Health Care in America

Great Debates
41

Re. the “greedy doc mentality” what makes anyone think they have a right to other people’s involuntary services? Doctors, like everybody else, charge what the market will bear and there’s nothing wrong with that. If you don’t like it then become a doctor yourself. Or I guess we are all “greedy” then. (I got a call this morning from the wife of a friend who was just outraged because a house painter had had the gall to ask so much for a simple paint job. I told her I could not share her outrage as the painter is free to ask whatever he wants and she is free to reject the proposal.)

To sustain my breathing air I need food and shelter before I need health care and no one is giving us food and shelter for free because we assume those who would work to give us food and shelter are entitled to compensation. Medical care is no different and I cannot see why we should not just pay for our own. So the rich get better health care. So what? Why should that bother me? They also get better everything else. That’s the point of being rich.

Suppose a doctor discovers the way to cure AIDS and wants to charge 5 million dollars per patient. Even if I cannot afford it, isn’t it better that even one person is cured than no one is cured? (Not to mention that treatments come down in price and in a decade it would be accesible to more people).

And the “greedy pharma companies” is another stupid stereotype. If they really provide such a higher return on investment everybody would invest in them and nowhere else. The market allocates capital just like it allocates other resources. If you are so sure these corps have a license to print money then go and buy some stock.

“Free” health care in Europe is a bad joke. You think they get it for free? Has anyone seen the taxes in Europe? Sales tax of 18%? Gas tax which makes driving around the block a luxury? I remember my first visit to Canada when I discovered a box of cereal there cost the equivalent of an apendectomy. No wonder health care is “free”.

There is no free lunch and, rather than the government take my money and paternalistically administer it for me, I would rather decide on my own how to best spend it. Then I can choose a health plan which I think fits me best interests.

That Europeans are all happy about the system is an American myth. How many Americans travel to Europe to find better health care? How many Europeans to the USA? I bet many more Europeans travel to the USA to get better health care. I know a few myself.

It is ironic but I may be opening a thread asking for help for a friend I have in London because she is having difficulty getting health care even though she is supposedly covered. I tried to find a private hospital but the costs were out of sight so. . . we’ll see.

42

Yes, but should it have cost me in excess of $4,000 for the ten-minute ride to the ER, having my broken leg set, and spending one night in a hospital room? (I wasn’t hooked up to any machines or anything, even an IV, mind you; I was just there for observation.) The doc saw me for about 15 minutes total, and it took me quite a while to pay off his $1400 bill. (Do the math; that’s a $5600 hourly rate.) OK, it was Thanksgiving weekend, but c’mon!

Should something as simple as setting a broken leg cost me $4 grand because I was 2 days short of the insurance kicking in at my new job? Setting a leg isn’t exactly a high-tech procedure; basically, they just shot me full of Demerol, held me down, and yanked until the 6 pieces of my leg were in reasonably close proximity to each other again.

I should have been covered on COBRA from my former job, you say? Not eligible; the old job was an 8-person business, and COBRA only kicks in at 50 full-time employees. Something is wrong when it takes $4k to set a broken leg. We’re not talking heart transplants, for chrissakes. (I did eventually pay it off, by the way, because I have a sense of reesponsibility.)

43

Eva, there are many reasons it was so expensive but part of the cost of doing business for hospitals is taking care of all those who do not pay. In effect you paid for your care and shared the cost of someone else who could not or would not pay.

I agree that if we impose on hospitals the obligation of taking care of anyone, regardless of their ability to pay, then we should reimburse the hospitals for that cost and not expect them to recover it from other patients.

44

Err, no. They are paid a salary.

Average universal EU expenditure on health care is under 10% of GDP, US expenditure is just hitting 15%. Spot the bargain.

You can’t have it both ways. We also pay for our own. But collectively. You must be a real big (sales tax) consumer if you think you’re better off paying profit hungry shareholders a chunk of your health care premiums.

It is ? Show me someone who doesn’t agree with the principle - which, BTW, is not the same as not being happy with what has been an under-funded service in the UK (6.8% GDP)

FWIW:

http://www.who.int/whr/2000/en/press_release.htm

**The U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, **the report finds. The United Kingdom, which spends just six percent of GDP on health services, ranks 18 th .

