Monday, March 22, 2010

IT PASSED!!--Part 7 of The Itch for Healthcare Reform

     Finally, last night, after over one year of debate and some of the dirtiest politics, lies, scare tactics, and slander I have ever seen, the United States Congress passed a healthcare reform bill. It will help about 30 of the about 46 million uninsured Americans get healthcare insurance, and will help many who can't afford it pay. It is not the bill that I, or many other Progressives, would like to have seen passed, but it is a start, a strong foundation on which to build. 
     For now, it is the Senate version of the bill, the Patient Protection & Affordable Care Act, that passed. This bill, despite popular rhetoric, is complete with over 200 amendments proposed by the Republican members of our Congress, despite not getting a single Republican vote. And, many Democrats in the House agreed to a yes vote knowing a bill of minor changes will be passed, too, and sent to the Senate to pass using the reconciliation process. Either way, it is a start we can work with, be proud of, and that will help millions of Americans get healthcare, stay healthy, and live better lives. 

     Despite the dirty politics that went along with the passing of this bill, and the cries from Progressives that it doesn't do enough, the bill does some wonderful things for healthcare in America, and does not do some of the things claimed by its opponents. And although some politicians and polls indicate the American people were largely unsupportive, many of the components of the bill are very popular. In a bullet point summary, here is what the newly passed healthcare reform bill does:
  • Prohibits refusal of or cancellation of insurance based on a pre-existing medical condition;
  • Prohibits insurance companies from charging different rates based on medical history or gender;
  • Prohibits insurance companies from establishing life-time maximum insurance benefits;
  • Repeals anti-trust law exemptions that health insurance companies previously enjoyed;
  • Establishes minimum standards for health insurance policies;
  • Requires most, but not all, employers offer health insurance to employees, or face monetary penalty;
  • Restricts abortion coverage on government funded insurance plans;
  • Expands Medicaid program;
  • Subsidizes health insurance policies for families earning up to about $88,000;
  • Creates a health insurance exchange for consumers to compare rates and policies;
  • Creates a mandate that most Americans obtain health insurance, or face a monetary penalty;
  • Increases Medicare tax on Americans earning over $200,000 or families earning over $250,000;
  • Creates a tax on high priced, premium health insurance plans;
  • Reduces fraud and abuse in Medicare;
  • Requires small insurance companies spend 80% of premium dollars on medical costs, and large insurance companies spend 85% of premium dollars on medical costs.
     Most of the above provisions are very popular among Americans. None speak of death panels, government take over of healthcare, and there is not even a public option. So, although it was a long hard battle between very divided factions, healthcare reform has what I hope is only a robust start, with more to come.

     I believe that, despite some polls and criticisms of the plan, that Americans will quickly support this bill and its provisions; I hope it is before the mid-term election this fall!  
     To those who claim this bill violates their freedoms and liberties: Not worrying about how you or a loved one will pay for healthcare costs for an accident or illness, that is freedom; knowing that your health insurance can't be canceled or run out, that choices between food and doctors will less likely have to be made, that an illness will be caught earlier rather than later, extending quality of life, and that we are on the way towards a healthcare system that puts people before profits, that is liberty.

Tuesday, March 16, 2010

The Cure for What Ails U.S.!-- Part 6 of The Itch for Healthcare Reform

      After writing about what the goals of our national healthcare system should be, it is finally time to introduce what I think would best solve our healthcare problems in a way that would work best for almost everyone involved: doctors, hospitals, other healthcare providers, and most importantly, patients. Everyone but, perhaps, the health insurance companies.

     I would like to see the United States adopt a single-payer healthcare system for all Americans who want it-- basically, Medicare for all. Despite complaints about waste and abuse in Medicare, it is still more efficient and operates with a much lower overhead than private insurance companies. Waste and fraud can be dealt with--wresting away billions of dollars in profits from insurance companies can not.
    Implementing Medicare for all would not be terribly difficult, and could be done by increasing Medicare eligibility over time, starting with reducing the age of eligibility, then by allowing self-employed to join, followed perhaps by uninsured children, and continuing until everyone is eligible. In this way, growth could be slower, fraud and abuse could be worked out, and other changes could be made.  Of course, anyone who does not want Medicare would be able to buy alternate insurance, and a market for supplemental insurance would also be created.
     Clearly, any single-payer system for 300,000,000 Americans would be expensive. I have never heard of nor seen results of a study that would confirm this, but I have a hunch it would be less expensive than healthcare today. For example, if all the money collected by insurance companies in premiums and all the money paid directly for patient care were re-directed as a payroll tax, would it be enough to fund Medicare for all?
     Looking at the advantages to a single-payer system makes it obvious to me just how involved the health insurance industry is in the legislative process. Under a single-payer system like this, health care providers, doctors, and hospitals would remain private. Prices would be negotiated between Medicare and the payees. Why wouldn't the providers be happy with this arrangement? They would no longer have the overhead of working with multiple payers, they would not have to deal with billing and collecting directly from patients, and they would have 46,000,000 potential new paying patient-customers.
     Why wouldn't employers also be in favor of Medicare for all? Although they may have to pay a percentage of their employees salary as a Medicare tax, it would likely be cheaper than what they are currently paying for health insurance premiums today. My employer provided health insurance costs over 17% of my pay for arguably poor quality insurance. Would a payroll tax that would cover Medicare for all be more than that? I don't think it would, and would like someone to find out.
     So that leaves the insurance industry, the only real loser in a single-payers system, they are who is preventing this change. 

