Firstly I want to preamble this with the fact that I’m obviously biased. I was trained in a national health service and I’ve spent my entire medical career in an academic medical center, somewhat sheltered from the pressures of medicine as a business and surrounded by Docs who certainly didn’t go into medicine for the money. No-one in Pediatrics does it for the money… So my impression of how a Doc should think about medicine and patients may not jive with everyone else’s. That’s fine. But I did want to put down my thoughts on healthcare as a part of society – how we should think of it, and therefore how we should pay for it. My opinions at least have a lot of facts to back them up, in fact I have these opinions BECAUSE of these facts – there is simply no other way I can interpret them.
One of the most contentious parts of the United States Affordable Care Act (healthcare reform, the misnomer “Obamacare” or whatever you want to call it) is the “Mandate” – the requirement that everyone needs to purchase some form of healthcare insurance, or pay an additional amount on their income tax return. What this does is bring the US in line with every other developed nation in having universal healthcare (coverage for all its citizens). The existing systems of Medicare (for the Elderly) and Medicaid (for the Destitute – the only way I could keep them straight as an outsider) have huge coverage gaps, and healthcare costs are the leading cause of bankruptcy in the US. This is embarrassing. Or at least, it should be.
Instead, there is a prevailing view among many that “The US has the best Goddarn Healthcare System in the World!” and any attempt to change it will drag it down.
The US is 38th in the world ranking for life expectancy. Cuba is 37th. EVERY other major industrialized nation ranks higher. And they all have universal healthcare. Childhood mortality in the US is also at the bottom of the pile. The WHO rates the US as 1st in terms of in cost, 1st in responsiveness, 37th in overall performance, and 72nd by overall level of health.
Despite these mediocre results, the US pays more than anyone else. In fact the healthcare spending in the US is almost TWICE that of anywhere else, with the exception of the island nation of Bermuda where it’s about the same.
So something dramatic has to be done, of that all sides agree. But why are there even sides? What are the arguments for and against universal healthcare, or in other words to consider healthcare as a right?
The Golden Rule
“Treat people as you would like to be treated.” Since I love the fact that I don’t have to worry about catastrophic medical costs, and my employer pays for most of my medical insurance, I think it would be awesome if everyone had that. It has made headline news for years, how many millions of Americans are uninsured and as a result decline healthcare (or leave it too late) since they can’t afford it. The issue is compounded since those who are in good jobs (and could afford to live without insurance) already have health insurance, typically heavily subsidized by their employer – so they may only see 10-25% of the actual premiums. For those without this luxury, or those who were in a job but lost it and had to pay COBRA to extend coverage, the true price of healthcare premiums is shocking. This simply exacerbates the healthcare divide. Medicaid will pick up the pieces for the very bottom of the pile, but there is a big chunk in the middle who don’t fit. It is only humane that everyone gets the same opportunity, regardless of income or employment status.
If you disagree with that, then you’re basically saying that some people don’t deserve to have access to good healthcare. That’s mean, and probably morally indefensible. Who actually WANTS another human being to be sick?
The insurance companies
Oops, was that bad word placement? No, not really, but sometimes it does seem that way. I have lost count of the number of times I have had to fight with insurance companies to get approval for a test (!) or treatment for a life-altering or life-threatening diagnosis. Insurance companies are not there to pay for your healthcare – their agenda is profit, and they will do anything they can to deny payment since it hurts their bottom line. If their agenda was patient care, they wouldn’t fight these fights. The documentation that goes into justifying reimbursements is crazy. The Affordable Care Act (ACA) was targeted primarily AT the insurance companies, since Congress effectively gutted the ability of the bill to do anything else more meaningful. What it basically said was “You can’t ‘Not cover’ someone because they’re sick, you can’t stop paying because people get sick, preventative healthcare should be 100% covered, and you have to allow kids on their parent’s plans until 26″. This targeted the most vulnerable people – those with serious or pre-existing illnesses who would be excluded from plans (to help the bottom line) and young adults who weren’t in jobs with healthcare benefits. However, there was an issue here. If you add all these people onto the list, you WILL increase payouts. That is inevitable. Little Sally’s chemo for her leukemia doesn’t some cheap… You need a large number of non-claimants in the system to keep things reasonable, and this is where the Mandate comes in (my initials, for emphasis). If everyone is on board, revenues can keep up better with the payouts. Simple math. Since it is only humane and humanistic to want everyone to be healthy, everyone has to be in the game. Everyone needs to be covered.