45

For those who can afford it, the US offers health care which is as good as can be got anywhere in the world, and better than can be got in most places.

Through a very well-developed system of private health insurance, more people in the US can afford the best healthcare than in most other countries. 56% of the population are covered by private health insurance; this is higher than almost anywhere else in the world.

However I don’t think US health expenditure is efficient. Americans pay very dearly for their healthcare; they certainly pay more than Europeans do, even when account is taken of the much higher taxes that Europeans pay to cover healthcare. And, while for those who are covered by good private insurance the quality of healthcare in the US is excellent, for the country as a whole it is not. The US as a nation gets bad value for its health expenditure.

Even if we look at public healthcare expenditure alone, the US actually spends more as a % of GDP than Italy, Japan or the UK. Yet the public health systems of these countries are much more comprehensive, and provide (I think) a higher level of care with (certainly) a better outcome overall, than the public health system in the US.

There could be a couple of factors at work here. The US population is more dispersed, and delivery of healthcare services could be more expensive as a result. (This would affect both private and public healthcare, of course.) And, as has been pointed out above, lack of access to affordable primary care may mean that a lot of public patients defer getting treatment until they present as emergency cases, with significantly higher costs and poorer outcomes. And no doubt there are other factors involved also.

Bottom line: Americans who are covered by private health insurance enjoy excellent healthcare, but may pay more for it than they need to. Americans who are not covered enjoy fairly poor healthcare (relative to what other developed economies provide to the uninsured) and, almost certainly, even for this poor level of care, American taxpayers are paying more than they need to.

The challenge for the US must be to develop reforms to their system which preserve the standards of excellence that they already enjoy and the other advantages of their system, while improving coverage and – this is the really tricky bit – efficiency of expenditure.

46

Sailor: Doctors, like everybody else, charge what the market will bear and there’s nothing wrong with that.
London_Calling: Err, no. They are paid a salary.

Err, , , so? As opposed to airline pilots who are compensated with handjobs by the flight attendants? Can you explain to me why doctors are “greedy” and plumbers are not? What about ice cream vendors? Are they greedy? What makes one qualify as “greedy”? What is so specific about doctors to make them “greedy”? Are only American doctors “greedy”? How about European doctors?

>> Show me someone who doesn’t agree with the principle - which, BTW, is not the same as not being happy with what has been an under-funded service in the UK (6.8% GDP)

Um. . . I guess I do not qualify as “someone who doesn’t agree with the principle”? Well, I have quite a few friends who agree with me. Like my friend who works for Alcatel and was diagnosed with colon cancer and they took forever to operate him and then forever again to give him the chemotherapy so the cancer spread to the liver and he needed to be operated and subject to chemotherapy again. When it became apparent this would also take forever and he’d be dead before he was treated, he went to a private hospital which cost him a fortune and he had to sell an apartment he had as an investment in order to pay for the operation. He has recently completed the chemotherapy and I will be glad to put anyone in touch with him and he will give you an earful. BTW he was operated by an American institution (University of Texas or some other such place specialising in cancer). He is not bitter that he had to pay for the treatment, he is bitter that he has been paying fucking taxes for decades to be taken care of if and when something like this happened and now they leave him out in the cold. They don’t say “we won’t treat you” but they say “the waiting list is 8 months” which amounts to the same: a death sentence.

Right now I have a good friend in London who seriously needs a gynecological checkup and she is telling me she just gets put on a waiting list. She needs a serious gynecological checkup NOW! and I am pissed about this. She is paying taxes to have health care, not to be put on a waiting list. I am fucking pissed with this because I am the one who may have given her something and I feel obligated to pay for a private exam and possibly treatment (several hundred pounds) rather than telling her waiting for several weeks on a waiting list is ok. Where is the fucking UK health care system when you need it? She asked for a gynecological exam and they asked her why she thought she might need one (Jesus Christ!). I told her to go back and say “because my fucking boyfriend has been fucking diagnosed with a seriously fucking STD!!” and they said, “oh, ok then. . . we’ll put you on the list”. Great. So here I am, trying to find out about private clinics in London for her which will not bankrupt me.