     If Medicare for all is too objectionable, and private insurance is the only acceptable way to move forward, then it is time to eliminate profit in health care and introduce strict price controls to reduce costs. Insurance must be affordable, and for those that can't, there must be government subsidies to pay for it.
     Unfortunately, the US seems far from ready for real healthcare reform. For now, we'll have to settle for health insurance reform.  For real change in the way we approach healthcare, we'll have to change the way we approach our outlook on human life and on government.  We must acknowledge that all human life is worth taking care of, and worth paying for. Everyone would likely say that is true, but actions clearly show differently. When this happens, we'll know it, because schools will be properly run and funded, people will have enough food to eat, and people will speak out, in force, against people making money by making even the most basic of human needs--health care--unaffordable.
     Next, Americans will have to change our view of government. It does not have to be the enemy-- it is not always the inefficient beast that it is made out to be. The federal government and state and local governments all over the country efficiently provide services to people every day, services we take for granted. I will not deny there are abuses and excesses, and a lot of room for improvement. But there is a lot done well, and I think providing single-payer healthcare could be done well, too.

     The next post in The Itch for Healthcare Reform will address the proposed legislation. What will the bill really do? Will it help improve our rankings worldwide? Will it make insurance more affordable? Will it make insurance more accessible? Will it reduce overall costs?  Perhaps by then, the proposal will not longer be just a bill, but be passed and signed into law!

Sunday, March 14, 2010

The Goals of Reform-- Part 5 of The Itch for Healthcare Reform

     The Itch for Healthcare Reform has already addressed the whys and why nots of the issue, provided statistics that demonstrate that other nations in the world have successfully implemented more affordable healthcare with better results, and given examples of how a few of those systems worked. Now, in part five, I will address what I believe the goals of healthcare reform should be.
     The first goal of any healthcare system should be simple: to provide good quality healthcare, at all levels and stages of life, regardless of ability to pay, to everyone. However, as nice as this goal sounds, and for as many people who would certainly agree with it, the US is not prepared, at least not now, to see it through.
     In the meantime, there are a few things we can accomplish that will help. There seem to be two problems with our current system: affordability and access.  While the US has some of the best doctors and hospitals in the world, the results of our healthcare system don't reflect that. That is largely because millions of Americans can't afford health insurance, or are under-insured, and therefore unable to visit our excellent doctors and hospitals. Sometimes they can't even afford regular physicals, vaccinations, and other routine care.
     So, our first step is to bring down costs and increase access to good healthcare without eliminating the profits of the insurance companies. This is a difficult task, because any way the crisis is solved, the approximately 46 million people who currently aren't getting care are going to need it, and someone will have to pay for it. While the insurance companies, hospitals and doctors don't want their profits to be reduced, and many don't want a public option that will provide insurance without a profit and therefore be less expensive, extending insurance to those who can't afford it will have to come from government subsidies.
     Does anyone see the irony in this? While the government could provide a public option, which still may be subsidized but should cost less because no profit is necessary, people oppose it; but they are less likely to oppose government subsidies going to private health insurers, part of which would be profit for the companies, and cost the tax payer even more than a single-payer or a public option.
     The government subsidies will improve access to health insurance for those who can't afford it, but that is not enough. We also must eliminate the ability of insurance companies to cancel policies when an insured needs care. We have all heard the horror stories of someone who has paid for insurance for fifteen years and hardly used it, but when they develop a serious medical problem, the insurance company cancels the policy for some strange reason, like an inaccuracy in the fifteen year old application. So, they knew about the problem all along, took fifteen years worth of premiums, and then deny coverage when it is really needed.
     Next, we need to eliminate the insurance companies ability to deny coverage to people based on pre-existing conditions. There are too many horror stories about that, too: someone loses a job or their health insurance for some reason and can't get coverage, even though they can otherwise afford it, because they are a bad risk.
     Finally (maybe not finally, but finally for the purposes of this post) we need to eliminate the ability of the insurance companies to set limits (known as lifetime maximum benefits) to policies, which are often as low as $1,000,000.  While it seems like a lot of money to most of us, it can be reached quickly, and a family who had financial security is left in ruin because of healthcare costs. My wife is a nurse on a unit that deals with chronically ill patients, and has several times witnessed patients meet their maximum policy benefit and be left with nothing, while still being reliant on medical care to live.

