We are two steps back but ready to take one forward.
Are you depressed that the Tea Party Republicans are knocking on the door, with the express intent of repealing our hard won health care reform? Don’t worry too much about it, it might be just as well if they succeed. Look, I’m a good liberal, I think Obama is the bees knees and I rooted for health care reform all the way through the laborious, if wince inducing process. So why would I say this? My conclusions are based the revelations in T. R. Reid’s excellent book, The Healing of America which provides a survey of health care systems around the world. When I read it I flashed back to the 1992 presidential debates between George H. W. Bush, Bill Clinton and H. Ross Perot. Health care reform was a big issue for Clinton and the question came up in the debate. Clinton and Bush gave their stock answers but Perot said something to the effect of, I don’t know if health care in this country needs to be reformed but I would look at how it works in other countries and if their systems are better I’d do the same things they do. At the time I wrote this off as a cop out and didn’t think much of Mr. Perot for it, but after reading T. R. Reid’s mind blowing tome I have to say, at least in his approach, Ross was right. Note to self, holy shit, maybe it wouldn’t have been such a bad thing to let an insane midget run the country.
We Americans tend to be a provincial lot, if we know how anything anywhere else works, its probably in Canada, because hey a lot of us have been there on vacation. Don’t get me wrong, Canada has some pretty cool stuff, but when it comes to health care it offers a rather limited world view. Interestingly though, Medicare, the system that most Americans over 65 use is modeled largely on the Canadian system with even the name lifted directly from the land of the maple leaf. What T.R. Reid has done is travel the world, visiting, interviewing and actually receiving health care in a wide rage of countries. He then synthesized his findings into a book that walks a fine line by giving personal and accessible accounts of health care in other countries while providing enough statistics and facts to satisfy a policy wonk. The clear eyed assessment of U.S. Health care is damning, while the straightforward look at how things work elsewhere reveals that skillful health h that underlay much discussion of health care in this country are cut through. I am also sad to report that as I read the book I developed a sickening feeling that our hard won health care reform is little more than a temporary patch on an unworkable system.
Let’s start with some of the mind blowing revelations:
The U.S. health care system sucks. O.K. maybe this isn’t a revelation and you have to be careful even with this statement. There are a lot of good things about health care in the U.S. we have some of the best doctors, technology, and research in the world and we shouldn’t forget that. But notice that when I mentioned health care in the last sentence I left the word “system” out. We have the worst system for delivering health care in the world, especially if you consider how much it costs. In any analysis that considers what we get vs. what we pay we come out on the bottom and this is largely driven by the fact that in terms of percentage of GDP we spend more on health care than any other country in the world, which leads to point number two.
It is cheaper to cover everybody! Are you worried universal health care will break the bank, raise taxes become an entitlement budget nightmare? Fundamentally, this should not be a problem, because every country that covers everybody spends less than we do. But you wouldn’t guess this after listening to the byzantine arguments used by the Democrats struggling to explain why their plan won’t be a budget buster.
We don’t have a unified health care system. Even using the phrase “health care system” to describe what we have is a stretch in that there is very little systematic about it. What we have is a patch work of different systems that don’t work together in any cohesive way. If you have a job where your employer offers health insurance you’re in one system, if you are over 65 you’re in another system, if you are a veteran or a Native American you may be in another system, if you don’t fall into any of these groups then you likely don’t have a system at all. However, even this last group of people with no coverage can be ascribed to a system that is called the out of pocket model. It turns out that this very lack of a system is what makes U.S. health care so expensive. Handling health care in a piecemeal fashion is simply not an efficient way of delivering services. I have a personal anecdote that runs along these lines. There is a horrific genetic disorder called Huntington’s Disease that runs in my family. I have been getting e-mails from a Huntington’s advocacy group asking me to petition my congressional delegation to have HD designated in a certain way so that people who have it are eligible for benefits. I have dutifully done this, as my brother and his family are struggling to find a way to cope with getting him long term care. Systemically, however this is a very bad approach, if advocacy groups for every disease lobby to have different bits of legislation modified it leads to an incredibly complex and inefficient system. And this leads to the next revelation…
Administrative costs are eating U.S. health care alive. The inefficiency of our patch work system is the reason why U.S. health care is so expensive. Doctors and hospitals must maintain complex and expensive bureaucracies to function within the system. Much of the purpose of these bureaucracies is to shift costs from folks who are paying out of pocket to those with insurance. If a single doctor wants to open a practice today she would likely need to hire a full time person just to deal with billing insurance companies and various health care entities. In any reasonable system one administrator should be able to handle the billing for ten doctors. Every insurance company negotiates or dictates a different fee for each service provided and develops a different method of paying doctors and its clients. This leads to the perverse situation where not even doctors know how much a procedure or medicine costs because every patient actually pays a different price. We pride ourselves in being a free market economy but our medical payment system is really the antithesis of a market. Patients and doctors can’t perform the basic premise of a market which is to choose the best option for the best price because no one even knows how much anything costs! The government must step in and lay the guidelines for a system that reduces administrative costs. No insurance company can do this because if a single company set up a system they would naturally gain a competitive advantage in doing so. This is what led to my disillusionment with the current effort to overhaul health care. I don’t see anything that addresses the fundamental issue of reducing administrative overhead, to me it just looks like another band-aid on a patchwork system that doesn’t work.
