“Just
because you can make a profit on
something, doesn’t mean you should.
Some things should be sacrosanct.”
- Robert Cheek,
2011
Healthcare
has become a contentious debate in America for the past few years. With the
passing of the Patient Protections and Affordable Care Act, Congress and the
President are realigning citizens’ relationship with their healthcare insurers
and providers. There has been much political hay made about the new healthcare
law. The right has sired the law “Obamacare.” If I were the President, I would
take that name as my own (like Reaganomics), because the good that this bill
will do, will vindicate it when we look back in 5, 10, or 20 years.
As is my
policy, let’s start with a look at history and come to the present. For this
topic, I'm going to start with the more recent past, then go back to the
beginning and move forward again.
The
question I have been asked more than any other is why? Why do we need to reform
healthcare at all? For those who have insurance, they are generally happy with
their care. They can go to the doctor when they need to. They feel “taken care
of.” For those without insurance, I often hear, “well, what can you do?” They
sense that it is out of their hands. The emergency room is there for people who
get too sick to handle it on their own. This sense isn't the end of the story.
There are facts to back it up.
First,
and many people already know this, but the United States is the only
industrialized country in the world without a universal health insurance
system. Universal Healthcare can be defined many ways. Some countries offer a
single-payer health insurance through the government. That means that all
citizens are issued health insurance cards or access to care is granted with
only a social security number. This is the way Canada provides health
insurance. In other countries, the government owns and operates the hospitals,
pays the doctors, and controls every aspect of care. Healthcare is provided for
free at these facilities. This is how the United Kingdom provides healthcare.
In 2006,
the U.S. Census reported that between 45 and 46 million Americans have no
health insurance. This includes more than 9 million children, despite the
continued efforts to insure children through programs like CHIP (Children's
Health Insurance Program). Eighteen thousand people die each year because they
are uninsured, and unable to get preventative care or treatment when they get
sick. According to the UN Human Development Report, “The uninsured are less
likely to have regular outpatient care, so they are more likely to be
hospitalized for avoidable health problems. Once in hospital, they receive
fewer services and are more likely to die in the hospital than are insured
patients. They also receive less preventive care. Over 40% of the uninsured do
not have a regular place to go when they are sick and over a third of the
uninsured say that they or someone in their family went without needed care, including
recommended treatments or prescription drugs in the last year, because of
cost.”
The
impact doesn't end at health. Half of all bankruptcies are caused by medical
bills. Three-quarters of those filings are people with health insurance. U.S.
health care spending is approximately $2 trillion per year, or $6,697 per
person. This means the United States continues to spend significantly more on
health care than other countries in the world. Yet, according to the UN Human
Development Report, while the United States leads the world in spending on
health care, “countries spending substantially less than the US have healthier
populations.… The infant mortality rate for the U.S. is now higher than for
many other industrial countries.” We have lower overall quality of care and
fewer results for the money paid. A baby
born in El Salvador has a better chance of surviving than a baby in Detroit.
The infant mortality rate in Detroit is 15.5, compared to El Salvador's rate of
9.7. Cubans have a lower infant mortality rate than the United States and
according to the U.N. Human Development Report, a longer average lifespan.
Canadians live three years longer on average than we do. A study in the Journal
of the American Medical Association found that older Americans are
significantly less healthy than their British citizens. We have more diabetes,
heart attacks, strokes, lung disease and cancer. Even the poorest British citizens
can expect to live longer than the richest Americans.
While
this is the current situation, there are four times as many health care
lobbyists in Washington as there are members of Congress. Ninety percent of
Americans believe the American health care system needs fundamental changes or
needs to be completely rebuilt; and, according to a CBS poll, two-thirds of
Americans believe the federal government should guarantee universal health care
for all citizens.
The
history of health insurance is really a story of the 20th century.
Medical care before the 1900s was, for the most part, subjecting to guessing
and trial and error. In our history classes we learned about blood-letting as
treatment for illness. During the civil war, thousands were amputated rather
than having their wounds treated. Antiseptics, for all their importance today,
weren't common practice until after the turn of the century. One of the
earliest health care proposals at the federal level was the 1854 Bill for the Benefit of the Indigent Insane,
which would have established asylums for the indigent insane, as well as the
blind, deaf, and dumb, via federal land grants to the states, but was vetoed by
President Franklin Pierce. Pierce argued that the federal government
should not commit itself to social welfare,
which he believed was properly the responsibility of the states. After the
Civil War, the federal government did establish the first system of national
medical care in the South. Known as the Freedmen's Bureau, the government
constructed 40 hospitals, employed over 120 physicians, and treated well over
one million sick and dying former slaves. The hospitals were short lived,
lasting from 1865 to 1870.
