, by the way. She ran out of Plaquenil- they wouldn’t let her get any in advance under her plan, although she could have paid $8- per pill (2 a day) and stocked up. We called a clinic in Helsinki, and went there. The clinic was very nice, modern, and efficient, the doctor was very good, she got the medicine, and it cost very little. I don’t remember exactly how little, but it was dramatically, hugely, less than the US. We went on a bus tour of Helsinki, and the tour guide spoke with pride about Finland’s health care program, and the high level of public health- and proudly called Finland a “welfare state.”
It seems to work in Finland. And the treatment my SO has received from her “provider” is far far worse than any of the sound bites from the Harry and Louise" commercials.
JDM

35

I still can’t figure out why nearly everyone from a country with nationalized health care expresses satisfaction with their coverage, while nearly every American expresses disatisfaction with their coverage, and yet Americans obstinately stick to the idea that their system is best.

-Jennifer, who has a giant hole in her tooth from a root canal that she’s not going to be able to afford to fix for at least three months.

36

Nearly every body does not express satisfaction with their coverage. Every day on the BBC web site there is another article about the failings of the NHS. When I was on vacation in England there was a TV special about a woman who was unable to get the NHS to treat her pain so she went to a private South African hospital for treatment. She now has a business helping people go to South Africa for cheaper private treatment.

For the record I am extremely satisfied with my health coverage and I live in the US. Most every body I work with is satisfied which is not surprising as they have the same coverage package.

37

I am so very torn on the issue of health care. I feel we are probably at a point where even though I see no obligation to provide it, that we could cost-effectievly provide it through oligopolistic insurance companies that offer specific plans (mandated by panels of doctors and hospitol financial officers and statisticians etc, not by the insurance companies), and in a typical old-fashioned sense the insurance companies compete for business through services rendered by price.

Under no circumstances do I want democracy to act to decide what health care we will get, and that means no politicians. This is a business decision: they must offer some services to everyone, after that they can charge whatever they all feel is reasonable, just like any other business in the world must comply with certain regulations and then handle things from there.

Local insurance companies suck. Two or three large companies attempting to service the entire country should have a very nice assessment of risk from such a sample size. They would be compelled to provide a free minimum to all members, after which people would have to pay. Hey, the government will provide you a lawyer if it is going to prosecute you, but it doesn’t get you the best possible lawyer money can buy. To survive in court you need a lawyer, to survive in life you need some health care (anyone who quibbles with one should probably have to quibble with the other, eh?).

Paying people to innovate services and procedures seems to fall under market economics in a strictly definitional way, doesn’t it? Why not leave it to them? I don’t understand.

Then health care will become like a police force. Us po’ folk will get the runt of the litter (overtaxed police force) and the welathy businesses get private security guards and such. Big deal, you know? As a model for distributed risk, the police isn’t the worst model to use, is it?

38

But then I think of something like food and I wonder why it isn’t as nationalized as health care when it is certainly more necessary.

I hate this topic. None of it seems to make any sense.

39

A few simple alternatives with minimal bueracracies-

1)Have gubberment provide payment (comparable to private payers) to cover primary care for the poor through the lower middle class if otherwise uninsured. ER visits allowable with a copay significant enough to motivate only using it for real emergencies (not as a doc with conveinent hours). Specialty care is covered too and meds with a reasonable copay. Docs elect to participate or not. Businesses that provide health insurance get a modest tax credit for doing so.

2)Make health insurance mandatory just like car insurance is. Mandate that insurance companies must take all comers only charging differentially based on elective behaviors (eg smoking) and must have minimum outreach to all age groups and socioeconomic groups. Partially underwrite the expense of the premiums for the poor and the lower middle class on a sliding scale (possibly as a tax credit for those with incomes). Individuals can choose plans with a variety of coverage options as they can today.

3)Kill all the lawyers. Sorry. Forget I said that.

40

I mean a certain level of outreach at a minimum …