     In part four of The Itch for Healthcare Reform, the healthcare systems of Canada, the United Kingdom, Germany, and Japan were briefly reviewed. There are other countries with similarly effective programs, including France. Switzerland, Thailand, and more. While these systems all operate a little differently from one another, there are some significant similarities, and four that deserve attention.First, they all see to it that everyone is covered--through a single-payer, a mandate to have insurance, or an ability to pay for healthcare without insurance.
     Next, they all have health insurers or payers who are not for profit. In the single-payer systems of Canada and the UK, those payers are the government, and there is no profit. In the other countries, where there are private insurance companies, the companies are, by law, not for profit.
     The third similarity is that all the countries reviewed had some type of strict price controls. In Canada and the UK, the government, as the payer, sets how and what they'll pay, which is similar to the US Medicare model. In Germany, the insurance companies negotiate regionally with care providers to set prices. And in Japan, although the insurance companies and hospitals are private, the government sets the prices for each and every aspect of medical care.
     Finally, in each of the countries reviewed, doctors earn significantly less money than doctors in the US-- sometimes less than half. But, they usually have free or near-free medical school, and so carry no debt as they enter their profession. They also have little or no malpractice insurance to pay for.
     Each of these differences would have huge hurdles in the US. Although it is unconscionable to me, there are those that would not have everyone insured because of the cost of subsidizing those who can't afford it. Of course the insurance companies would fight hard to protect their $12 billion per year profits, and many would be opposed to government price controls. Finally, doctors, like everyone else, would not likely volunteer to make half of their current earnings! (Oddly, this last hurdle may be the easiest to overcome, since doctors retire and are replaced with new ones who do not know any differently, and because I am hopeful that most doctors get into the profession to help people. As long as they were paid a fair and livable wage, they should be OK with it.)

     There are things we can do to improve healthcare in the US. But will it be enough? I don't think so, and in part six of The Itch for Healthcare Reform I'll present my solution for the health-care crisis.

Friday, March 12, 2010

Healthcare Systems Around the World, Part 4 of The Itch For Healthcare Reform

     In part one The Itch for Healthcare Reform, the need for reform in the United States was explained; part two addressed those who are opposed to healthcare reform; part three provided statistical evidence that it is possible to provide high quality, low cost universal healthcare. Now, part four will give examples of healthcare systems around the world that do, in varying ways, what the US seems to have so much difficulty accomplishing. Below, the healthcare systems of Canada, the United Kingdom, Germany, and Japan are briefly explained, but with enough detail to see how each of them are similar and how each of them are different. Since part three provided a lot of statistical information, I will not provide much here; instead, I want to provide a general idea about the workings of the systems.
     Once again, I should give credit to investigative journalist TR Reid, whose book The Healing of America, and PBS Frontline documentary Sick Around the World, have been paramount to my enlightenment on healthcare around the world. If anyone wants just one source on the healthcare issue, this book is it. 
     In Canada, there is single-payer government healthcare run at a provincial level but mandated by the federal government. Although the care is funded by the government, most doctors and hospitals remain private, and healthcare related information is strictly between the patient and doctor. The single-payer system has no deductible for patients and low or no co-pays. Some provinces require a small monthly premium, which can be reduced or eliminated based on ability to pay. Specialty care is directed by a patient's general physician, and pharmacy costs are negotiated by the Canadian government to keep costs down.
     While there are complaints about the wait times in Canada for special procedures, much of that is exaggerated. Most Canadians are happy with their healthcare system, and a survey in 2009 indicated that 86.2% supported the public system, and 82% preferred the Canadian system to the United States. In fact, in a 2004 contest held by the CBC, Canadians voted Tommy Douglas, the founder of Canadian Medicare, the Greatest Canadian of All Time!  And, while those in the US claim Canadians prefer to come to the United States for medical care, surveys indicate only 0.5% of Canadians received any sort of health care in the US, and of those people, only 25% sought out US care; most others were traveling when they were sick or injured. 
     In Canada, life expectancy is 80.7 years (US: 78.2), infant mortality per 1000 births is 4.8 (US 6.3), $3895 USD is spent per person, per year, on health-care (US: $7290 USD), and the government spends 16.7% GDP on health care (US: 18.5).