By the
1920s, doctors didn't charge very much as there were few guaranteed solutions.
Doctors generally provided little more than emergency care for those who were
sick. Most people paid out of their own pockets and most patients were treated
in their homes. Only a few big employers offered health insurance, and it was
very uncommon. Early industrial sickness insurance, purchased through
employers, was one influential economic origin of the current American health
care system. These late-19th-century and early-20th-century sickness insurance
schemes were generally inexpensive for workers. Their small scale and local
administration kept overhead low, and because the people who purchased
insurance were all employees of the same company, that prevented people who
were already ill from buying in. The presence of employer-based sickness funds
may have contributed to why the idea of government-based insurance did not take
hold. Thus, at the beginning of the 20th century, Americans were used to
associating insurance with employers, which paved the way for the beginning of
third party health insurance in the 1930s.
When
doctors began learning more about diseases and effective treatments, costs went
up and expense also went up. Doctors needed to treat people in hospitals to
take advantage of new medical technology, which further added to the costs.
Just as these new developments were arising, the start of the Great Depression
made the situation was even worse.
To help
ease the healthcare problem, Baylor Hospital in Dallas created a system to help
people pay their medical bills. As science, medicine, and hospitals grew more
sophisticated and more successful, more people turned to them for care. As more
came for care, and technology developed, costs continued to rise. Insurance, through
the hospital, for doctors' services started gaining ground in the late '30s as
a way for doctors to protect their interests and their payments. This system
eventually became known as Blue Cross and Blue Shield.
The
success of the Blue Cross and Blue Shield model encouraged other insurers to
enter the healthcare market. The shortage of labor during World War II
encouraged employers to offer health insurance as an added benefit to the
employment package to entice more workers. Soon it was a commonplace for
employers to provide health insurance. As this became common practice, the
government provided tax incentives to do it. This happened at a time, during
and just after WWII, when many other countries were moving toward national
health insurance or healthcare programs. But with the US system focused on
employer provided insurance, those nationalized healthcare ideals did not take
root here.
Following
the Second World War, President Harry
Truman called for universal health care as a part of his Fair Deal in 1949 but strong opposition stopped
that part of the legislation. However, in 1946 the National Mental Health Act was passed, as was the Hospital
Survey and Construction Act, or Hill-Burton
Act. These bills would be the extent of the government foray into
healthcare for twenty years. In 1951 the IRS declared group premiums paid by
employers as a tax-deductible business expense, which solidified the
third-party insurance companies' place as primary providers of access to health
care in the United States.
In the
early days, after the success of Blue Cross and Blue Shield, private insurers
were eager to get a piece of the business. But they only wanted to insure
young, healthy people who were employed and less likely to use the coverage,
which meant more profit for the company. Private insurers didn't want older,
sicker individuals, so they began charging premiums based on different factors
like age, gender, health status, and pre-existing medical conditions. Because
of Blue Cross and Blue Shield's status as a nonprofit company, they had to
charge the sick and healthy the same premiums; private insurers did not.
Private health insurers could offer employers better insurance rates than Blue
Cross could, and the commercial health insurance business took off. With the
low-risk, and frankly more profitable, patients migrating to cheaper,
for-profit businesses, the non-profits had no choice but to follow their lead.
Each time the subject of national health insurance was mentioned, it was
quickly killed off, even though most other developing countries were heading
that way. Doctors, through the American Medical Association, and insurance
companies, threatened by having their power and profit challenged, used their
influence to kill them.
From
1940 to 1960, a completely commercial health insurance program developed.
The supply of health insurance increased as commercial insurance
companies entered the market. The use of healthcare increased as medical
technology became more sophisticated. The government encouraged employers
to offer health insurance, through private insurers, as part of employee
compensation packages. Union negotiations during the 1940's also reinforced the
employment-based health insurance system. By the 1960s, it was clear the system
of private health insurance in the United States was well established and in no
danger of being dismantled. However, there were glaring problems. The poor, day
laborers, workers for small companies that didn't provide insurance, the
self-employed, and those who had no job also had no health insurance. And once
workers retired from their jobs, usually at or near age 65, they lost their
health insurance and moved into old age without a healthcare safety net.
After
John F. Kennedy was elected president in 1960, the climate toward national
health insurance was somewhat more favorable. But the American government
realized the only way to successfully enact government-sponsored healthcare was
to start slowly. The elderly were a natural target segment.
