Getting to the next health care system, with a side order of outrage

Politics and religion
1

Atul Gwande has a good roadmap for healthcare this week in the New Yorker. Let’s take a detour first, however, to look at the stories at the beginning and end of the article.

In every industrialized nation, the movement to reform health care has begun with stories about cruelty. The Canadians had stories like the 1946 Toronto Globe and Mail report of a woman in labor who was refused help by three successive physicians, apparently because of her inability to pay. In Australia, a 1954 letter published in the Sydney Morning Herald sought help for a young woman who had lung disease. She couldn’t afford to refill her oxygen tank, and had been forced to ration her intake “to a point where she is on the borderline of death.” In Britain, George Bernard Shaw was at a London hospital visiting an eminent physician when an assistant came in to report that a sick man had arrived requesting treatment. “Is he worth it?” the physician asked. It was the normality of the question that shocked Shaw and prompted his scathing and influential 1906 play, “The Doctor’s Dilemma.” The British health system, he charged, was “a conspiracy to exploit popular credulity and human suffering.”

In the United States, our stories are like the one that appeared in the Times before Christmas. Starla Darling, pregnant and due for delivery, had just taken maternity leave from her factory job at Archway & Mother’s Cookie Company, in Ashland, Ohio, when she received a letter informing her that the company was going out of business. In three days, the letter said, she and almost three hundred co-workers would be laid off, and would lose their health-insurance coverage. The company was self-insured, so the employees didn’t have the option of paying for the insurance themselves—their insurance plan was being terminated.

“When I heard that I was losing my insurance, I was scared,” Darling told the Times. Her husband had been laid off from his job, too. “I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.” So she prevailed on her midwife to induce labor while she still had insurance coverage. During labor, Darling began bleeding profusely, and needed a Cesarean section. Mother and baby pulled through. But the insurer denied Darling’s claim for coverage. The couple ended up owing more than seventeen thousand dollars.

…

For all that, the majority of state residents would not go back to the old system. I’m among them. For years, about one in ten of my patients—I specialize in cancer surgery—had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

I once took care of a nineteen-year-old college student who had maxed out her insurance coverage. She had a treatable but metastatic cancer. But neither she nor her parents could afford the radiation therapy that she required. I made calls to find state programs, charities—anything that could help her—to no avail. She put off the treatment for almost a year because she didn’t want to force her parents to take out a second mortgage on their home. But eventually they had to choose between their daughter and their life’s savings.

Maybe it’s just me, but my reaction to reading this sort of thing is blinding rage; I just want to put my fist through a wall. Why has it taken us 50 fucking years to elect a government that can solve this problem? What the fuck is wrong with us? Are we all moral cretins?

Oh, the article? A very good overview of how other countries got their universal health care systems (it’s a wide mix of approaches), and provides some interesting ideas on how to get there from here.

2

because ah shouldna hafta pay fer someone else’s prollems!!! don’t yew take mah moneys, i earned this arbitrary amount fair n square!

3

Because if you are not amazingly wealthy or unless you die a quick death you too are destined to die broke because of health care expenses or long term care expenses.

You would think that people who hate estate taxes would like to see nationalized health care. I bet those last few months in the hospital to treat your cancer have destroyed more small businesses and farms than the estate tax has.

4

When my wife had cancer, our insurance (which was supposedly a very good plan) covered a large portion of it, but refused to cover ten thousand worth of the oncologist’s charges.

“We only pay $400 for a lymphademectomy [or whatever it was called].”

“They had to remove 29 of them, there were three surgeons, and it took hours.”

“Sorry, $400 is the most that we’ll pay to doctors outside of the network.”

“… but there aren’t any gynecological oncologists in the network!”

“There’s nothing we can do beyond $400, sorry.”

In the end, the oncologists waived some of the fee, but we still got hit for about five grand, as removing the extra 28 lymph nodes was apparently optional or something.

Health insurance in this country is seriously fucked – but most people don’t realize how fucked up it is until they (or a family member) run into it directly themselves.

5

It doesn’t help that the system is (or soon will be) overburdened with people full of illnesses and problems because of preventable shit, like extreme obesity and smoking. Not that this is some kind of excuse or apology for either side of the health care “debate”, but it still sucks.

6

Watch the PBS Frontline documentary, Sick Around The World.

In Sick Around the World, FRONTLINE teams up with veteran Washington Post foreign correspondent T.R. Reid to find out how five other capitalist democracies – the United Kingdom, Japan, Germany, Taiwan and Switzerland – deliver health care, and what the United States might learn from their successes and their failures.