The Mandate is nothing new – Govt has imposed mandates on all sorts of things – they’re called “Laws” – for hundreds of years. There have been efforts to Mandate healthcare coverage going back to the Founding fathers, from the Left and the Right. This should be an issue that has no party lines – and yet here it does. Why? The biggest criticism is individual choice. There is no choice about it – well, there is, but you then have to pay more on your tax return. Hey, that seems unfair…what if they can’t afford it…? Well the ACA establishes insurance markets to help individuals purchase plans more fairly, it sets up a special plan for patients with pre-existing conditions, AND if you’re low-income the plans are subsidized AND the penalty is reduced, or even waived. Bottom line – no-one should be on the hook, at least no more than they are now! However, this is a hodge-podge approach. People can still opt-out, and pay the fine (which incidentally, is used to reimburse the healthcare system when they DO use it as an uninsured patient…) and religous-political restrictions have been placed on certain plans in the exchanges carrying abortion coverage. (Wait, wasn’t there a separation of Church and State in the US…never mind).
But the funny thing to me is that either (A) You already have coverage and aren’t affected by the mandate, or (B) you don’t have coverage and WILL GET HELP GETTING IT. It’s a win-win. Who DOESN’T want healthcare coverage? Do you really want to exercise that right, put yourself (and your family) at risk of massive financial losses AND put the rest of society on the hook for your bills when you can’t pay up? Hardly fair. There is an element of social responsibility here. The Mandate isn’t the Government forcing you to do something that is solely about individual choice, it’s helping you do something that is frankly irresponsible of you NOT to do. Personal choice is only ok so long as it doesn’t impact others, whether you intend it to or not. At some point, personal choice is NOT ok – and as a society we decide where that line is drawn (see next section).
Some (myself included) have argued than a mandate to purchase some kind of insurance is nothing new – think of car insurance after all. Others have countered that not everyone has a car, and they don’t have to purchase insurance. Yeah, but since everyone needs healthcare, doesn’t that help the “Healthcare should be a right” argument? Since we all need it, we should all get it, and we all have a responsibility to maintain it.
We all live in a society – be it a tent village in the Amazon or a metropolis like Los Angeles. In that society there are certain rights, and responsibilities. We expect people to treat each other a certain way. As a whole we don’t steal from, rape or kill each other and can go about our lives in a reasonably predictable and productive manner. We expect people to stop at red lights, and we in turn are expected to stop. So how does this fit into healthcare? Well, since it’s morally indefensible to argue that some people are more deserving of healthcare than others, and that in order to provide protection for everyone we have to have everyone on board, THIS is where social justice comes in. If you want to benefit from the system, you have to be part of the system. Since you CANNOT avoid being part of the system (short of moving out of the country), you have to contribute. The only difference between a mandated health insurance bill and a mandated tax is the lettering on the bill. It is money going from you to somewhere else for a service (protection from healthcare costs).
The US needs to think of healthcare differently, since we know that everyone needs it, as part of our social fabric as much as clean water and clean air are. If they are part of the social fabric, we should expect government help to get it, and that means we should be expected to contribute to support it. The US has, mostly, moved out from the days of the Wild West – healthcare seems to be the last frontier to go.
Let’s look at another aspect of American society – we all expect to be able to dial 911 when we’re being burgled, or our house is burning down, and the police and fire department will show up, free of charge to help. The ambulance will show up too if you dial 911…but they’ll send you a bill afterwards. Why doesn’t that strike anyone as odd?