     In England all care is paid for by the government through tax revenue. The program is run by the National Health Service, and is free at the point of service. There is a private insurance market that provides care for those who choose not to participate in the NHS provided care, but it is used by a small portion of the population, and usually to cover services not provided by the NHS. There has been a trend to privatize some aspects of medical care, making more of the providers and facilities private, but the patient's care would still be paid for by the government through the NHS. The British Medical Association opposes these efforts.  A newly created Constitution for Health Care explains the role the NHS will play in health care and outlines what patients rights and responsibilities are. Some items listed include that healthcare will be administered free of charge to all, regardless of age, sex, religious or personal beliefs, care will be continuously monitored for effectiveness and improvements made where necessary. The document is long, and has a lot of other rights and obligations, but the idea is that all people in the United Kingdom, will have access to quality healthcare, free, regardless of ability to pay.
     There are some minor expenses in the British system: there is a co-pay for prescriptions, about $10.  However, certain groups, like children, anyone over 65 years old, pregnant women, and the chronically ill, don't have to pay. In the early 1990's, there was a plan to create a small co-pay for office visits, supported by the BMA. The plan met with such public opposition that it was dismissed!
     Most General Practitioners are independent, but their only payer is the NHS. They are paid a certain amount per patient, regardless of what the patient needs, so it is in the doctor's best financial interest to keep his or her patients healthy. Patients can choose their GP, but the GP acts as a gatekeeper for other services and specialists. If your GP doesn't think you need a specialist, you can't get an appointment. A patient may visit a different GP anytime for a second opinion, but generally treatment courses are very similar. Waiting times for services used to be an issue, but Prime Ministers Tony Blair and Gordon Brown put resources in the the NHS to reduce these times, and they are now about the same as waits in the United States. One example, provided by Mr. Reid in The Healing of America, was an asymptomatic hernia repair, which might have a three month wait. He was clear to add that if it was acute, it would be a much shorter wait. Mr. Reid wrote that all cancer patients are seen typically within two weeks, and acute cardiac cases are hospitalized immediately.
     There are some downsides to the NHS, such as the GP as gatekeeper and longer waits for procedures determined to be elective. But the results of the system speak for themselves. According to the WHO, The UK is 18th worldwide (US: 37th). The CIA World Fact Book projects 2009 overall life expectancy in the UK is 79.1 (US: 78.1). Infant mortality per 1000 births in the UK is 4.8 (US: 6.3).