The
elderly and the poor were among the most medically needy in society and were
the least likely to be covered by an employer's health insurance plan. To keep
doctors from opposing, as they had before, a newly proposed legislation, which
would become Medicare and Medicaid, legislators agreed that the government
would reimburse doctors at their "usual, customary, and reasonable
rate" for taking care of the elderly and the poor. This means doctors
stood to gain a great deal from Medicare, as they accessed new populations
while receiving the conventional pay. The bill was passed in 1965 and consisted
of two parts: Part A covered hospital services and Part B covered doctors'
services. In addition to Medicare, Medicaid was enacted as a federal-state
program to provide medical services for the indigent. Although both programs
started small, expenditures in Medicare and Medicaid grew dramatically in the
late 1960s as the programs began to gear up. Since then, Medicare has evolved
into Original Medicare, provided by the government, and Medicare Advantage, or
Part C- an HMO style provider that has since fallen into disfavor, provided by
private insurance companies that contract with the government to provide this
insurance to seniors.
In 1993,
Healthcare Reform gained the most steam behind it since the 1960s. Running for
a Senate seat in a special election in Pennsylvania in November 1991, Harris
Wofford came from 40 points behind to win an upset victory after making universal
health coverage a central issue in his campaign. The national parties suddenly
sat up and took notice. Gearing up for
the 1992 campaign, President Bush put forward a lackluster, lukewarm healthcare
reform plan. Democratic front runner William Clinton, made hay of the plan, and
focused his talks on total reform of a broken system. However, he didn't make
reform a central aspect of his campaign, instead running on the economy. Once
elected, he formed a task force, putting first lady Hillary Rodham in charge.
After some legal and political wrangling, the task force produced a report
which would later become the basis of the bill.
The
basic idea was not complicated. Consumers, not employers, would choose health
plans. Firms would pay into a regional health insurance purchasing cooperative
(later called an "alliance"), which would offer private plans of
varying types to all residents under age 65 in an area (Medicare would remain
separate). The alliances would be required to offer traditional, fee-for-service
insurance as well as health maintenance organizations and preferred provider
plans. Benefits, co-pays, and other features would be standardized so as to
make it easier for consumers to compare prices and get the best value for
money. Health plans would have to offer coverage to everyone without exclusions
of preexisting conditions, and they would be paid according to the
characteristics of the population they enrolled. If a plan enrolled a
relatively older and sicker population, the money it received from the alliance
would be adjusted upward; if it enrolled younger and healthier members, it
would get less. Many people misinterpreted "managed competition" to
mean "competition among managed care plans." But "managed"
as a modifier of "competition" referred to a variety of measures --
open enrollment, standardized benefit packages, risk-adjusted payments to
plans, independent assessment of the quality of care -- intended to stop
insurers from trying to cherry-pick healthy subscribers and to get them to focus
instead on providing higher-quality service at lower cost.
Unfortunately,
this plan failed to get support, first among all Democrats, and then once
adopted, by Republicans. This happened despite the fact that it had zero impact
on the budget and would have required no tax dollars to be spent. It floundered
in Congress. After failing to incorporate the bill into the proposed budget,
the Majority leader declared the bill dead for that session of Congress. It
wouldn't be revisited for 17 years, until President Obama.
This
brings us to the recently passed PPACA, which I’ll refer to as Obamacare. There
have been a lot of myths tossed around about Obamacare. Let's address some of
those. First, this is a 'government takeover' of the health care system. This
talking point was and is used by Republicans repeatedly to bash Obamacare, but
it is simply not true. In fact, PolitiFact.com labeled this claim the 2010
"lie of the year," but that has not stopped lawmakers from
making this claim. In many ways, the health care law resembles the
Massachusetts reform enacted in 2006 under then Gov. Mitt Romney. It builds on
the existing private insurance system but adds requirements and incentives to
ensure that most people have some form of health insurance.
Under
the new law, there is no government alternative to the private system (this was
a potential provision that was dropped during the congressional debate) but the
number of people who qualify for the existing federal-state Medicaid program
for the poor will be expanded. States (or the federal government) will run
"exchanges,” or essentially marketplaces, in which private insurers will
sell insurance to individuals and small businesses, but this should mean more
people will get private insurance, not fewer. Tax credits will also be offered
to people who have trouble buying private insurance.
Certainly,
the law bolsters government regulation of the health care system, such as
forcing insurance companies to no longer deny coverage to people who have
existing medical conditions. People who currently do not have health insurance
will be required to buy it. But the core of the health system in the United
States will remain the existing private insurance market. So it in no way
resembles the government-run health systems used in most industrialized
countries in the world.
