Sunday, November 25, 2007

SiCKO

I am less than satisfied with our medical system here in the United States. This sentiment derives from both personal experience and policy analysis. Let me explain.

Insurance Companies
I watched Michael Moore’s new documentary, SiCKO, approximately one week after receiving a large sum of money from my insurance company for medical bills dating back to 2006. This reimbursement came only after acidic phone calls and emails. In fact, every reimbursement over the past year and a half has been delayed until I’ve filed complaints and become "unfriendly" on the phone. So yes, I already greatly disliked our health system with its third-party payers (insurance companies) before putting Moore’s documentary into the DVD player.

Cost
The high cost of care here is frustrating. For example, I received an MRI in South Korea for less than $200 (which my insurance paid for); I’ve been told this procedure would cost closer to $2,000 here in the U.S. While births are estimated to cost between $7,000 and $9,000 in the U.S., our American friends just had a baby in South Korea for $160 out of pocket.

Even with insurance here, you can still go under. Last year my wife had an outpatient surgery, and our portion of the bill, the part insurance didn't cover, was $3,000. I'm glad she had insurance back then, yet it is frustrating to still be paying off the bill a year later. A study published in Health Affairs has estimated that approximately one half of all personal bankruptcies involve medical bills. Crippling.

Let's look at this from a macro view, rather than the micro view of my life. Spending on health care as a percentage of GDP has risen significantly in the U.S. In 1960, it was 5.1% of GDP; in 2002 it was 15%. Also, the U.S. spends more per capita on health care than does any other country (Rand Health, U.S. Health Care).

This leads me to two different thoughts. First, if we're spending the most, then our system should be the best, and consequently, our health should be the best. Second, if it turns out that we don't have the best care even though we're spending more, then we shouldn't fear the so-called "high cost" of other systems (read universal health care/socialized medicine).

Performace
Is this the best health care system that industrial societies have devised? The World Health Organization’s 2000 ranking of health care systems around the world placed the U.S. at number 37. Forty-one countries have longer average life spans than the U.S. (Boston Globe).

Also, "American babies are three times more likely to die in their first month as children born in Japan, and newborn mortality is 2.5 times higher in the United States than in Finland, Iceland or Norway" (CNN.com, Jeff Green, 10 May '06). Our infant mortality rate places behind 32 other countries (Wikipedia).

So, no, we are not the best. We can be humble and realize that we can learn something from other countries. But then why do people from other countries come to the U.S. for medical treatment? I agree that we have some of the best medical equipment and some of the best research hospitals. People in foreign countries with significant financial resources can afford to come here for world-class treatment in these fine centers. But excellent equipment and expertise in specific centers is very different from having an overall healthcare system that provides for all of its citizens. In fact, we are the only industrialized western country that does not offer universal healthcare.

We have free public schools, free libraries, free police protection (yes, there's no "free lunch," these are financed through taxes). Why do we accept these government services, but then worry about “socialized medicine” when the conversation turns to our nation’s health? And increasingly, Americans are going abroad for medical treatment. Three Billion New Capitalists describes “medical tourism.” For example, it may be less expensive to fly to India to have hip surgery than it is to have the procedure at home--possibly one tenth of the cost.

Access to Insurance
My wife and I are currently among the 47,000,000 people in this country without health insurance (National Coalition on Health Care). Reason? We’re currently unemployed. Attaching medical insurance to the place of work is crippling. If you change jobs, then you have to go through a waiting period before benefits begin at the new job. Also, ailments that were being treated in the previous plan are now considered pre-existing conditions. Because of my neck problems, I’ve been told that group plans are my only chance for coverage.

What other insurance is through the employer? Only workman’s comp, as far as I can tell, which makes sense. But we don’t lose our auto, fire or life insurance when we change jobs. Why health insurance? Let’s take a look.

I took Human Resource Management during my business studies, so I can share a bit of the history of how we got here. In the 1940s, employers were looking for ways to increase employee compensation while staying within wage limits. Non-wage benefits were seen as a positive way to cope with the system. A good idea, right? Sure, at the time. But with decreased job stability and increasingly stubborn insurance companies, it is time for a new system.

Hopefully, tax laws will change soon, making it easier to get insurance directly. However, even if these laws do change, the dramatic upward trend of healthcare costs will continue to push insurance out of reach for many individuals and families.

We have seen that the U.S. healthcare system is (a) expensive, (b) below industrialized performance standards, and (c) not reaching millions of people. We need to admit that it is in our society's best interest to consider other systems.

Options
What countries can we learn from? How about these (WHO world ranking): France (1), Austria (9), United Kingdom (18), Canada (30) and Australia (32) are good starters. We don’t have to copy every policy from any one country, but we can learn from them. It’s time.

You can start by watching SiCKO. This film can’t replace a more systematic analysis of the issue, but it is a good place to get motivated to do the more mundane policy and statistical research needed to improve our health.

