the realm of Asclepios: part 3
Previous entries summary in 3...2...1...
I covered these two premises: 1) receiving health care is not an inalienable right, 2) it is not the designated role of government to run health care. Regarding the first, I explained here and here that whether or not receiving health or having affordable health coverage is an inalienable right, it is best for society as a whole to pursue the goal of ensuring that the highest number of Americans have access to affordable health coverage and available health care. I pointed out that in other areas (namely education), it has been long understood that it an item not seen as an inalienable right of humans is nevertheless viewed as a beneficial item to provide to as many people as possible. Regarding the second, I noted here and here that there are several (I outlined five in particular) areas where while it is not the designated role of government to involve itself, it is nevertheless positive and even necessary for it to become involved for the good of its citizenry.
Tackling the third premise, that this country would be not only ill-affected itself while also ill-affecting others were we to find ourselves in the midst of a limiting and narrowly run system: now!
Since HCR has been proposed, concern has been raised as to how it would affect the quality of care that we have available here. That is a legitimate concern. There is something to be said for living in a country with a higher physician rate per capita than either of our closest neighbors. We also have more MRI machines and CT scanners than our closest neighbors (and the UK). Of course, more doesn't always mean they're used in a better manner; but still, in the most obvious areas of technological health care advancement, the US get high marks. As I've noted previously, though, accessibility to said technology is limited by the costs. The argument behind HCR is that medical technology should be more accessible to everyone. In fact, the question could be asked, "What is the point of having one of the most advanced medical systems in the world if it cannot be accessed affordably by the entirety (or almost the entirety) of the population? In assuring that this affordable access occurs, though we must be careful not to inhibit the strength of the medical system we would like everyone to enjoy.
Small sideline: Even in the realm of pharmaceuticals, we must take care to exercise caution. A case can be made that pharmaceutical companies make an incredibly high margin of profit. (see also here and here.) The ability to make a decent-sized (to say the least) profit is one reason that so many pharmaceutical companies choose to headquarter in the US. Of course, when profit margins are considered, it is also advisable to consider the cost and time required to bring a new drug to market. Although there is a range of numbers on cost and time, the general consensus is that it costs at a minimum over $800,000,000 and 5 to 10 years depending on the drug. (sources: here, here, here, here, and here.) Valid criticism has arisen over the pharma industry, not so much because of the profit margins involved, but the skyrocketing amount of money spent on advertising. (table taken from this NEJM article) Another growing criticism concerns CEO salaries. Now, it's certainly a different debate to consider what CEOs should be paid and whether they large portion of their salary should be salary or stock options, etc.; however, in relationship to HCR, I think it's more important to look at where pharma money (particularly federal research money) is going rather than merely the profit margins. Pharma research has entered the stage of very narrowly focused research for finding treatments of very specific diseases and symptoms. This costs more money and takes more time. Phara companies should be given the leeway they need to conduct more and more advanced research in a profitable manner, else they would be reluctant to take research risks, but they should be kept from unethical profit (such as evergreening to extend patents and block generic competition) and spending practices that hurt the most needy consumers of all: the ill who need their products. This is a fine line to walk for reform, but the right set of regulations can do it.
Now, back to the more at-point topic: reform without crippling medical technology and system quality. One of the comparisons that is often used to protest government involvement is the comparison with Canada and Britain. Of course, all of my readers can call to mind anecdotal tales of delayed or denied care in both of these systems. Conversely, Canadians and Britons can blithely recite anecdotal tales of denied insurance application and exorbitant health care bills that lead to insolvency and bankruptcy. Anecdotal evidence is a part of the picture, but should always be recognized as just that: a part of the picture. There are pros and cons to every system. A better way to look at things is to look at the overall numbers and then discuss why HCR as it is currently proposed will serve to focus health care rather than limit it.
Let's look at some important statistics from the World Health Organization (WHO) and the Organisation for Economic Co-Operation and Development (OECD). Now, while all statistics are dependent for their accuracy upon the data used and submitted, it is worth noting that by and large, the countries listed in this data have no history or reason to manipulate the data on any large and systemic scale.
First, let's look at the amount of money that countries spend on health care:
WHO statistics on per capita spending
*Notice that the US government spends more per capita on health care even though the US citizenry spends more private money than in any other of the compared countries. (Note: I include Switzerland because of their mandatory and subsidized private health coverage system...in other words, similar to what's on the table; but more on that later.)
OECD data on per capita health care spending
*Notice that the US spends considerably more than any other comparable nation.
Now, these statistics on expenditure cannot stand alone. After all, if the end result of the spending was considerably better/of more value than the end result of health care spending in other nations, it would certainly be worth the extra cost. The statistics fail to support this scenario, however. Instead, we spend significantly more on health care in the US for essentially the same results as our peer nations. Of course, there are variable in any set of statistics, for example: when it comes to cancer survival rates, the US ranks quite high, consistently scoring higher than Europe as a whole. This figure can vary from state to state and ethnicity to ethnicity even within the US, though, and is due in part to widespread awareness and early screening practices. This high mark does not extend to all areas though, with the US ranking low on diabetes and asthma care. Something to keep in mind when considering the health care system in the US is that our one country has the variable rates of most groups of countries, with regions and state playing large roles in the quality and cost of care (Another reason why a federal minimum standard would help provide more consistent basic and preventive care across the board.) In general, though, life expectancy statistics are used to determine the overall quality and effectiveness of health care. Here is where the rubber of dollars spent meets the road of product received. The numbers don't show that, in this case, more money equals better product:
OECD life expectancy data
*Notice that for all those extra dollars spent, life expectancy is not extended in the US beyond the countries with health care systems we love to hate.