     Germany has the oldest modern day Universal Healthcare system in the world. It was started in 1883 when Chancellor Otto von Bismark proposed and passed the Sickness Insurance Law.  This law provided a health insurance plan that was paid for jointly by employers and employees. At first it was only for a certain group of workers, but it was eventually extended to all Germans. Today, the law requires that almost everyone have health insurance, funded jointly by employers and employees as a percentage of income. The only exceptions are for the very rich, who were originally excluded from the mandate because it was thought that they had money to pay for their own health-care. Today, however, most of the very wealthy who choose not to participate in the mandated insurance program, about 7% of the population, buy their own coverage without the aid of the employer. In Germany, even illegal immigrants are able to participate in the health insurance programs. 
     Despite the government mandate for coverage, both the insurance providers and the care providers remain private and competitive. There are about two hundred insurance companies that people can choose from; all are non-profit companies and all have the same fixed premiums, a percentage of income, that is split between the employer and the worker. The competition between the insurance companies is not about lower rates, since the rates are set, or for more coverage, because the prices are negotiated regionally between the insurance companies and the doctor's unions. Instead, they offer faster pay times or other fringe benefits to entice members. Hospitals or other care facilities are mostly run by either a charity or a city or regional government, but there has been an insurgence of privately run hospitals. 
     Healthcare in Germany is one of the more expensive, accounting for about 11% of GDP (still much lower than the US). There have been measures taken to reduce these costs, including digitizing all patient records and, starting in 2006, required a small co-pay for office visits (very small, it may not exceed about $13.00 per quarter). Doctors unions are getting concerned because there is also talk about putting a max on how much is spent on health-care, and after that, no more. 
      Since the insurance industry is private, and the doctors are private, and both work with little government interference, one might conclude that the German system and the American system are similar, and they are. There are three main differences, as pointed out by Mr. Reid, and they are that the insurance industry, by law, is non-profit; that insurance follows the insured and his or her family from job to job, and if the insured becomes unemployed, the government pays the entire premium, no matter how long; and a person may choose any insurance provider for the same cost, and change at almost any time. 
(Reid, Chapter 5)
     Japan has a system similar to Germany's, but there are some significant differences. The doctors and hospitals are private, and an insured shares the cost of the premium with his or her employer. When service is provided, the insurance company pays 70% of the bills, and the patient is responsible for 30%, with a maximum out of pocket expense for a patient of $650 per month. There is a mandate for insurance, and an insurance company may not deny coverage to anyone. 
     There are about 3500 insurance companies in Japan, and all are non-profit. Despite the high number of companies, they fall into only three basic categories, each for a different type of person and with different government subsidies. The first category includes large company plans that cover employees. These plans require the company pay a portion of the premium and the employee pay the rest; they get no government assistance. Some of the big companies that use these plans have their own doctors and hospitals in an attempt to reduce costs. The next group includes smaller companies. It works similarly to the previous group, with the employer and employee splitting the premium, but gets a 14% subsidy from the government. The third group includes the self-employed and retirees. For those in this group, the government subsidizes the employers portion of the premium, and the insured pays his or her portion of the premium.
     In this system, employees don't get a choice in their insurance provider, it is whoever the company chooses. And although the insurance companies, doctors, clinics, and most hospitals are private, there are very strict price controls set by the government for every procedure, and the prices are dirt cheap by American standards, so cheap, that many Americans would consider not having insurance at all. The biggest problem in this system is that, because of the low prices set by the government, many clinics and hospitals are having difficulty staying open.
(Reid, Chapter 6)

     There are other countries with unique healthcare systems that perform well, but these basic models are the most common. They include single-payer systems run by provincial governments or national governments, multi-payer systems with private insurers and private care providers that regionally negotiate prices to private care providers, and multi-payer systems with private insurers and providers that have prices controlled by the government. There are many other countries with variations of the systems described here that also work well.
     There are some similarities, both good and bad, among all these systems and the ones not mentioned. One, which American doctors will be quick to criticize, is that doctors don't make nearly as much money in the countries highlighted. Generally, they make about one third to half of what comparable American doctors make. They are never poor, but earn about what a mid-level manager would make at an American company, between $120,000 and $150,000 per year. There are some benefits for the doctors, though. There is significantly less overhead because the paperwork and payments are streamlined, often electronically, and payments are usually made within a week, and claims are never declined. Doctors in every country highlighted also get free or extremely low cost medical school; none graduate in debt. Finally, in each of these countries, medical malpractice insurance is a minimal expense, often between $1200 and $1400 per year, which is what some doctors in the US pay in one week. 
     Another similarity between these systems is price controls. Whether they are set by the government, like the UK and Japan, or negotiated regionally so there is a lot of bargaining power, they are strict and the same for everyone, regardless of their insurance provider. 
     The final similarity is the mandate for insurance. In Canada and the UK, there is no mandate because there is a single-payer system that covers everyone, but in Germany, a person must participate in the insurance program or be wealthy enough to be able to pay for care out of pocket. In Japan, everyone must participate. That way, even healthy people pay into the system to help cover costs, and the system will be there for them when they need it. 

     A critic of healthcare reform in the US will easily and quickly be able to find examples of health-care gone wrong in any system they examine, including the four presented here. But overall, the results speak for themselves. American economist Tsung-Mei Cheng, for Mr. Reid's book, discussed what he called the Universal Laws of Health-Care Systems, which states: 1. No matter how good the health care in a particular country, people will complain about it; 2. No matter how much money is spent on health care, the doctors and hospitals will argue that it is not enough; and 3. The last reform always failed.  (Reid p27)  These laws were meant jokingly, but are likely very accurate, and should be remembered when critics of reform are spouting off about the horrors of any changes. 

     The Itch for Healthcare Reform will continue with part five, when I talk about what has to happen in America before real reform can take place.

Sunday, March 7, 2010

Affordable & Universal Healthcare is Possible Part 3 of The Itch for Healthcare Reform

     Part one of The Itch for Healthcare Reform dealt with why America needs reform. Part two addressed the reasons for opposition to reform and why those reasons are not sound arguments. Now, part three will demonstrate that healthcare for everyone, with lower costs and better results, is possible and being done in other countries in the world.