Reid’s first stop is the U.K., where the government-run National Health Service (NHS) is funded through taxes. “Every single person who’s born in the U.K. will use the NHS,” says Whittington Hospital CEO David Sloman, “and none of them will be presented a bill at any point during that time.” Often dismissed in America as “socialized medicine,” the NHS is now trying some free-market tactics like “pay-for-performance,” where doctors are paid more if they get good results controlling chronic diseases like diabetes. And now patients can choose where they go for medical procedures, forcing hospitals to compete head to head.

While such initiatives have helped reduce waiting times for elective surgeries, Times of London health editor Nigel Hawkes thinks the NHS hasn’t made enough progress. “We’re now in a world in which people are much more demanding, and I think that the NHS is not very effective at delivering in that modern, market-orientated world.”

Reid reports next from Japan, which boasts the second largest economy and the best health statistics in the world. The Japanese go to the doctor three times as often as Americans, have more than twice as many MRI scans, use more drugs, and spend more days in the hospital. Yet Japan spends about half as much on health care per capita as the United States.

One secret to Japan’s success? By law, everyone must buy health insurance – either through an employer or a community plan – and, unlike in the U.S., insurers cannot turn down a patient for a pre-existing illness, nor are they allowed to make a profit.

Reid’s journey then takes him to Germany, the country that invented the concept of a national health care system. For its 80 million people, Germany offers universal health care, including medical, dental, mental health, homeopathy and spa treatment. Professor Karl Lauterbach, a member of the German parliament, describes it as “a system where the rich pay for the poor and where the ill are covered by the healthy.” As they do in Japan, medical providers must charge standard prices. This keeps costs down, but it also means physicians in Germany earn between half and two-thirds as much as their U.S. counterparts.

In the 1990s, Taiwan researched many health care systems before settling on one where the government collects the money and pays providers. But the delivery of health care is left to the market. Every person in Taiwan has a “smart card” containing all of his or her relevant health information, and bills are paid automatically. But the Taiwanese are spending too little to sustain their health care system, according to Princeton’s Tsung-mei Cheng, who advised the Taiwanese government. “As we speak, the government is borrowing from banks to pay what there isn’t enough to pay the providers,” she told FRONTLINE.

Reid’s last stop is Switzerland, a country which, like Taiwan, set out to reform a system that did not cover all its citizens. In 1994, a national referendum approved a law called LAMal (“the sickness”), which set up a universal health care system that, among other things, restricted insurance companies from making a profit on basic medical care. The Swiss example shows health care reform is possible, even in a highly capitalist country with powerful insurance and pharmaceutical companies.

Today, Swiss politicians from the right and left enthusiastically support universal health care. “Everybody has a right to health care,” says Pascal Couchepin, the current president of Switzerland. “It is a profound need for people to be sure that if they are struck by destiny … they can have a good health system.”

7

As much as people rag on our Canadian system, I like it even though we have delays that occasionally kill. In the US my dad never would have been able to get his knee replaced unless he sold the family farm, up here he had to wait 3 years yes, and those years were excruciating for him but he did get it and now can continue to enjoy life and work.

I’ve got a story like this for my uncle, spine injury when he was in his late teens (it still seriously financially damaged my grandparents, but they could keep the house and the farm), my grandfather who had skin cancer twice, and then an uncle or two with cancer.

(That doesn’t mean it couldn’t be drastically improved though, I just prefer it greatly to what the US has)

Edit: Great link Eric, thanks.

8

I just hope we can get it done this time. Is it going to be the read deal or yet another bandaid?

9

Good link, thanks.

I have said for a long time that if we can’t figure out and pass a comprehensive health care plan, at least start with something that ensures that no one loses their retirement savings or house or goes bankrupt due to a health issue. Start with something no one can argue against. People may try to argue back and forth over cases where people are turned away due to not being insured and argue that this is not supposed to be allowed in today’s systems, etc., but no one will be able to come up with any argument (valid or not) when you line up the heart breaking list of people who have lost their homes, retirement savings, gone bankrupt, etc. to try to help a loved one with a medical problem.

As for whether we’ve finally elected a government that can solve this problem, we’ll see. I’ll never underestimate the ability of all the members of Congress to get petty, focus on their own self interests and power and purses, etc. and be completely ineffective on anything of any size or import. I’m hoping but wouldn’t bet that they’ll get anything significant done, and not because those mean old Republicans won’t play nice (though that will make a great excuse.) But I am hopeful - let’s watch and see.

10

It would suck if we spend all our treasure and effort changing to a system that still “could be drastically improved.”

Jason’s walls would have even more holes in them.