I have a friend in Madrid who pays for private HMO because he says the national health care system is a bad joke. The name of the HMO is Sanitas and it is huge. Why would a a country with universal health care need or have private HMOs which people voluntarily pay for in addition to their tax paid health insurance. Contact any of the people who are members of such HMOs all over Europe and ask them what they think of socialised medicine. If they think it is so great why would they pay for a private HMO?

How about Dutch patients being sent to private hospitals abroad because the waiting lists were just unbearable?

I am glad you like the system, but do not assume everyone does.

>> Average universal EU expenditure on health care is under 10% of GDP, US expenditure is just hitting 15%. Spot the bargain.

>> The U.S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends just six percent of GDP on health services, ranks 18 th .

You get what you pay for. In the EU you get crappy health care and waiting lists. I am glad you like what you have but I prefer something else. You know about different strokes for different folks and all that. I just hate it when I am not given a choice. Not to mention that the US investigates and develops stuff that benefits the rest of the world.

It would be almost impossible to make meaningful straight copmparisons but let us try. Money spent is not the only or even main factor in the quality of health care but let us try to compare. The UK spends less on health care. The quality of care you get is also lower. (BTW, there is nothing wrong with that). The USA has the best health care in the world, the best hospitals, the most advanced investigation, they develop the best drugs. . . and they pay for this which other countries later benefit from. So a lot of what Americans pay is for the benefit of other countries.

It would be interesting to factor in other things like violence. In Washington DC hospitals treat victims of gunshot wounds on a daily basis which is a huge cost. What this means is that they are delivering more care. The fact that people who go around shooting each other need more health care and yet have shorter life expectancy is hardly an indictment of the health care system. There are so many factors that no straight comparison is possible. The entire culture and lifestyle has to be factored in.

In summary, my points are: 1- Socialised health care is not as great as some people like to think, 2- even if it were good in the UK, that does not mean the system is directly transferable to another country. If the US implemented the UK system, then the development of drugs and medical research would slow down which would harm everyone, including the UK.

Americans pay much lower taxes on everything and get to keep more of their money which they can choose how to spend, whether on a larger house or on better health care. In Europe the governments get much more of your money and get to decide how to spend it. You like the European system better? Fine. Good for you! But what about those of us who don’t? I believe no one is better qualified to decide how to best spend my money than yours truly.

47

sailor, You quoted the above but I don’t think you read it fully. The WHO figures you quote show that UK and other EU countries not only spend less on healthcare than the US but they also have better healthcare than the US, not worse.

In both systems healthcare is rationed; in Europe through political decisions about how much resources to devote to healthcare, and what priorities to set; in the US by ability to pay. The advantage of the US system is that it allows excellence to flourish; the advantage of the European system (I think) is, first, that it makes for more efficient expenditure and therefore secures a higher overall level of healthcare at a lower cost.

A further advantage of the US healthcare system for you personally, as you point out, is that it enables you to secure the level of healthcare you want or need through making choices about how to spend your own money, but this is not an advantage for the US as a whole. For every sailor who benefits from this, there is another American who is unable to secure the level of healthcare he wants or needs because he doesn’t have enough money, and the figures suggest that, on the whole, this aspect of the US system is more of a disadvantage to the US than an advantage.

48

UDS, I understand (and understood) that but my point is that it is not as simple as that. This is like debating gun control. Some people say the US should have similar gun control laws to the US and then the crime rate would be similar to that of the UK but that does not take into account that the population and culture of the US are not British. Others can point out that in Switzerland all males are armed and they don’t go around killing each other. Smae thing with health control. . . oops, I mean health care. That the UK as a whole gets better health care than the US is highly debatable and definitely proven wrong by my personal experience. Expenditure is one aspect of health care just as it is one aspect of education. Some schools do a lot better with less money than others with a lot more money. Just throwing money at problems is rearely a good solution.

The US has higher social and cultural differences among the population. Many people are unhealthy due to ignorance rather than lack of means. When kids in DC kill each other and decrease the overall life expectancy of the population, the answer is not better health care, it is more education (and maybe fewer guns). Also, I have pointed out that the UK benefits from American expenditure in R+D. etc. It is not as simple as saying “people in the UK live longer and spend less on health care, ergo their system is better”. Following that argument we could probably arrive at the conclusion that the Chinese system is the best because they live quite long and spend close to nothing on health care. But they eat differently and practice QiGong and . . . they are Chinese, so maybe their model is not the best for us. (BTW, health care in China sucks big time)

49

You mean the solution which is best for the UK is not best for the US, and vice versa? I completely agree.