For profit insurance companies must go. Mr. Reid deftly describes the health care systems in a wide range of different countries and the systems are as varied and complex as the cultures themselves. In some places the government administers health care but in many places this job is done by private companies. However, one thing that all of the developed countries with private insurance providers have agreed on is that health insurance companies must be not for profit, that is of course with the glaring exception of the U.S. Mixing “for profit” with health care leads to a number of perversities. Among them are that Wall Street analysts’ demand that 20% of all income received should go to administrative costs and profit. Any company that doesn’t follow this guideline is considered inefficient. Compare that to Medicare’s administrative overhead of only 3% and of course no profit. Actual payments to doctors or hospitals are considered a business loss in the insurance model. This leads to your insurance company using your premiums to hire people to figure out ways to deny your claims or in insurance parlance to “prevent business loss”! Mission statements for health care administration entities must read “To provide health care for…” not “To provide a return for our investors…” it makes a difference.
Socialized medicine is not the cure. Contrary to our conventional political meme most countries in Europe (e.g. France, Germany and Switzerland) have less socialized medical systems than the U.S.! And what’s more, in my thinking, and I am veering from Mr. Reid’s evenhanded reporting into my own rant here, the socialized systems don’t offer the best care. The U.K. has a highly socialized system and Canada has a quasi socialist system and granted these systems are better than ours, but that’s no stretch, every health care system in the developed world is better than ours. Political discourse in this country is rife with distortions and half truths. After hearing “European socialized medicine” for so long I had come to take it for granted. In fact, I even had to look of the definition of socialism because there were two vague and conflicting definitions in my head one of a small town conservative that thought it meant some kind of evil witchcraft and a second liberal Seattle version that thought of socialism as something akin to steam table broccoli dull but it’s supposed to be good for you. When I found out that it meant that the government owns and controls the means of production, in this case owns the hospitals and equipment and pays the doctors it was some kind of revelation. It turns out that, to name a few examples, in France, Germany and Switzerland, hospitals are privately run, doctors practice privately and insurance companies are private albeit not for profit. Now in the U.S. we have the Veterans Administration health care system which is completely socialized, and although this is of course un-American, it is exclusively reserved for out military heroes. Now back to my assertion that the socialist health care systems aren’t the best. The caricature in our political discourse is that socialized medicine rations care and is characterized by long wait times for treatment. It turns out that there is an element of truth to these assertions.
Mr. Reid uses his sore shoulder as test case to see how he would be treated in each country he visits. In Canada he is told that he should see a specialist and he can, after a wait of ten to twelve months. In the U.K. he is told that his shoulder problems aren’t serious enough to warrant treatment of any kind. Contrast that to his visit to one of the best orthopedic surgeons in the all private Japanese medical system which was scheduled on the same day that he called. He was also told in Japan that if he opted for the most extreme treatment, a total shoulder replacement, it would be covered by his insurance and could be scheduled within a week.
There is a real point of ignorance for liberals who want health care reform in the U.S. but automatically associate it with socialized medicine. Somehow we have come to equate government run health care with universal coverage when the two things are completely independent. In Seattle our liberal member of the House of Representatives, Jim McDermott, who also happens to be a doctor wants a single payer health insurance system and I have to wonder, why? Look at France, Germany, Switzerland and Japan they have the best health care systems in the world, not Canada and the U.K. What’s worse is that in pursuing more socialized medical policies we play right into the hands of the “Big Government”, “Socialized Medicine” mantras that have been hammered into the American psyche for decades. Could you imagine the power of President Obama going on the air and saying the top priority of his health care reform plan was to eliminate socialized medicine in America? That’s the kind of political jujitsu that I’d like to see, the kind of change that would bring some hope to my liberal soul.