Single payer – the Public Option
This, in most reasonable people’s minds, is really what “Obamacare” was all about. A government health insurer for all. It doesn’t exist. It was stripped from the ACA in order to get the insurance reforms through, so although the ACA went through it lost the most important part of it. Why do I consider this important? What are the advantages of single payer? Well, for starters instead of dealing with the HUNDREDS of insurance companies there would be one. The plethora of billing staff who exist solely to shuffle paper around and sort through this mess wouldn’t exist. Fully 30% of private healthcare dollars is wasted on administration (ie doesn’t reimburse for the actual medical care) whereas for Medicare, one of the US Govt plans, it is closer to 3%. That’s quite a difference. In addition, the public option would streamline the whole “Mandate” thing, avoiding the situation where we are now with a Govt mandate to purchase a private company’s product.
This wouldn’t be Govt-run healthcare, it would be Govt-financed healthcare. Same Docs, same hospitals and labs, much easier reimbursement system. Insurance companies were terrified that a Government-sponsored plan would put them out of business, with its improved efficiency, larger insurer based and no need to kow-tow to CEO’s and shareholders for profits. This is why they lobbied so hard to strip it out of the ACA. That alone should tell you something about the Status Quo and how messed up it is.
This is where many of the physician complaints are coming from. It is well known that Govt reimbursements are lower than insurance companies’ reimbursements. There is a concern that a single-payer plan from the Govt would hurt Doc’s salaries. It might. But if you can fire all your billing staff that is a smaller overhead to pay for There are also the issues of Doc’s incomes going to unimportant things like, y’know, massive student loans and malpractice premiums. The fact is, there may not be a great solution here. Short of asking medical schools to stop charging so much, and asking patients not to sue so much, those things are going to remain. Doc’s salaries are high in the US, but aren’t even the biggest part of the problem – drug costs and institutions take a huge chunk too. The pharmaceutical companies and hospitals have their part to play in fleecing the consumer and driving up healthcare costs, which ends up hurting everyone in the long run. One solution is to scrap it all and start again. Another is to tackle one piece at a time, like insurance companies abuses, and work towards a better system. This is what the ACA is all about – one step in the right direction.
My personal opinion is that salaried Docs would help a bit – remove the incentives to prescribe and test inappropriately (you know docs can actually bill more for doing that, even if it’s unnecessary…?). Lower salaries would mean the Docs who were in medicine were less likely to be doing it for profit (instead of for the patients). If we can change the entire mindset of medicine towards it being a public service, and Docs as public servants (rather than a for-profit enterprise) it might help. But this would need massive overhaul from the ground up…and what to do with all those newly graduated docs with loans to pay etc? So much to fix….
The “R” word, the big scary “Death Panel” myth, the fear of some nameless bureaucrat controlling your healthcare. Well, it’s already here. Insurers dictate what does and does not get covered, which in turn dictates what your Doc will or will not provide to you. Medical judgment is often not a part of the decision it seems to me – at least, every time I have spoken to a real medical director of an insurer to fight my case they have agreed with me. Every time – which implies they either weren’t involved with the case or didn’t understand it until then. With a finite pot of resources though SOME form of rationing is inevitable. The difference to me is intent – do you want a public service rationing resources so the most needy can access them when they need to, or a private company rationing them to help their bottom line? Do you want a system where the billing requirements of various plans dictate who gets what care, or the same system for everyone?
There will always be a role for private medical care, but basic, life-saving and emergency healthcare should be free. We’re not talking facelifts and tummy tucks on the public purse here…!
Finally I have something to say on whether or not the ACA is Constitutional. Some people have dragged up various aspects of the Constitution (or rather, its Amendments since it needed fixing along the way…) against the Mandate. In the Declaration of Independence (the document through which Abe Lincoln said the Constitution should be interpreted) the following is said:
We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.
It is hard to pursue happiness, be truly free, and ultimately live, without good health. It’s hard to be healthy without healthcare.
That is all.
Links to facts quoted above: