Nothing is ever done until everyone is convinced that it ought to be done, and has been convinced for so long that it is now time to do something else. — F.M. Cornford
There are no simple solutions to complex problems — unless they’ve become so complex that only a simple solution will do. Welcome to health care and insurance in all of their complexity.
Engineers like to say that if a new machine of structure has too many parts, it’s not ready. Not a bad idea to keep in mind when creating a societal structure like health care. One should know where one wants to go; knowing what one doesn’t want isn’t a starting point.
I submit that the goal of health policy, stripped of its advocates, denigrators and rentiers, should be to get everyone insured for the minimum amount of money and best care result. Simple, eh?
Some aspects:
- There ought to be enough money for the United States to have universal health care, not a patchwork — a crazy quilt with holes and weak seams. We spend 19 percent of our GDP on health care, but Germany and the Netherlands spend just under 12 percent of theirs on hybrid public/private, comprehensive systems.
- Insurance is a probability game, ergo it’s not unreasonable to ask the able-bodied to pay for the sick.
- Mandates are not alien to us. We are mandated to pay taxes, drive with licenses and even wear clothes.
- The more people covered by insurance, the lower the cost to all.
- There seems to be no good explanation in the public record as to why medicine is so expensive in the United States — so much more expensive than elsewhere on earth, under wildly different systems.
- The United States is the only country that leans on employers to provide health insurance to employees and to administer the policy and deal with issues that arrive with disputes.
- The cost of the service patients receive is opaque once a third-party payer is responsible: the insurer. The basis of a hospital charge is hidden from the patients and policymakers. The patient has little idea what a procedure costs and who benefits from the expenditure, including doctors who own imaging companies, testing labs and even operating theaters. At the time of delivery, as Norman Macrae noted in The Economist years ago, neither the doctor nor the patients has an interest in the cost.
- Hospitals are burdened with emergency rooms that can’t refuse the uninsured and hide this cost by overcharging elsewhere.
For more than 30 years I operated a publishing business and provided health care for my employees. It cost. It cost in time. It cost in premiums. It cost in employee well-being because as the premiums (well before Obamacare) rose by 15 percent to 25 percent, I was forced to shop for providers — which meant, in many cases, new doctors for my employees every year.
After salaries, health care was the big expenditure. I thought I was in the publishing business, but I was also, reluctantly, in the health care business.
I was keen that people have the security that goes with not having to be frightened of getting sick or falling off a bicycle. Some of my employees were on a spouse’s policy as well as mine and didn’t tell me. One man, a printer, said he didn’t like to fill in forms, so he, his wife and three children just told the hospital emergency room that the family had no money. He wanted me to give him what I was paying the insurer so he could spend it.
None of the proposals now before Congress, nor those codified in Obamacare, address the fact that as a nation we backed into health care and created complex set of stakeholders — some of whom should leave the field.
For someone who has wrestled with health care as a provider, as in other things, I believe that if the purpose is not defined, you’ll get the wrong result no matter how hard you try.
The big questions Congress should be asking of the House Republican health care plan, backed by President Donald Trump, are: Will it save money? Will everyone be covered adequately? From my point of view, Congress is proposing to replace a monster with a monstrosity.
That’s no prescription for a healthy nation, free from fear of accident or illness. Time to grab a clean sheet of paper and start again, maybe check on what works around the world, if that isn’t too damaging to our self-esteem.
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Thank you for this sane assessment of where we’re at, and for calling for a fresh look at the health sector.
I would suggest, though, that there is abundant ‘explanation in the public record’ that shows us why the U.S. health care sector costs so much more than any other country’s. That information isn’t lacking — there are hundreds of studies that shine light on this question — it’s just that the information is very complex, in itself. For starters, there are the huge administrative and legal costs that come with so many interfaces and transactions among so many players (some of which you experienced as a publisher.) There’s the fact that so many people don’t get good primary care, and end up getting worse and then going to ERs or being hospitalized when that could have been averted. There’s the fact that the government protects high profits for the pharmaceutical industry and other actors in the health-industrial complex. There’s the problem of fee-for-service medicine still padding reimbursement claims. There’s advertising that generates inappropriate demand for drugs and services. Etc, etc, etc.
It is also a fundamental truth about shopping for health insurance or a health care provider that it just isn’t anything like shopping for a pound of apples or a new pair of shoes. There is so much we as individual ‘shoppers’ don’t know about what we’re buying when we enter the health care arena. We don’t know if or when we’ll get sick or have an accident, or how unhealthy we’ll be as we age. Frankly, most of us don’t know enough about medicine to evaluate whether or not we’re buying good quality care until after the fact (and maybe not then.) We have to rely on strong professional standards, effective government regulations, and the legal system to ensure high-quality health care. It is folly to expect that individuals making “informed and rational choices” in the health care marketplace will drive down health care costs. Instead we are overwhelmed and confused and disempowered by the bewildering complexity of options. And when we are sick and need care we are particularly vulnerable to being swindled.
Personally, the solution I favor is expanding Medicare to cover everyone. It would be a single, government-based, tax-financed insurance system for all ages that leaves health care delivery (doctors, hospitals, clinics, suppliers) in the private sector. Medicare for seniors is a successful and cost-effective program overall. Not perfect, but practical and viable. That approach would have the best shot at controlling the unsustainable rise in U.S. health care costs, guaranteeing access to health care for all, improving health outcomes in this country, and removing the health coverage burden from employers.
The huge obstacle to realizing this kind of fix is what you’ve called the ‘complex set of stakeholders’ that would fight it tooth and nail. As with every other public policy issue before our democracy now, the people of this country will ultimately decide how to deal with this great challenge. And, as you have recommended, that’s why there’s ‘good reason to look at health care anew.’
I hope you are aware of Steven Brill’s book, “The Bitter Pill” in which he attempted to get an understanding of the costs in medicine. He discussed the Charge Master in every hospital that sets prices on everything. He found that prices vary so much between different hospitals with little reason. He also highlighted the profits and CEO salaries which usually exceed one million dollars. Even nonprofit hospitals pay CEO’s very well. Your view on mandates is correct. Any system that spreads the costs needs this element.
Why is the medical lobby working in Washington so large? I’ve read it is the biggest lobby group. What are they trying to keep control of? Brill said too many expensive tests are given to patients to avoid litigation from malpractice cases. Researching other practices in foreign countries is a good idea.