Technology can help. And when I say technology I don’t mean more MRIs, CAT scans or wonder drugs, we have those things in spades, I mean digital record keeping and administration. I learned that in France everyone carries their complete medical records around encrypted on a microchip embedded in their health care card. The backwardness of our records systems was recently driven home to me when I accompanied my mother on a visit to a dermatologist. My mother lives in a nursing home and is incapacitated to the point where she can’t speak. My father rode to the doctor’s office with her in a medical transport and I met the two of them there. When they left the nursing home my father was given a few photo copied sheets of medical records to hand to the doctor. Between the recountings of myself and my 85 year old father and the photo copied pages we had been given we were able to transmit enough information to get the right procedure done, but really though, is that any way to ensure that people get the right medical care? The real power of a system of digital medical records though would be to reduce administrative costs. At the same time the French health card adds a procedure to a patient’s medical record it automatically sends the bill to their insurance company. As a result a typical doctor’s office in France doesn’t hire any secretarial staff to file records and handle billing insurance companies. The next time that you visit one of your health care providers look at the floor-to-ceiling racks of paper files and wonder why we are still using them. Hello people, we invented the internet, electronic data management is something we excel at, we could create a digital record and billing system, we could do this. Once again though this is something that the government must do and once again I am very disappointed to say that I haven’t heard the first thing about it in the current health care system overhaul.
We can create a system that works a lot better. There is really no reason why we can’t move to a better health care system. Sure we’re a big country and we have vested interests that oppose change and we have political issues and blah, blah, blah. But the fact is that there are also forces that are driving us to reform and other countries around the world have overcome all kinds of obstacles with good results.
There are a couple of examples of health care reform from The Healing of America, that resonated with me, one of them is Taiwan. Taiwan went from having a patchwork system that only covered about 60% of its people to universal coverage in about two years. Taiwan started their effort in 1993, coincidentally the same year the Clinton’s tried to reform our system, with the delivery of a nationally commissioned report that made recommendations on health care reform. Taiwan had a similar political dynamic in that a liberal progressive party was advocating for reform while the conservative pro-business party opposed it. In Taiwan the conservative party decided to switch positions and in doing so robbed the progressives of their biggest issue and as a result stayed in power for another presidential election cycle. I suppose this could happen here, although the day I see the Republicans kick the insurance companies to the curb, I’ll shit a brick. By 1995 Taiwan instituted universal coverage with a Canadian style single payer system. More interesting to me though is the case of Switzerland, which shares some remarkable parallels to the U.S. They are a conservative country that has higher per capita gun ownership than the U.S. and are home to some of the largest banks, insurance companies and pharmaceutical companies in the world. The Swiss insurance companies followed the lead of Wall Street in the ‘80’s and started buying up not-for-profit mutual health care plans. As long as companies could keep their pool of insured customers low risk, by denying pre-existing conditions and thinking of ways to deny claims, the profits were fantastic. But per capita health care spending sky rocketed to the second highest in the world (behind us) and so did the number of uninsured, until it was 5% of the population. At that point, people started to see that the fabric of Swiss society was threatened. A reform referendum that mandated universal coverage and nonprofit insurance was proposed and voted on, with fierce opposition from the insurance companies. The referendum barely passed in 1994 again coincidentally about the same time the Clinton’s reform effort died. Now fast forward to 2009, in an interview with the Christian Democratic Party (read European republican) President of the Swiss Federation Mr. Reid asks if the reform was a good idea and is told “Nobody would want to go back to the system before, when some people were locked out of the insurance … We are happy that we made the changes.” This brings home an important point, if changes are made that improve the system, everyone will like them, when they see them work.
So where am I now, that the Republicans and Tea Party activists are running strong campaigns with a major theme of repealing health care reform? I don’t know what is going to happen, but I do think that if the Republicans succeed in repealing some of or even all of Obamacare, it may not be such a bad thing, that is if we can make it lead to a next and better round of reform. We still have a long way to go with health care reform and any dynamic that keeps it on the table could help in the end. In my final pitch at the end of this article that has been half book review and half policy rant I have to say: “Read The Healing of America” and encourage your friends, health care providers and even government representatives to read it. Because if a significant number of people in this country read it we will get a better health care system. The book makes the faults of our system too glaringly obvious for anyone to still think that health care reform isn’t necessary. And seeing how other countries have faced the same problems and developed systems that work gives encouragement and practical information about what kind of policies might actually work for us. About 22,000 people in the U.S. die every year from easily preventable causes, and about 70,000 go bankrupt struggling to pay medical bills, when you realize that these issues could be addressed and that it could actually cost less, how could anyone be against major health care reform?
Mark Helsel is a geek who lives in Seattle with his wife Cheri, his son Lewis and two cats. He hasn’t written anything for a non-technical publication since he wrote for his college newspaper The Daily Pennsylvanian a long, long time ago. He has been a life long participant in the U.S. health care system, which he recently found out, really sucks, even worse than he thought.