     Much of what I've learned, but by no means all, about health care around the world came from two wonderful sources, both involving the same investigative journalist, T.R. Reid. I first saw a PBS Frontline special hosted by Mr. Reid called Sick Around the World. In this hour long show, Mr. Reid traveled the world looking at the different healthcare programs and asking doctors, government officials, and most importantly, the people what they thought of them. After seeing this program, I was inspired to learn more, and read a lot of articles about the subject, until finally, last fall, Mr. Reid's book, The Healing of America, was released. The book goes in more depth than the Frontline speical, and tackles a few other topics on the health-care debate. It is good reading, and I suggest the book to anyone who wants to learn more, especially those who are afraid of a healthcare system like the ones in Canada, France, Great Britain, Germany, or Japan. Any reader will quickly see that we have much more to be afraid of than anyone getting healthcare in those countries. 

     The United States is ranked 37th by the World Health Organization, an agency of the United Nation. The rating is based on many factors, including improving health, eliminating health disparities, and the systems ability to provide care without causing financial ruin to those it serves. The top ten in that list is as follows, with some other countries of note and their ranking:
1         France
2         Italy
3         San Marino
4         Andorra
5         Malta
6         Singapore
7         Spain
8         Oman
9         Austria
10        Japan
18        United Kingdom
25        Germany
30        Canada
37.       United States

     Another frequently referred to statistic is the overall life expectancy.  Here are the estimates by the United Nations:

1.  Japan                  82.6
2.  Hong Kong          82.2
3.  Iceland                81.8
4.  Switzerland          81.7
5.  Australia              81.2
6.  Spain                   80.9
7.  Sweden                80.9
8.  Israel                    80.7
9.  Macau                  80.7
10. France                 80.7
11. Canada                80.7
22. United Kingdom   79.4
23. Germany              79.4
38. United States        78.2

     Another valuable measure of the success or failure of a healthcare system is the Infant Mortality Rate. Here is a list of the lowest per 1000 births, according to the United Nations:

1.  Iceland          2.9
2.  Singapore      3.0
3.  Japan            3.2
4.  Sweden         3.2
5.  Norway         3.3
6.  Hong Kong    3.7
7.  Finland          3.7
8.  Czech Rep.   3.8
9.  Switzerland   4.1
10. S. Korea       4.1
12. France          4.2
14. Germany       4.3
22. UK               4.8
23. Canada          4.8
33. US                6.3

    Finally, the amount of money spent on healthcare as a part of the Gross Domestic Product. The US spends the most of any country in the world, despite the poor results as demonstrated above. Below are the top ten spenders in healthcare, by GDP, in 2005, according to the Organization for Economic Cooperation and Development Health at a Glance, 2007:

1.  USA                    15.3%
2.  Switzerland          11.6
3.  France                 11.1
4.  Germany             10.7
5.  Canada                9.8
6.  Sweden               9.1
7.  UK                      8.3
8.  Japan                   8.0
9.  Mexico                6.4
10. Taiwan               6.2

To put the above numbers into perhaps a more understandable context, consider that the US spends about $7000 per person for healthcare, while Japan spends about $3000 per person. 

     So, while the US spends more than any other country in the world for healthcare, both as a percentage of GDP and a per capita dollar amount, we have much lower performance by nearly all measures.  And the trend continues towards more expensive care, with fewer people having access to it. It seems more and more clear to any results oriented person that the healthcare system in the United States is falling short on many levels.
     Next, part four of The Itch for Healthcare Reform on healthcare will review how some other countries are able to provide better care to their citizens overall, while spending significantly less money than the United States.  

Wednesday, March 3, 2010

Why No Healthcare Reform? Part 2 of The Itch for Healthcare Reform

     Part one in the series of posts on healthcare reform outlined many reasons for the need for serious change in the way America cares for the health of its people. Part two will review and critique some of the reasons reform is being so vigorously opposed.  Given the obvious need to fix a system that is broken, why would anyone stand in the way? 

    There seem to be three groups of opposition to reform. The first is based on an ideology; people who agree change is needed, but feel their methods are better than those being proposed to improve the system. The second group seems to be people who either believe we have a great system that doesn't need changed or that any change will result in significant damage to the care we all receive. And the third are those who profit greatly from the current system. To be sure, all three feed off of each other, some may subscribe to the philosophies of more than one group, and all are using underhanded methods to accomplish their goals. 

