– by Jill Quadagno
Hank at Insureblog has written a thought-provoking review of my book, One Nation, Uninsured. I appreciate his willingness to take on this task and welcome the opportunity to engage in a debate about how we finance health care in this country.
First, let’s consider Hank’s claim that I consider our current system unfair. Guilty as charged. How can the wealthiest nation in the world leave 46 million of its citizens without coverage of their basic health care needs? Why should the United States be the only industrialized nation that places people at risk of losing their health insurance if they lose their jobs, become widowed or just get sick?
Is this a problem? Of course it is. Most uninsured people do not have a regular family doctor and thus do not receive preventive care like cholesterol-lowering drugs or screening for cancer and heart disease. Frequently, the care they do receive is in an emergency room where there are no follow-up services. Many receive no care at all because hospitals in poor neighborhoods, where there are large numbers of uninsured people, have been closing.
Can the private sector resolve this dilemma? I think not. The employer-based system that most people of working age have relied on since the 1950s is unraveling at the seams. Each year for more than a decade a smaller percentage of employers have offered health insurance coverage. The only reason the situation doesn’t look worse is that the government is picking up the slack – through Medicare, Medicaid and coverage provided to government and other public-sector employees.
Guaranteeing universal coverage does not mean nationalizing the health care system. There are many ways to achieve universal coverage without eliminating an industry. Most other countries allow, and some encourage, private insurance as an upgrade or second tier to a higher class of service and a fuller array of services. Some even depend on private insurance companies for basic coverage. But the practices of these companies are heavily regulated to prevent them from engaging in the more pernicious forms of risk rating. That is not the case in the United States, where private insurance companies are allowed to use sophisticated forms of medical “underwriting” to set premiums and skim off the more desirable employee groups and individuals.
If history provides any lesson, it is that vast, politically influential industries cannot be eliminated. But that doesn’t mean we shouldn’t hold them accountable. Nor does it mean that the government has no role to play, whether that be through more regulation of private insurance companies, expanded public programs for those who are uninsurable in the private market or vouchers for people cannot afford to pay premiums on their own.
LINK to review at InsureBlog.
Read more from Jill Quadagno on OUP Blog HERE, HERE and HERE.
I don’t think the fact that we have a private health care system in the US is the problem. I believe the problem lies at a more fundamental level. The structure of our health care system is based on at least two bedrock beliefs that make the cost structure as expensive as it is. One is that cost should not be a factor in determining the amount of care a patient receives. Hence we have a system where the consumers as well as the providers of health care services have very little knowledge about the cost of the services they are receiving and providing. This leads to a system where 30% of health care spending goes to 1% of the population.
The other belief is that we have to spend an inordinate amount of money to train only the best qualified doctors and that those doctors should be held punitively accountable for their inevitable mistakes, as well as thinks that are outside the control of a doctor. The result of that belief is that doctors are not as plentiful as they should be. Therefore supply and demand plus the costs of being a doctor (liability insurance and schooling costs) dictate that doctors salaries will be high. As a result 25% of health care spending is to pay doctor’s salaries. Being a doctor is the highest paid profession in the US. It need not be. It’s not the case in most other countries.
Unless we address these underlying beliefs how we distribute health care will matter little. Already 14% of our GDP goes to health care spending where in other western countries it’s usually more like 7-8%. I would not be concerned with that number if we actually got what we paid for. But looking at medical statistics such as life span, cancer survival rates, infant mortality, etc. it hardly seems like we are. But even switching to a government administered health care system will not bring down the cost and bringing down the cost is what will make universal health care possible. To put it another way there are two specific areas where market forces are not allowed to limit the rise of costs and as a result they have risen precipitously. The people who are hurt by this are the people at the lower end of the economic ladder (or those who are too stupid to realize who easy it is to game the system).
As one of the 46 million uninsured, as a former health care worker and as the sufferer of a non-life-threatening but quality-of life-destroying chronic disease, I have had ample reason to ponder these issure.
I am a little confused by the above post. Mr.Bandsma seems to both think doctors are overpaid and that their liability is too high, causing those same potentially overpaid individuals from taking up the profession and causing a shortage. I can’t make out what disallowed “market forces” he thinks would resolve these issues.
He is right about our overspending as a percent of GDP and what we get for our money. But among the most wealthy countries we are most definitely not suffering a shortage of physicians per capita. In per capita terms We have almost triple the number of doctors as Canada, 35% 0 40% more than France or Germany, almost 3-1/2 times the number of the UK. (These are rough, but I just looked this up on the UN Development index last week and it was shocking.) In Canada and the UK the claim is that poor pay discourages doctors from practicing there. That may well be true. When I worked in Detroit we had an astonishing number of doctors crossing the international border to practice on the American side. Americans have heard plenty of horror stories about Canada’s physician shortage and long waits for care. The long waits may be true but on every indicator that matters, Canada does much better than we do in outcomes. So, maybe doctors aren’t the problem or the answer.