Summary
We have world-class facilities and practitioners in certain research centers, but we have nearly 50,000,000 people who can’t afford these services because they lack health insurance. Even with insurance, medical costs are still debilitating. Getting health care through an employer creates significant problems. While U.S. citizens on average pay more for healthcare than anyone else on the planet, our system still ranks only 37th in the world. I think we need to seriously consider major changes.

Possible Solutions
I am for universal health care coverage. This can take different forms. Two options are national care provided by the government and compulsory health insurance through the private market with government subsidy. This is sure to continue as a headline issue as we move to the next presidential election.

Continuing Ed Starter-kit
Overview of health care systems (Wikipedia)
Overview of U.S. health care (Wikipedia)
Overview of U.S. health care (The National Coalition on Health Care)
Overview of Canadian health care (Wikipedia)
US/Canadian Health Care Comparison (Wikipedia)
Illness And Injury As Contributors To Bankruptcy
Learning from International System Comparisons
Rand Health, U.S. Health Care
Jim Wallis and Socialized Medicine (anecdotal)

11 comments:

Ellen said...

Jeff-

You're welcome for the heads up about Buy Nothing Day. Unfortunately, this year I did buy something, (a key chain digital camera that I took apart for an art project) but I rode my bike to the store. And in a rationalizing act, I balanced those two things out in my head.

Switching gears to your post about health care in the U.S., I agree with you that things are terribly out of control here. I'll add that as a landscape architect, I'm involved in a profession that is second to doctors in cases of liability lawsuits. If someone trips on one of my sidewalks, I get sued so they can cover their medical bills. Which, means I care a great deal about health care reform because I don't want to design places so safe that they become devoid of all character. However, I have my doubts about the United States' political structure right now and I'm thinking of emigrating.

Jeff said...
This comment has been removed by the author.
Jeff said...

Ellen, where to?

And if you say someplace dangerous, I'll sue you!

Ellen said...

Some place dangerous, like The Netherlands, or Norway!

Jeff said...

Last night I was talking this over with me father-in-law. The Wall Street Journal reported recently that the portion of European taxes that go for health care is between 7 and 17%. They have high taxes, but it isn't all for health care. Then we each figured out how much our respective health insurance costs relative to our income. His was 7%; 13% for me at my last job.

So our two families are paying basically the same percentage as Europeans for a system that ranks 37th in the world and leaves 47,000,000 people without insurance, 11 million of whom are children. It doesn't add up.

Wendy said...

Jeff thanks for this! Your logic is right on. Wanted to tell you about something that stood out at me as I was reading. You mention that children here in the states are more likely to die in their first month than in Japan and parts of Europe. I'd like to suggest that you look at the difference in vaccination schedules between the US and those countries. When Japan changed their plan from starting vaccination at birth to starting at 2 years old, their incidence of SIDS dropped drastically. What is SIDS, after all? It is just a tag meaning, we don't know (or don't want to talk about) what killed this child. Interesting also- their autism rate also dropped. This was also shown in a study done in Australia with children at risk of SIDS.
I think we are at the mercy of the large corporations here in the states. Are we free? I'd say not in a lot of areas- and the freedom spectrum is narrowing all the time.

Jeff said...

My friend Sara responded by email and said...

I have never been able to fathom how this wealthy and prosperous nation cannot provide for the most basic needs of its citizens. It's disgusting. It's bothered me for years, and yet I have personally done little besides be disgusted and switch to a health savings
account for my own family (which is an improvement, but still so inadequate and truly unaffordable for most people that are scraping by).

I'm paying $460 per month (instead of the over $1,200 per month on the regular group insurance at my old office), and then I fund $4,100for the high deductible (so the family total is $9,620 or $801 per month as opposed to over $14,000 a year on the old plan).

But the bad news is how many people can afford over $800 a month out of pocket for insurance? I am blessed with a steady income from my business right now, but if I were to get hurt and couldn't work, we'd be up a creek without a paddle.

The icing on the cake is that HMOs, after I've paid nearly $10,000, dictate where I can receive my medical care.

I TRULY feel like I shouldn't complain b/c at least I'm lucky enough to afford insurance, but it's just so frustrating, and I don't get what is wrong with our country.

The International Chef of Mystery said...

I know Michael Moore likes to make dramatic films. There's the music, with the violins and crescendos, that's supposed to move your heart. There are the mothers looking at photo albums of their children, the ones who died because there was some problem with the insurance company.

But before it all started, within the first five minutes of the film, I was crying. No one had died. No stringed instruments yet. Just a couple in their fifties, moving in the spare room of one of their children. They had lost everything when their insurance refused to cover their medical bills. "This isn't how it was supposed to be."

And I was crying because I know what it feels like when you or your husband (or both of you) get sick and you lose EVERYTHING. It tooks me a few hours to stop being angry, after watching the people in Canada and France and England being sent on medical leave when they were sick, still getting their salaries, and getting their medical bills covered too. I would give up 17% of my paycheck in an INSTANT if I knew that I would be taken care of when I got sick, that I wouldn't have to worry that one illness would change the course of my entire life.

bohunk? said...