I don’t think this can be correct. Your personal experience tells us how well the UK system served two or three people known ot you, but nothing about the UK as a whole. Your anecdotal evidence can be matched - indeed, has been matched in this thread - by anecdotes about people getting speedy and free treatment in Europe which they could never have hoped to get in the US.

To get an idea of the overall merits and demerits of the two systems we can’t rely on anecdotes. We need to rely on broader measures, and (in terms of health outcomes) both the raw mortality statistics and the WHO report seems to suggest that these do not tend to favour the US system.

Again, I completely agree. And the relatively poor experience of the US, which has the highest per capital health expenditure in the world, seems to prove the point.

I take the point about the guns. But what the broader point shows is that the US might benefit (i.e. enjoy better health at the same cost) if it diverted some of its healthcare expenditure from therapy to health education. Or if it diverted money into good quality public infant care, since infant care pays enormous dividends in terms of lifelong health.

I’m not saying the US would definitely benefit from measures like these, but it seems worth exploring. And it has to be acknowledged than an insurance-based system is not so good at “public health investment” of this kind.

Well, I take the point. But London_Calling’s post above suggests that, given its population, the US may be punching below its weight in terms of medical developments, rather than above it.

I agree. Life expectancy is an easy measure, but a fairly crude one. Lots of things that have nothing to do with healthcare affect life expectancy. More sophisticated measures are possible. The WHO report appears to use them, and the US still doesn’t rate too highly, relativel to countries with a similar level of prosperity and development.

Of course it doesn’t follow that the European system is superior in every respect, or that if applied in the US it woudl raise outcomes to European levels. But, having said all that, there does seem to be a national value-for-money issue as far as the US healthcare system is concerned.

50

Well, like gun control, I do not think we are going to settle this issue. Different people like different systems. I would just open all borders between the EU, Canada and the USA and let people settle where they like best. You like the goveernment telling you when and how to pee? Go live in France. You like the government out of your life? Go live in the US. Sounds like an easy way to make everyone happy.

51

I’m reading the thread, but have little to add.

Thanks, all.

52

sailor, are there any Planned Parenthood clinics in England? Your girlfriend could probably get treated there.

The U.S. health care system works great, if you’re lucky. If you have a full-time job with a company that chooses to provide good insurance. If you work two part-time jobs, work as a temp, have worked at a place for less than six months (the point at which many benefits kick in), or have the audacity to be unemployed, well, then you’re just screwed.

Frankly, at the very least, I think we should have national health care for all citizens under the age of 18. Children shouldn’t have to suffer because their parents don’t have insurance.

53

It comes down to taxes, I guess. Most other countries, seeing how vital an issue health care is, are willing to pay the taxes. Canada, appropriately enough, uses a very high tax on cigarettes to help fund our system (cigarettes sell for $8.25 Cdn a pack in my store, about 2/3 of which is tax).

America is more tax-and-government-phobic than the other industrialized Western nations.

FWIW, I’m really happy for the system. I’ve known people who’ve had to wait hours in the emergency ward, but it’s never happened to me. I was once able to get minor surgery on my leg on an hour-and-a-half’s notice at a government-run CLSC clinic.

In recent years, there’s been a major lobby of a small but very wealthy elite – an elite that often has the ear of the provincial and federal governments – to adopt the American system. If that happens, I know I’ll be left without insurance, which I find a terrifying prospect.

54

On the contrary, I don’t think anyone here has read it properly - either that, or they are just quoting the bits they are interested in and ignoring anything that disagrees with their pet theorem.

Take for instance the fact that the report is made up of several indicators, each individually weighted.

One of the key factors is responsiveness (defined on two criteria - respect & dignity with which the patient is treated, and also speed of treatment and availability of appropriate resources for treatment and investigation). The US came top of that section. Since it’s 9 months since I was in hospital overnight with a kidney infection and I still haven’t been treated for the original cause, I know which country I would rather be in.

Where the US was ranked lower, which greatly affected their overall standing, was on fairness of finacial contribution (they came around 54th or 55th).

