First of all, in the interest of full disclosure, I should say that I am Jed’s brother Matt, not Jed. I am a Family Physician practicing in Boise, Idaho. I am a registered Democrat, though not quite as angry and liberal as my socialist little brother Alex, who posted about foreign policy.
I’ve read a lot about the healthcare situation in this country, and because of my job I deal with the issue on a daily basis. Health care policy is a national issue but it affects real individuals in real ways on a daily basis. I’ve written a little about the personal side of the issue in my Daily Doctor Blog.
I think an understanding of this issue requires some background knowledge about the current state of affairs in the health care system. Current estimates put the number of people without any health insurance at about 45 to 47 million, about 8 million of whom are children. A significant number more, estimating the number is difficult, are underinsured. Meaning that they have some medical insurance, but it does not cover routine or preventative care or the cost of medications.
The mentality in this country is that if you don’t have health insurance, you can’t go to the doctor. Of course this isn’t true, you can pay for an office visit like you pay for groceries. But, the reality is that people who are uninsured or under-insured do not go to the doctor. They don’t take care of routine problems, they don’t get preventative care, they don’t manage chronic medical problems. All of this leads to more severe medical problems that don’t receive attention until the problems are very severe and very expensive. These people most often access the health care system at this point by going to the emergency room, the most expensive place to get health care. Because they are un- or under-insured they most often cannot pay the cost of their care. This leads to huge write-offs of bad debt by hospitals, causing community and urban hospitals to go out of business by the thousands, and high numbers of personal bankruptcies. In fact, health care debt leads to 50% of individual bankruptcies in the United States, estimated at about 2 million bankruptcies annually. Ironically, a significant number of those individuals had insurance at the onset of their illness. But because of high deductibles, exclusions, and coverage limits those people lost insurance at some point during their illness.
"The paradox is that the costliest health system in the world performs so poorly. We waste one-third of every health care dollar on insurance bureaucracy and profits while two million people go bankrupt annually and we leave 45 million uninsured" said Dr. Quentin Young, national coordinator of Physicians for a National Health Program.
This is a huge problem. Our population and our economy are suffering because of this problem.
Senator McCain and Senator Obama have both talked about the problem, both have made proposals.
A detailed side-by-side comparison of both sides’ plans with links to campaign websites has been prepared by the American Academy of Family Physicians. Click here for viewing.
An analysis by the Brookings Institute has estimated that McCain’s plan will cost 1.3 billion, Obama’s plan will cost 1.6 billion. The same analysis estimates that McCain’s plan will reduce the number of uninsured by 1 million in 2009 and up to a maximum of 5 million by 2013. The estimate for Obama’s plan is a reduction in uninsured of 18 million in 2009 and 33 million adults by 2018. Under Senator Obama’s plan all children would be covered by mandate. Senator McCain’s plan makes no similar provision.
This issue represents a clear choice. Senator Obama proposes dramatic decreases in the number of uninsured and proposes to get there through a combination of government mandates, personal subsidies, and changes in insurance regulations. Senator McCain’s plan hopes to decrease costs by a combination of tax incentives and insurance industry deregulation, thus putting health care coverage within the reach of more Americans.
The deeper issue here is what you think the role of government should be, more particularly the federal government. Senator Obama proposes a very significant, far reaching role for the feds. Senator McCain proposes a much more limited intervention.
I close with a few stats.
The World Health Organization ranked the health systems of the world’s countries in 2000. The US was 37th. They stopped doing the rankings because the US complained loudly.
The United States ranks 41st in the world in life expectancy and infant mortality.
As a primary care physician I feel like only Senator Obama's plan truly addresses the issue in a real and meaningful way. This is one of the main reasons I'll be voting for Senator Obama.
Feel free to post comments or ask questions about anything in the material on the AAFP website.
9 comments:
Great stuff Matt. Thanks for the post. To steal a page from Alex's book, this op-ed piece is one my favorites about expanded government-run health care and the arguments for and against it.
I was also wondering if you, as a practicing physician, have any thoughts about the prospect of increased government involvement/regulation in your line of work. Have any worries about it? Excitements? I've heard some in the medical field say that they feel jipped by all the "government" they have to deal with already while others in the "business world" get bailouts. Any thoughts?
Is anyone talking about taking away some of the power from the ins. companies?
Thanks for the good stuff.
To answer Ma's question: No, everyone's plan keeps insurance companies in the game. It's not politically feasible to get a plan through Washington that cuts insurance companies out of the picture.