Jeff-

You are a well-researched, sharpened individual. On the subject of health care...

It is interesting that although I work in health care I do not know the system well, or compare other countries' health care systems with our system intelligently. Try to diagram the previous sentence.

I agree health care costs are very high. I could do much to lower my contribution to the high costs by ordering fewer or less expensive tests (imaging or blood), using generic medications as much as possible, charging less for my services, etc. As I am in practice longer and build a rapport with my patients, I do order less if patients are comfortable and trust my diagnoses. Ordering less often takes more time because it is easier to order a CT scan of someone's abdomen than educating the patient on signs of a disease (e.g. appendicitis) and having the patient call with updates on their condition. Patients often expect exhaustive work-ups of symptoms and these are only revealing at times. I order many tests to cover myself in case of a lawsuit. I get paid well, although probably not as well as many people would think. Insurance reimbursement on many services does not cover our costs in providing the service.

The U.S. is blessed with advanced technology. Newer CT scanners and MRIs are much better at diagnosing problems than older machines. I can order a test and usually have results the following day when it used to take a week to get results back.

I think part of the problem with our health care system is mistrust. Patients mistrust (and often rightly so) doctors because doctors don't listen to them and try to quickly find a medication that might fix a problem. Doctors often don't trust patients because they are afraid of being sued. Interestingly enough, insurance companies were supposed to help make health care affordable. They have I think made hospitals and physicians try to work more efficiently by limiting reimbursement, but have not really made health care more affordable.

If we as Americans would eat simply like we are supposed to, exercise, weigh about what we are supposed to, fill our minds with less televesion, and rest one day in seven, our health would be greatly improved. We would still need health care, but as a society the need would be much less.

No answers, just a few thoughts...

Jeff said...

In case there was confusion, let me explain why I said I don't have insurance and also complained that my insurance was slow in reimbursing me...

The insurance money that I finally collected recently was from an injury that occurred while living in South Korea in 2005 when I did have insurance. They covered me for bills relating to that incident for two years, half of which I spent in the U.S.

So I do not have regular insurance, though I was covered for specific bills. That coverage has now expired as well.

Jeff said...

A friend of a friend gave this anonymous comment:

No, I have not seen the movie. I broadly agree with your friends points. In fact [ABC XYZ] was formed to try to address health challenges in rural and underserved areas. Anyone reviewing our sick care system would be disgusted by the inequality, wastefulness, and low quality outcomes. The U.S. health system is an embarrassment.

Americans love high tech and high cost technologies and the costs have to be passed on to the consumers. Higher insurance premiums, increased co-pays and escalating prescription drug costs are the future trend of ever more prohibitive individual healthcare costs. The healthcare system has had one major flaw...the fee-for-service method of reimbursement... fee-for-service system sent the cost of care out of control. Fee-for-service is in effect letting the fox watch the chicken coop. A provider has no disincentive for controlling costs when it is in their best financial interests to provide a complete array of "vital" tests and services to their patients. Nor do providers ameliorate the current healthcare system cost woes by this perpetuating these fiscally irresponsible practice behaviors. Providers may perform unnecessary procedures and increase the frequency of patient visits in order to increase the bottom line. Moreover, a provider might be susceptible to up coding and unbundling, whereby fragmenting charges and increasing the total amount charged.

Cost-containment efforts within the healthcare industry are forever challenged by unremitting consumer demands and incongruous expectations of the healthcare system borne from the current societal norms of mass consumption and waste. Within this context lies the thesis of moral hazard. If people have straightforward access to healthcare with managed or universal care, then over utilization will occur. The theory holds that in order to diminish moral hazard, some form of disincentive must be in place (Byzantium-style bureaucracy, copious amounts of insurance forms, other barriers) or large co-pays, thereby making the consumer accountable for a share of the costs. Prospective
Payment systems are one way in which to manage costs and provide sound patient care. Some critics will argue that by using PPS shortens overall hospital length of stay and that patients are released in more unstable conditions, but the overall outcome has been improved accuracy and improved patient care.

In my opinion, Americans' deserve the present healthcare system. I have never seen a more apathetic and ineffective population when it comes to healthcare reform. Several times in the past, alternative healthcare delivery options, namely single-payment system were introduced and every time they were shot down. American should rejoice and impress upon the world that their chosen system of healthcare delivery is the best at producing the most waste, having some of the poorest outcomes and excluding more than 46 million people from healthcare insurance. The forfeiture of choice in this country is the result of inept government inducement at the expense of the citizenry for the strengthening of an industry that seeks profit over patient care. The healthcare insurance industry is an excellent example of market forces maximizing profit and minimizing costs-consumer satisfaction is secondary. The quandary of healthcare and the consolidated power in the hands of a few healthcare insurance companies would be laughable if it were not so depressing.

Just some thoughts.

Me
Executive Director
“ABC XYZ” Health Education Center