Personally, I’d love to see how they decided this for countries with sliding scale tax schemes, some local elements of health coverage, and a centrally used extra tax included in things like food & fuel, like VAT in Europe, plus average cost of private health care in addition to still having the larger tax burden. The press release does not mention how it was calculated, nor are the extra items of information downloadable (at the moment, at least).

55

“pet” theorem, eh? Sounds more like a pocket monster to me. When you bring it out amongs friends it evolves into something truly frightening.

[note to self: never, ever stretch video game analogies]

56

A report which lists Spain as one of the countries with best health care cannot be taken seriously. Or maybe the use of sangría as an anesthetic was a criterium for “quality” health care? What a joke.

You want to know how bad government health care is in Spain?

Everybody: How bad?

It is so bad the government planned health care is for the general, tax-paying population, but government workers get care from a private HMO paid by the government (that is a fact). Does that tell you something?

It is so bad that, when the minister of health (I forget her name) was confronted on a tv program with the raw numbers of people who died annually while waiting to be treated, her best response was that the numbers were irrelevant because “many of those people would have died anyway, even if they had been treated”.

I could go on and on. I do not know what the criteria was that awarded Spain a position as one of the countries with best health care but I cannot take it seriously.

If the study awards points for “fairness” and defines fairness as “having a socialised system” then the report is meaningless as far as comparing the American system to socialised systems. I could define “fairness” as “what the Americans do” and then the US would rank right up there. It seems to me the report wanted to reach a certain conclusion and did just that.

57

fierra - I did look at the criteria , well, at least a year ago now and I’ pretty sure it is available from that link… IIRC, the fairness of the means of inclusion in (universal health care systems) was factored in at quite a high level.

sailor - And are the Spanish voting to adopt the US system ?

It does seem curious that you argue for choice when the only choices in the US are pay through the nose, rely on charity or suffer.

58

>> are the Spanish voting to adopt the US system ?

In a sense yes because everybody who can afford it gets private care and the people you see at the government clinics are mostly the very poor (mostly immigrants). I would call that “voting with your wallet”. And government workers get an American-style HMO. So, you do not consider that as an expression of how the Spanish rate their health care system?

So, you get to pay for your health care and you get to pay high taxes to maintain a government program (Grande Spanish Porko)which keeps a bunch of bureaucrats employed. Lovely.

I can tell you Europeans go to the US for health care in large numbers. Now, you tell me: How many Americans are moving to Spain or anywhere in Europe to take advantage of the great health care system? I do not think you can find many but I’ll wait for your response.

59

Another American chiming in here:

I’ve been insured and not insured. I’ve had private care, charity care, and paid out of my own pocket. My father used to work for pharmaceutical companies, and he used to work for hospitals. I’ve cursed insurance companies and I’ve worked for insurance companies, and I now work with medical researchers in evidence-based medicine.

You could say I’ve been around the block on this.

Yes, it is incredibly annoying to limp into an ER and be told to wait and fill out reams of paperwork and wait some more. But if you’re not dying you are just going to have to wait in line behind those who actually might be dying. On the other hand, every time my mother has shown up having a heart attack she has been seen first and paperworked after. On the one occassion I had a life-threatening medical emergency I went directly from the ambulance to a clump of doctors with not a scrap of paper in sight. If you have a GENUINE emergency it’s treat first, even in the US.

The US does have medical care rationing - just not as much as elsewhere. Back in the 70’s when my mother needed a coronary bypass there just weren’t enough doctors to fill the need of every patient qualifying for the procedure and she was put on a 6 month waiting list, even though she could have had a massive heart attack any given hour. She had to wait behind others who were sicker. Actually, she only waited 4 months, because a bunch of other people on the list died first. Now, we have more doctors who can do this surgery and people can be diagnosed one day and in surgery the next morning. But anytime demand exceeds supply you will get rationing of one form or another. Organ transplants are another example - more people want/need new organs than we have organs to give them. To some extent the decision is based on matching blood types and other factors, but anyone who thinks wealth doesn’t factor in to the decision is only fooling himself. Is our means of rationing better or worse than the Europeans? Is it better for the government to determine whether or not you get a procedure, or for your wallet? Here, if you need money you can hold a fund-raiser and potentially raise the bucks. Over there – if you have the money and the procedure is not available you have to go elsewhere, and that frequently means to the US.