In my opinion, the best way to force insurance companies to be more competitive is to make them compete against the nation's most efficient insurer: Medicare. Let anyone buy into Medicare if they so choose. (Medicare's administrative overhead is much lower than that of private insurers, even after normalizing for taxes and profits. See here.)
In fact, this was a provision of both John Edwards' and Hillary Clinton's health care proposals, so it's not outside of the realm of possibility.
Good stuff Matt. I'm a registered Republican who will be voting for Obama. I believe that health care, like education must now be run by the government. By "the government" I mean we the people. By "now" I mean...well, read on.
Mom and I continue to contribute to education even though we have no children in school any more. This is proper, and we're willing to do the same for health care.
But as long as Matt brought up the question of how we got into this mess, I think we should look back a little further.
The objective of "insurance" used to be to mitigate the unexpected. That's what the definition of "insurance" is. It worked because a large group "paid in" while a small group "took out". Everyone contributed to the benefit of an unfortunate few.
Then some idiot proposed that we insure against pregnancy. That was the beginning of the slippery slide, because pregnancy isn't an accident, usually, and it certainly isn't an infrequent occurrence. Now suddenly, there were a whole lot more who "took out".
No one noticed this dangerous change of balance, however, and the employers scrambled to offer this new benefit to their employees, so more and more people "took out", while relatively the same number of people "paid in".
Then somebody got the bright idea that if covering pregnancy was a good thing, how about covering dental care. And the slippery slide continued.
Matt noted that we pay as we go at the super market. But we expect someone else to pay for our fillings and our routine office visits.
So everyone is "taking out" and fewer and fewer are "paying in". The real tragedy that millions are now un-insured and under-insured isn't that they're not getting good health care. The real tragedy is that they're not contributing to the pool. They're not "paying in".
Which causes our only choice now to be to put it into the hands of the one entity with enough clout to insure that enough gets "paid in", the government.
Let's pray that someone will have the wisdom to do it right.
I don't think the life expectancy rate and infant mortality rate have much to do with our healthcare system.
I think the life expectancy has much to do with obesity and our need to deep-fry any food item, including twinkies.
I guess what I'm saying is that I think a lot of the deaths in the US could be prevented with our own personal responsibility in what we eat and how much we exercise.
I haven't looked it up at all, I'll admit, but it might be interesting to see our obesity numbers compared to other countries. Maybe the countries with a higher life expectancy have way fewer obese people, which would mean: less heart disease, less cancer, less diabetes, etc.
How would Obama's reformation of healthcare raise our life expectancy if we keep super-sizing our value meals?
Also...do other countries go to the efforts that we do to save 24 week old babies? A friend that I have out here just had a baby that died at 24 weeks. The doctors/staff at a great hospital here tried for over a week to save the baby, but sadly it didn't work out. Is this an effort that other countries put forth? When we are talking about infant mortality are we talking about at birth? Within the first year of life?
A person with or without insurance can go to the doc all they want. But a lot of healthcare is up to the patient and how much effort they are willing to put in. My husband had a patient that had previously received a kidney transplant and the patient chose not to take his meds to help prevent infection and rejection. This patient had insurance through the state, as in, we are paying taxes so that this guy can have insurance and get help. It was a choice (a very stupid one) that this person made to not take care of himself, with his medical care paid for by the state. This is not an isolated incident in our experience here at an inner city hospital where most people don't pay for insurance. In fact it is a regular thing.
When we are all under the government for our healthcare is it going to make the US population on a whole smarter? More responsible?
I agree that our healthcare does need some revamping. I will not argue that at all. I just don't agree with going the government route.
I'd like to thank Jenny for the points she raised and respond to them.
Jenny's right that our obesity problem is worse than most other nations', and that surely doesn't help our health statistics or the cost of our health care. Yet apparently that alone doesn't account for the discrepancy between the cost and effectiveness of our health care system versus that of other nations. The McKinsey Global Institute did a study that you can read here. It's synopsis says that "the United States spends approximately $480 billion ($1,600 per capita) more on health care than other OECD countries and that additional spending is not explained by a higher disease burden".
To Jenny's question about infant mortality rate, the rate is measured as the percentage of infants that die under one year old, so whether an infant dies in the first week or after 20 weeks wouldn't impact the rate. According to the CIA, there are about 40 countries where newborn infants are less likely to die than those born in the US (data here) and among developed countries, we're among the worst (story here). Why is our infant mortality rate so high? The primary reason seems to be that our poor and minorities (among whom the infant mortality rate is much higher) don't have access to good health care.