WHO life expectancy data
*The fact is, our total expenditure on health care is twice that of the UK, and they live, on average, a year longer.
And let's get down to the nitty gritty on life expectancy: seniors. I mention this statistic in particular because of the rampant discussion about how government involvement will lessen care given to and money spent to care for seniors. Senior citizens are the most expensive group to cover when it comes to health coverage and health care; therefore, it has been suggested that spending less and having government regulation will result in less care given to seniors, thus shorter life expectancy after a certain age. The statistics tell a different story, however:
OECD date on female life expectancy at 65
OECD data on male life expectancy at 65
*There is little noticeable difference between the major countries of comparison. In fact, in some cases, we fall behind other countries. Of course, there will be some variable depending on family history, ethnic group, and standard vices of choice (we are the nation of the obese, while other nations are the nations of smokers and drinkers). When it all evens out, though, the fact is...it's pretty even. We are spending more and more each year than our national counterparts without the things to show for it that we should have: increased life expectancy, above all, even among seniors where one would expect to see a difference if, in fact, nationalized health care really did result in the care rationing of which we have heard claims.
(Note: I am not including infant mortality rates due to uncertainty as to consistency of standards when labeling a "live birth." These standards can vary from country to country, and I'm unable to find a good database to use in the discussion; thus causing me to choose to leave that statistic out. It is relevant to note, though, that when taking into consideration the ability and standard practice of making all concerted efforts to save every child delivered by eliminating risky/premature births from the equation, we would end up running about even with our peer nations from what I can tell/have read.)
I know I seem to have gone far afield of my initial premise, but I want to show that fears of narrowing the health care system are, in most cases, unfounded. While we have significantly more advanced technology at our disposal than many of our peer nations, and a tendency to use it for screening purposes, when it comes to basic care and life expectancy, our way of paying is not garnering better results. There are many reasons why this is so, but one of the most significant ones is the way we pay for services: by procedure. In paying by procedure, we spend more money for the same battery of tests than we would pay if paying by treatment regimen or by hours spent. (Lest you think paying per procedure is necessary to produce a high level of quality care, I offer up The Mayo Clinic. There's a significant reason why it's the touted model for health care payment model change.) This idea of changing the way we pay for health care is just one of the pilot ideas contained in the HCR bills up for a vote. The New Yorker has an an excellent article about these programs and how they can impact provider side costs over time. (If you didn't/haven't read the New Yorker article I posted previously, take the time to do so. It's quite thought provoking.)
Thus, statistics show that while we are paying much, much more, our medical system is, in general, not significantly better. I have shown all this to point out that even were we to adopt a completely nationalized system after the model of Britain's NHS, we would likely not experience any deficit or narrowing of care. Yes, there might be a change in waiting periods while a shift in medical personnel numbers was made to accommodate patient number change, meaning that there could be longer waits for non-emergency appointments. This is not a new concept, though, as anyone who has tried to make an appointment as a new patient knows. (Furthermore, a point that I may address later is the issue of the AMA having a great deal of control on the number of medical students allowed each year as a means of controlling the amount of doctors outside of the supply/demand function.) This, of course, brings up a not insignificant question: if our opposition to change is that we may have to wait longer to see a doctor, what's the real issue here--the wait time, or our attitude? But I'll leave that question to my lovely readers to ponder whilst moving on to something else.
There is a more significant reason why HCR as it is proposed will not narrow the quality of availability of care: all of the HCR proposals continue to use private health care as we know it. Yes, that's right. Although the words "government takeover" and "socialism" have been bandied about, the truth of the matter is that these reforms make essentially no change in the nature of who provides health care nor who pays them. Please note this, if you note nothing else I've said--these HCR proposals are not, are not, socializing the health care system. Notice: here is a comparison I created (using the Kaiser Family Foundation comparison tool) between the House plan, the Senate plan, and the President's proposal. I used the term "state role." (I know the picture is small. Feel free to go and enter the search terms to see it larger.) Every item mentioned concerns how health coverage is paid for and regulated. There is no mention of health care providers because health care providers will not be employed by the state. Again, notice in this CBS news basic run-down there is no mention of employing health care providers or a "takeover" of health care. That is because the only area in which any HCR proposal increases government payment of health care personnel is in the expansion of Medicaid and possibly Medicare eligibility. Health care is still a private industry under all three major HCR proposals. In fact, calling this "health care reform" is largely a mistake. It is more appropriately "health coverage reform." Health care will still remain a private industry. The changes here are in how the bills are paid, not who provides health care. (I will discuss the issue of a single payer system in a further post, but that is not what is under consideration at this time, thus I am not discussing it here.) In other words, it will not narrow the care that is available at all. The health care available is still the same; HCR merely allows a significantly higher number of people to access it without worry. Under all three major HCR proposals, the system will be run exactly the same way. In fact, with the added competition of clear coverage plan comparisons, the pilot programs proposed to curb health care costs, and possibly a clear comparison of health care costs through different providers, the system has the potential to become more streamlined and therefore better than it currently is. Whatever the future for streamlining and honing health care, the fact remains that these proposals aren't about who runs or controls health care. They are about making health coverage affordable so that technologically advanced health care system we have is accessible for almost the entire population without the risk of insolvency. Thus, the third premise is tackled: limiting our system would serve us ill, but that is not what these proposals do.
There are a few things I would like to tackle further, especially as this post ended up going in a slightly different direction than I anticipated when I began planning it. Thus, there will be an "addendum" that deals briefly with the use of the word "socialism," briefly with the nature of the "public option," and briefly with single-payer or "nationalized" healthcare.
You can find a list of many of the HCR sources I linked as well as few I have not here. Have fun!