I am not sure about what percentage of the American health care dollar goes to doctors. 25% seems high, especially once one looks at what insurers actually pay per visit as opposed to what physicians’ offices bill. Maybe it’s a big city thing, but the physicians here in the city of Chicago seem far more concerned about their patients’ inability to access care than they are about malpractice insurance premiums, Which is the thing we heard so much about in the last election cycle. Talk about a manufactured crisis when there is a much more deadly one afoot. Without insurance getting care IS possible but it is difficult, slow, time-consuming, frustrating and frightening. An example: Last March I knew I was overdue for a mamogram. It was mid-May before I could get in to see the primary care doc. who could write the order. It was July before I had the test. Another set of pictures was needed. Got those, end of July. A biopsy is needed. It is now November 3rd, 8 months since I started this process. I will not have a biopsy and know the results until Thanksgiving. So much for early detection and treatment.
I also knew last March that I needed physical therapy for a damaged tendon. My 1st appointment after going through the proper managed-care channels of the county system? Mid-November again. The day after the biopsy. Do I DARE postpone?
Drug costs in this country are staggering. So are insurance premiums for those of us with chronic conditions. Just one of my Arthritis meds cost over $1400.oo per month retail. There was a period of time, before my life savings were wiped out, when I was paying out of pocket over $2000.00 per month, just in insurance and meds – and that was AFTER I stopped taking the pricey drug mentioned above, which was probably the one that helped the most. All that spending and I was still only partly treated.
Then there is the whole new bureaucracy that has arisen – and which we also pay for with our healthcare dollars– which exists mainly to put in place the “limits” on spending that the consumer is unwilling to place upon herself. An entire apparatus of billing co-ordinators and specialists, coders, reimbursement specialists, claims specialists, etc. has developed and grown exponentially since 1980 when the insurance industry began to be deregulated by the government, only to produce its own gargantuan internal reimbursement regulation apparatus. The amount of person-hours spent on fruitless phone calling to get claims reimbursed or approved or re-submitted is staggering. For every doctor’s order that is written, there must be at least a dozen people that it has to pass by before the order is transcribed, filled, billed, submitted, approved, entered as paid and, hopefully, finally reimbursed at some reduced rate negotiated on the other end by the insurer. Then there are the glitches- when something doesn’t go as it should — which happens often when dealing with 3rd party insurers and hospital billing systems that are patched together and poorly understood by half the people who use them. I am still battling over two visits from 7 years ago that I paid out of pocket because I knew insurance wouldn’t cover them, only to have the hospital submit them to the insurer anyway and have them denied. So, they re-billed. Using different codes and cost centers, making it virtually impossible for me to prove I did NOT make two emergency visits to a clinic I never set foot in.
Then there are the tricks of the insurers, seemingly designed to wear down the supposedly insured. My last policy refused to pay for standard bloodwork + liver and kidney function tests – a necessity periodically for people on long-term meds.
It also did not pay for a pap smear. the reason: pre-existing condition. “Well, yes,” I said to the unable-to-help, $10.00 an hour “customer care” person who got my call after 12 tries of getting busy signals and 25 minutes on hold, “I did have a uterus, kidneys & liver before that labwork was done, but as far as I know they were all ‘conditionless.'” His supervisor was also unable to help. Someone would call me back. It never happened. I tried calling back several times but I never got to speak to a live person again. The claim was still denied.
How on earth does this make sense?
UP
Obviously, I was incorrect (who’da thunk that?!)
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Today marks the 25th anniversary of the first reported cases of HIV/AIDS. How much progress are we making? Two good approaches to answering this question, from the Center for Global Development and the Global Business Coalition on HIV/AIDS (GBC):
The Center for Global Development’s HIV/AIDS Monitor tracks the aid effectiveness of the three biggest financing mechanisms responding to the epidemic: the Global Fund, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the World Bank Africa MAP.
GBC and Booz Allen address the private sector’s progress to date in the fight against the disease in their publication The State of Business and HIV/AIDS (2006): A Baseline Report. They find that the food/beverage, mining and minerals, and energy industries have the most extensive programs in place. Congratulations to the winners at the recent GBC annual awards for outstanding business action on HIV/AIDS: Unilever, L’Oreal, National Basketball Association, Xstrata, Merck and American Express.
Talk about a manufactured crisis when there is a much more deadly one afoot. Without insurance getting care IS possible but it is difficult, slow, time-consuming, frustrating and frightening. An example: Last March I knew I was overdue for a mamogram. It was mid-May before I could get in to see the primary care doc. who could write the order. It was July before I had the test. Another set of pictures was needed.
Maybe it’s a big city thing, but the physicians here in the city of Chicago seem far more concerned about their patients’ inability to access care than they are about malpractice insurance premiums, Which is the thing we heard so much about in the last election cycle. Talk about a manufactured crisis when there is a much more deadly one afoot.