Jenny also rightly points out that people make dumb decisions about their personal health care. I can't argue with that. But surely people make dumb decisions whether or not the government provides the care. Universal health care may not make people smarter, but it won't make us dumber either.
Let's be clear, though, that Obama isn't proposing that we adopt a government run health care system. His proposals would reduce the cost of private insurance and ensure that more people can get coverage.
Having responded to Jenny's points, I'd like to share my position on the issue. I believe that good healthcare should be available to all, regardless of wealth. I believe that an important part of caring for our fellow men, particularly the poor, is ensuring that they have access to healthcare. We are tempted to say that "the man has brought upon himself his misery; therefore I will stay my hand," but I don't think that's the right perspective.
I recognize that private industry has little incentive to offer healthcare to those that are poor or predisposed to poor health. This problem won't be solved by relying on the free market. Only as a collective group can we ensure that the system works for the less fortunate. And the side effects of better healthcare for all might just be that healthcare is less epensive for us, too. At least that's what the statistics tell us.
Great stuff and good points from Jenny and Alex. Stories like the renal transplant patient are aggravating. I would offer the following counter argument. Our health care payment system puts priority on management of acute disease and performance of procedures. Transplants are high dollar affairs and doctors/hospitals like doing them. What our health care payment system doesn't value is care coordination and management of chronic disease. I bet the transplant patient didn't find too much difficulty finding a place to get the transplant or a surgeon to do it. But I bet he had a really hard time finding a primary care doctor to coordinate the follow up care and monitor whether or not he was actually taking the anti-rejection meds. I bet he had an even harder time finding a care coordination team to make sure he was educated about his disease, had his social and psychological needs met, make sure he made his follow ups, etc.
Now, of course, none of this may be true of this particular patient, maybe he was just a jerk. But maybe he was depressed, maybe he couldn't afford the meds, maybe he found the side effects intolerable and wasn't truly aware of the risk he was taking by not taking the meds.
My point is our health care system values the wrong things. We value easy access to expensive procedures. We devalue easy access to primary care and chronic disease management. We're paying for the wrong things.
I totally agree that the transplant patient probably didn't deserve the transplant. The answer to that is to shift our resources away from stuff like that and toward health care spending that will do the most good for the most people. That type of shift will mean more scarcity in things like kidney transplants. But, as the patient you described demonstrates, that's probably a good thing. That type of shift will also mean more access to routine health care which will mean better control of diabetes and high blood pressure, lower rates of smoking, all which will mean less need for things like kidney transplants.
Wouldn't the tort reform and other changes that McCain proposes help lower the costs of private insurance?
Thank you Matt and Alex for clarifying a lot of this and for reading and responding to my points/questions.
It is a hard thing for me to divide my desire to help my fellow man from the negative things I've seen take place in the hospitals here, my own experience with government healthcare, and my experience in my work place where a huge chunk of my co-workers were illegal aliens using false SS#s, lying to the government about employment and scamming the system--all the while taxpaying citizens are covering this. I have had my eyes opened to some pretty terrible abuse of the government system that is already in place.
That's an excellent question about tort reform. If I understand what you're saying, it's that malpractice insurance contributes a lot to the cost of our health care and you wonder whether tort reform (reducing patients' ability to sue doctors or the payouts that are awarded when they do) would reduce malpractice insurance premiums.
According to a study by Dartmouth College, "frivolous lawsuits" and large jury awards aren't responsible for the increase in malpractice premiums. It says: "government officials have been blaming multi-million-dollar jury awards and frivolous lawsuits for ballooning malpractice insurance premiums. But that blame is wildly misplaced, according to a recent study by Dartmouth health economist Amitabh Chandra, Ph.D." You can read more here.
By the way, the candidates seem to have similar positions on the topic of malpractice. Here's what I found on their websites.
McCain's website says: "John McCain will lead the fight for medical liability reform that eliminates lawsuits directed at doctors who follow clinical guidelines and adhere to proven safety protocols. Every patient should have access to legal remedies in cases of bad medical practice but that should not be an open invitation to endless, frivolous lawsuits that drive up health care costs for everyone and make the practice of medicine unaffordable for good doctors everywhere."
Obama's website says: "Obama and Biden will strengthen antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance and will promote new models for addressing errors that improve patient safety, strengthen the doctor-patient relationship and reduce the need for malpractice suits."
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