     The idealists are those who think the free market is the best way to solve most problems, including healthcare. They often believe government involvement in anything tends to ruin it, and therefore they would like to keep the government out of healthcare. Although they don't often advertise how strongly they feel about this, many of the people in this group would like also like to abolish most social welfare programs, including Social Security and Medicare. The most recent attempt to do this was in 2005, when the Bush Administration suggested privatizing Social Security contributions, allowing for investment in the stock market, potentially greater returns, and potentially significant losses. (Oddly, many who are offering this argument against the current healthcare reform legislation are the same people who voted for Medicare Part D, the nearly entirely unfunded Medicare prescription drug benefit.) This group has suggested healthcare reform alternatives that would theoretically lower insurance and healthcare prices, so anyone who wants insurance would be able to afford it. Their ideas include a more open market for insurance, like allowing for the sale of insurance across state lines and increasing competition, and enacting tort reform. They propose that each of these measures would work to reduce costs, making healthcare more affordable.
     There are a few problems with this reasoning. The first is that it is uncertain that it would reduce prices. Several states have enacted tort reform to limit the amount of punitive damages or pain and suffering damages, but it has not significantly reduced overall healthcare expenses. In fact, Texas enacted tort reform and is one of the most expensive states in the country for healthcare. Additionally, medical malpractice, while expensive, is estimated to account for less than 2% of overall healthcare expense.  Selling insurance across states lines may increase competition, but it would also allow insurance companies to sell insurance using the regulations from the state in which they are headquartered, not the states in which they are selling. Therefore, all the insurance companies could relocate to one state with particularly low requirements for health insurance, and sell insurance to people in other states. This is similar to what credit card companies do now, with so many being headquartered in Delaware. Or what many corporations do now, basing their operations, on paper anyway, in another country. That type of competition will likely only provide insurance with fewer benefits.  And while insurance companies would compete strongly to cover young, low risk people, they would not do so to cover older, higher risk people, offering no benefit to those who need insurance the most.

     The next group that opposes healthcare reform are those who think that either our current system works well, or that the alternatives would be worse than our system today. They often use more emotional arguments, including buzz words like socialized medicine, loss of liberty, death panels, and government take over of healthcare; and they often don't know or understand much of how the current system works (or doesn't work), and what is in the currently proposed legislation.
     While the fear instilled in people who subscribe to this philosophy, and the fear they are working hard to instill in others, is strong, it is unfounded and based on inaccurate information. For example, nothing in the current healthcare reform legislation would include a government takeover of health-care. Doctors would not become government employees, hospitals would not become government owned, and insurance companies would be permitted to remain in business, even for a profit. 
     This group offers nothing to solve the problems of sky-rocketing costs or the high number of uninsured Americans; it only fights to prevent change. In fact, I know several people who subscribe to this theory of healthcare, and most of them will unabashedly say that they don't care that there are millions of uninsured Americans. They say those people should pay for insurance on their own, and the rest of us should not be burdened with higher taxes or insurance rates to fund those who are uninsured. It appears former Massachusetts governor and presidential candidate Mitt Romney falls in this category of healthcare reform opponents. He said today on NPR's Talk of The Nation that the United States already has universal healthcare, citing laws that prohibit hospital emergency rooms from turning down patients based on ability to pay, and therefore poor Americans get free healthcare. What he didn't mention is that the hospitals still bill these patients, but they can't afford to pay, and don't, leading to higher prices for those who can pay and bankruptcy for those who can't. He also failed to mention that hospital emergency rooms are only required to stabilize uninsured patients, not provide long term care, follow-up care, prescription medications, or even surgeries or other life saving procedures. Ironically, Mr. Romney, while governor of Massachusetts, signed into law health-care reform that is in many ways similar to what is being proposed today for the country, and it worked well.    

     Then there the insurance and pharmaceutical companies making billions of dollars every year on the health, or lack thereof, of all Americans. In 2009, the top five health insurance companies made a profit of $12.2 billion; in 2007, the American pharmaceutical industry made $315 billion. A report published by economists Jack Hadley and John Holahan estimate it would cost between $33.9 and $68.7 billion to insure Americans without insurance. That estimate was in 2001 dollars and was published in 2003. Since 2001, the number of uninsured Americans has increased from 41.2 million to 46.6 millions, or about 12%.  Taking into account inflation and the increased numbers of uninsured Americans, the cost to provide insurance to those currently uninsured would be between $47 billion and $95.7 billion. The combined profit between the top five health insurance companies and the American pharmaceutical companies was $327 billion dollars. That sure is something to think about. And although it would take, at most, less than 33% of those profits, the big businesses are fighting hard to earn every dollar they can at the expense of the health of Americans.