The
second myth is that Medicare benefits will be cut and payments will be cut to
Medicare doctors. This was another GOP attack line. The politically charged
word "cut" is a misnomer. Under the health care law, Medicare
spending will continue to increase year after year, but at a slower than
anticipated pace. Both parties, in theory, agree this would be a good thing.
The health bill will reduce projected Medicare spending by $575 billion over
ten years, primarily by reducing projected fees to hospitals and other
providers and by reducing payments to private Medicare Advantage insurance plans.
Benefits have also been added, eating into the overall projected savings, but
the impact on the Medicare Advantage plans is unclear. Richard S. Foster, the
chief actuary of the Medicare and Medicaid, has estimated that seniors may need
to pay more in out of pocket costs for such plans. He has also cast
serious doubt on whether the Medicare savings claimed in the second decade
could be achieved without significant pain for many hospitals, nursing
facilities and other providers. In fact, since 1997, Congress all but once has
waived a planned cut in Medicare payments to doctors, mostly recently in
December. So depending on the political pressure, some of these projected
"cuts" may never materialize in any case.
The third
myth is that a secretive government committee ('death panel') will be created
to make end-of-life decisions about people on Medicare. This claim, first made
by former Alaska Gov. Sarah Palin, the 2008 GOP vice presidential candidate,
has been thoroughly debunked and was labeled "lie of the year"
in 2009 by PolitiFact.com. Yet, it persists in the popular imagination.
The September Kaiser poll found that 30 percent of seniors still believed this
to be the case and 22 percent were not sure, meaning fewer than half knew the
claim was false.
The
charge partially stemmed from a proposed amendment to the bill that would have
covered the cost of end-of-the-life planning discussions. Democrats quickly
dropped the provision after the firestorm created by Palin's assertion, even
after it was proven to be factually incorrect. But the issue remains
politically sensitive. In late December, The New York Times reported that
under new Medicare regulations for annual physical examination, "the
government will pay doctors who advise patients on options for end-of-life
care, which may include advance directives to forgo aggressive life-sustaining
treatment." The White House reversed course days later, ordering
the Medicare agency to delete references to end-of-life planning in its new
regulations. Further, the myth continued with allegations from the 1993
Healthcare reformed that a government panel, in an effort to reduce costs,
would decide when a patient should get treatment and not. No part of the bill
says anything about appointing people to decide whether or not someone dies.
The decision over whether or not your claim is approved is still in the hands
of your doctors and your insurer. However, now there’s an appeals process so if
your claim gets turned down by the insurer, you can challenge it. And the
government watches that appeals process to make sure it’s not being unfair to
customers. So, if anything, the PPACA is trying to stop the
death panels. The Independent Medical Advisory
Board, formed by the PPACA, is intended to give recommendations on how to save
Medicare costs per person, deliver more efficient and effective care, improve
access to services, and eliminate waste. However, they have no real power. They
put together a recommendation to put before Congress, and Congress votes on it,
and the President has power to veto it. What’s more, they are specifically told
that their recommendation will not ration health care, raise premiums or
co-pays, restrict benefits, or restrict eligibility. In other words, they need
to find ways to save money without reducing care for
patients.
The fourth
myth is that Obamacare gives free insurance to illegal
immigrants. However, there are multiple parts of the bill that
specifically state that the recipient of tax credits and other benefits must be a legal
resident of the United States. And while the bill doesn’t specifically forbid
illegals from buying insurance or getting treated at hospitals, neither did the
laws in the US before the PPACA. So even at worst, illegals still have just as
much trouble getting medical care as they used to.
The fifth myth is that Obamacare uses taxpayer money for
abortions.
One part of the bill says, essentially, that Congress isn’t touching that
issue. It basically passes the buck on to the states, which can choose to allow
insurance plans that cover abortions, or they can choose to not allow them. Obama
may be pro-choice, but that is not reflected in the PPACA.