11

There are plenty of ways to greatly improve the system without nationalizing it. I am afraid that without the near-miracle that was the drafting of the U.S. Constitution, you would end up with a system that would arguably be worse overall with the only benefit being “universal access” to the same crappy system. It will require getting outside of the ideological box that is “government-run healthcare is the only solution”. There is no box that keeps the free-market people in, as there is very little “free-market” left in the U.S. healthcare system.

12

Sure, I’ll concede “government-run healthcare” (medicare at 3% administrative costs) is worse than private insurance (30% administration costs).

You need to have healthy, young people to be in the same risk pool as older, sick people. Unless you know, you wanna just say screw it, it’s every man for himself. After all, if you mandate healthcare as a right what about housing for homeless or hungry people? Darnit, it’s damn right UnAmerican.

13

I heard some dirt-farming redneck on NPR a few days ago being asked why he didn’t vote for Obama. His answer? “I think I’ll have to pay a lot more… he likes to spread the wealth around, and he’s going to take what little I have.”

14

I can understand when poor people are against high taxes by principal.

I wonder how much of this hate of social programs is racist undercurrent thinking that “they” (meaning brown skinned people) are going to take away what white people have.

15

Actually, it’s more age-ist fear that “they” (meaning dirty old unhealthy people) are trying to take away what “we” (meaning clean healthy young people) have. Since “they” already have better paying jobs, more money and less debt than “we” do, it strikes “us” as unfair that “we” should also pay for “their” health care.

16

Actually I’m in the boat with that one, the baby boom generation has had the best lifestyle of anyone here on the planet in history. I would love to see taxes raised NOW while they are still working because they really need to pay for the stuff that they’re demanding in retirement.

Social security and medicare aren’t going broke because of poor government policy they’re going broke because the greedy bastard baby boomers are thinking that they can get a free ride through a retirement that they didn’t spend enough to fund.

I hope they fail in this exercise.

17

Indeed it would be stupid to adopt our system wholesale without trying to improve it, but then again I never said you should adopt our system.

I’m just saying that for as, well not entirely bad, mediocre maybe, our system is the US system seems far far worse in my eyes.

I’ll never understand you yanks valuation of efficiency over quality in something as important as healthcare.

18

We talked a bit about our jobs to each other, but I usually have a pretty smooth time dealing with Medicare. It’s the private insurances that usually give me the most trouble with ‘out-of-network’ and ‘pre-approval’ crap.

19

My mistake - My original post is missing sarcasm tags with the 3% vs 30% bit. I was trying to get the whole “government sucks” bit out of the way. Congress-mandated stuff is pretty stupid at times thought - for example part of the HIPAA rules mandated providers and insurance companies switch to one national ID number. I think it started around 2001 and yearly “final deadlines” keep being extended. Finally, in May 2008 the last deadline passed and presumably the companies got their computer systems working properly (kinda). Some systems thought still only worked with the old id numbers. Since all the rules said they could no longer ever, ever, ever ever use the old Provider ID numbers… They just call them PTAN now. What’s a PTAN? It’s the old provider numbers. You still use them, you just can’t call them old provider numbers.

One problem with government health care is it’s open to lobbying by the AARP, for example. I I imagine this makes discussions like raising retirement age or raising premiums much more difficult politically.

Another problem I imagine the Right has politically is the concept that health care is a right. Say I find a homeless guy in the subway and he has pneumonia. We check him in the ER and they give him some antibiotics and set him loose after a day. Then he gets it again, cause he sleeps in a cardboard box.

The US just voted against that UN proposal for food to be a fundamental right (according to that recent thread). How can we make healthcare a right but not shelter (it’s COLD here) or food for the hungry? Otherwise this is just … passing a lot of money around for healthcare. On utilitarian terms we may need to be more careful on our resources - get very basic healthcare for everyone (vaccines and xrays okay, no MRIs or angiograms). Food, shelter.

Pride, jobs, a reason to exist. I guess to a lot of people sneer it is distasteful that the government would now be legally be bound to make you happy.

I’m running away too much from the argument, and I apologize for rambling. I guess we cannot let government decide how one should be happy just as I would not want them to mandate faith or allegiance to a God I don’t believe in.

P.S. I was talking my recently-married Ontario cousin recently: “Hey, so how much are your copays when you see the doctor anyway?” “Copays? What’s that?” “Erm, the part you have to pay yourself.” “We don’t have to.” “What?” boggle

20

It’s not as big as you think. It’s also completely irrelevant to how our current system bankrupts or outright murders people.

Tim, switching to the Canadian health care system would increase the effectiveness of what we have in pretty much every metric. The French system is even better, however.