     It is clear in part one in this series, Why America Needs Healthcare Reform, why we need to reform our system. Now it is clear why some oppose healthcare reform: for some, it is an ideology, for others it is fear, and yet others it is profit; and all of those factors have come together to create a storm of opposition that for decades has been hard to beat. But the alternative has been worsening, too: a growing population of uninsured, cost increases that are threatening to price more and more Americans out of the market, and comparative results that are unacceptable for the United States among the rest of the world. 
     Part three will provide examples of the health-care systems in other parts of the world and how they compare to the United States.

Monday, March 1, 2010

Why America Needs Healthcare Reform Part 1 of The Itch for Healthcare Reform


     The healthcare reform debate is now back in full swing in Congress and is again dominating the news. President Obama offered the Republican members of Congress another opportunity for involvement in  bipartisan healthcare reform legislation last week, but by all accounts his efforts fell on deaf or stubborn ears, forcing Democrats to start the reconciliation process in the Senate in an attempt to pass any type of meaningful healthcare reform this year. Of course, this has met opposition from the Republicans, who are quick to forget their own frequent use of reconciliation. 
     Healthcare reform must happen in the United States, the sooner the better, and by whatever means are legally available. The next few posts will be a part of the series The Itch for Healthcare Reform, and will be about this issue, including why it is so important, obstacles to change, more efficient and effective healthcare systems in other countries, what has to happen in the United States to make change a reality, and some ideas that will make healthcare in the United States second to none.

     The first question is why is there such a need for US healthcare reform.  Although the answer has many parts, it is also very simple: our system is broken. It is ineffective, inefficient, and by almost all measures, substandard when compared with healthcare systems in other first world countries. 
     Our system basically consists of doctors and hospitals that bill patients based on services provided. If a person can't afford the services, they may not receive treatment. There are laws that prohibit hospitals from turning away extremely sick or injured people, but they are only required to stabilize the patient, not provide full treatment. 
     Because of the expenses of healthcare, most people have health insurance, provided mostly by employers as part of a compensation package. People are able to buy insurance privately, but it is usually more expensive, less comprehensive, and more difficult to get. For those whose employers don't offer insurance and are unable to afford or obtain insurance individually, they may be eligible for government sponsored Medicare, Medicaid, or another government assistance program. If not, they must go without, and hope they don't get sick or injured. Unfortunately, the number of Americans who are without insurance has been growing and is currently disturbingly high. In 2008, it was estimated that over 46 million Americans are uninsured
     Because of the rising healthcare expenses, insurance companies are cutting back on what will be covered or how much they'll pay. Most policies have a lifetime maximum benefit, and it is not unheard of that patients exceed that amount. Deductibles and co-pays been increasing, and co-insurance of twenty percent is almost standard now. Some policies have an out of pocket maximum for co-insurance, but many do not.
     As a result of some of the increased in heath-care costs and insurance changes, you can see how even with insurance healthcare bills can pile up. It is estimated that 25 million Americans are under-insured; that is, they have health insurance, but not enough to protect them from financial ruin if a serious injury or illness stricken a policy holder. 

     The rising costs of healthcare and the inadequacy of health insurance coverage is indicated not only by the numbers of uninsured and under-insured but also by the number of bankruptcies in America that are a direct result of health-care expenses. In 2007, 62% of bankruptcies were caused by medical expenses. Of those, 78% of those who filed bankruptcy had health insurance; 60% with private insurers. The percentage of bankruptcies file as a result of healthcare expenses in 1981?  8%. 

     The United States spends more money per capita on healthcare than any other country in the world; in some cases, more than double. As a percentage of Gross Domestic Product (GDP), Japan spends only 8%; the United Kingdom spends 8.3%; Germany 10.7%; Switzerland 11.6%; and the United States is 15.3%. 

     We have been hearing a lot lately that America has the best healthcare in the world, as is evidenced by the number of world leaders that come here for care. When looking at the huge expense of our system, one might think that is right. Unfortunately, by many measures, that is wrong. The US measures 37th according the World Health Organization in overall healthcare.  Our infant mortality rate is higher than most other first world countries at 6.8/1000 births (Japan is lowest at 2.8/1000 births; the UK 5.1; Germany 3.9). Our life expectancy is lower than many other countries, too, at 77 years (Japan is highest at 82.1; Switzerland 81.3; the UK and Germany are 79).  

     I think it is clear that our costs high for results that are poor. Our insurance industry leaves 71 million people behind, almost 24% of our population. Our system is not meeting the needs of our country, at the expense of low quality and prematurely lost lives. This is clearly not acceptable. Reform is needed. Now.