There are a LOT of differences between the US and Europe. We can start with the inner city gun violence (and I firmly believe it’s the combination of guns+poverty+crowding that breeds this violence, not just guns or poverty alone - where populations are less dense there is less violence regardless of gun ownership). Life expectancy is lower in inner cities because so many young men die from bullets, not because health care or nutrition is inadequate. The US population is also enormously diverse on a physical level. We have sub-populations prone to diseases other groups aren’t. We have pockets of poverty and squalor that are barely up to third world standards. We find that, even after correcting for education and income and lifestyle that blacks are more prone to high blood pressure, premature birth, and some have sickle-cell anemia and whites are more prone to osteoporosis and some have cystic fibrosis and some of our immigrants have inadvertantly brought tropical diseases into the country with them such as Chagas disease from Central America - and I think that if you really analysed the situation you’d find that this is more of a problem in the US than in Europe. People get altitude sickness in Colorado (never a problem in Denmark) and the bends scuba diving in the Atlantic and Pacific (can’t happen in a land-locked country) and bit by poisonous snakes and spiders in the mid-west and south (doesn’t happen in Ireland), frostbite in the northern part of the country (unlikely in Italy or Greece) and so on. Any system we institute in the US will have to treat a wider variety of people and a wider variety of ailments than any individual European country. Which is why no one should assume a European style system would work in the US. For starters, there is no ONE “European system” but a collection of different systems. But US needs may be different than European needs.

Are doctors greedy? Some are. But most people look at income and not outgo. Sure, a doctor may make $400,000 a year - but if he pays $200,000 in malpractice insurance (some premiums ARE that high!) which he MUST have in order to practice, and has to pay for an office and staff out of his own pocket… in the end he may be left with $50,000 or less to actually live on. A decent wage, but hardly rich in this country. If a doctor choose to practice in rural America, or at a non-profit charity clinic in an inner city neighborhood he or she may be outright poor. There is no garaunteed income for a doctor in this country.

Are pharmaceutical companies greedy? You bet. Some of them are out to suck every last time out of sick old grannies. Some of them, although wanting to make enough to keep the light on, genuinely do want to serve the common good as well as make a profit. The company pushing “Claritan” and now “Clarinex” is trying to convince the entire population that should take their allergy drugs 24/7 - even though only 20% of the country is allergic to anything, most of those don’t need medication except a few months out of the year, the drugs don’t work for every allergic condition, and aren’t even the most effective medications out there - they are greedy bastards. Obscure companies you never heard of producing high quality generic medications despite legal attacks from multi-national corporations and offering equally good medicine at a 10th the price of the big guys - they’re alright.

Are insurance companies evil? Some of them are. Once worked with a woman whose health insurance paid not a penny for routine pregnancy care - but they’d pay for complications. Not a penny for prenatal checkups, but they’d cover the bills for a late-term miscarriage. And - surprise! - this lady wound up with a cesearian, which the company paid for, and not a vaginal birth, which is wouldn’t pay for. Did she need that ceasearian? Maybe. But later she found that the cesearian rate for women under this insurance was 60% - that’s WAY out of line. But if the choice is $10,000 out of your pocket vs. a fully paid cesearian should we be surprised if people choose the knife? On the other hand, some health insurance in this country is excellent, even covering things like organ transplants or some of the cost of participating in a clinical trials.

One of the most frustating thing about the American system is that it is inconsistent. We have both the best healthcare and worst healthcare existing side-by-side. Those with top-shelf care don’t want to settle for less – and those without desparately need something better than what they have.

60

One more point I forgot to mention: At any given time there are hundreds, if not thousands, of young, recently graduated, Spanish doctors in the US doing internships. Just in the Washington area I have met many who are working at the NIH, Johns Hopkins and other such places. They come to get better training and opportunities they cannot find in Spain. Many return to Spain after a few years and a few stay on.

Is this not another indication that American health care is indeed ahead? How many American doctors go to Spain to improve their training?

So we have both Spanish patients and Spanish doctors going to the US to take advantage of the system. It seems to me this is a pretty good indication that the system cannot be all that bad.

In effect, America’s health system is contributing a lot to the Spanish health care system in terms of R+D, development of new technologies and drugs, doctor training, etc.