Finally,
there is a myth, this time from Democrats, that repealing the bill will
increase the deficit. This is technically true. It comes from a Congressional
Budget Office estimate, but there are documented problems with both this
statement and the estimate. This is a pretty shaky claim for Democrats to make,
especially since the health care law was not really intended to reduce the
deficit, but to reduce the number of uninsured Americans
So what does
Obamacare do? There are certain provisions already in effect. It allows the FDA to approve
more generic drugs (making for more competition in the market to drive down
prices). It increases the rebates on drugs people get through Medicare (so
drugs cost less). It establishes a non-profit group, that the government
doesn’t directly control, PCORI,
to study different kinds of treatments to see what works better and is the best
use of money. It makes chain restaurants display how many calories are in all
of their foods, so people can have an easier time making choices to eat
healthy. It makes a “high-risk pool” for people with pre-existing conditions; basically,
this is a way to slowly ease into getting rid of “pre-existing conditions”
altogether. For now, people who already have health issues that would be
considered “pre-existing conditions” can still get insurance, but at different
rates than people without them. Obamacare forbids insurance companies from
discriminating based on a disability, or because they were the victim of
domestic abuse in the past (yes, insurers really did deny coverage for that).
It also renews some old policies, and calls for the appointment of various
positions. It creates a new 10% tax on indoor tanning booths.
A big change is that it says that health
insurance companies can no longer tell customers that they won’t get any more
coverage because they have hit a “lifetime limit.” Basically, if someone has paid for health
insurance, the company can’t tell the person that they’ve used that insurance
too much throughout their life so the company won’t cover him anymore. They
can’t do this for lifetime spending, and they’re limited in how much they can
do this for yearly spending. A new website is made to give people insurance and
health information.
For
children and young adults, they can continue to be covered by their parents’ health
insurance until they’re 26. There are no more “pre-existing conditions” for
kids under the age of 19. Insurers have less ability to change the amount
customers have to pay for their plans.
Insurers
can’t just drop customers once they get sick. Insurers have to tell customers
what they’re spending money on (instead of just “administrative fee,” they have
to be more specific) Anti-fraud funding is increased and new ways to stop fraud
are created. A limit is placed on just
how much of a percentage of the money an insurer makes can be profit, to make
sure they’re not price-gouging customers.
People
in a “Medicare Gap” get a rebate to make up for the extra money they would
otherwise have to spend. Medicare extends to smaller hospitals. Medicare
patients with chronic illnesses must be monitored more thoroughly. It reduces
the costs for some companies that handle benefits for the elderly.
A limit
is placed on what type of insurance accounts can be used to pay for
over-the-counter drugs without a prescription. Basically, your insurer isn’t
paying for the Aspirin you bought for that hangover. Employers need to list the
benefits they provided to employees on their tax forms. Any new health plans
must provide preventive care (mammograms, colonoscopies, etc.) without
requiring any sort of co-pay or charge. As of January 1st 2013, if
you make over $200,000 a year, your taxes go up a tiny bit (0.9%).
Starting on
1/1/2014, a lot of the big changes start happening. There will be No more “pre-existing
conditions” at all. People will be charged the same regardless of their medical
history. If you can afford insurance but do not get it, you will be charged a
fee. This is the “mandate” that people are talking about. Basically, it’s a
trade-off for the “pre-existing conditions” elimination, saying that since
insurers now have to cover you regardless of
what you have, you can’t just wait to buy insurance until you get sick.
Otherwise, no one would buy insurance until they needed it. You can opt not to
get insurance, but you’ll have to pay the fee instead, unless of course you’re
not buying insurance because you just can’t afford it. (On 6/28/12, the Supreme
Court ruled that this is Constitutional, as long as it’s
considered a tax on the uninsured and not a penalty for not buying insurance.
This is nitpicking about wording, mostly, but the long and short of it is, it
looks like this is accepted by the courts); Medicaid can now be used by
everyone up to 133% of the poverty line (a lot more poor
people can get insurance); small businesses get some tax credits for two years.
(Specifically businesses with 25 or fewer employees); Businesses with over 50
employees must offer health insurance to full-time employees, or pay a penalty.
Insurers now can’t do annual spending caps. Their customers can get as much
health care in a given year as they need. Limits how high of an annual
deductible an insurer can charge customers Place a $2500 limit on tax-free
spending on FSAs (accounts for medical spending). Basically, people using these
accounts now have to pay taxes on any money over $2500 they put into them. Health
insurance exchanges will be established and rebates for the lower and
middle-class will be created, basically making it so they have an easier time
getting affordable medical coverage. Congress and Congressional staff will only
be offered the same insurance offered to people in the insurance exchanges,
rather than Federal Insurance. Basically, we won’t be footing their health care
bills any more than any other American citizen. A new tax on pharmaceutical
companies will be created. A new tax on the purchase of medical devices will be
created. A new tax on insurance companies based on their market share will be
created. Basically, the more of the market they control, the more they’ll get
taxed. Finally, the amount you can deduct from your taxes for medical expenses
increases.
Starting on
1/1/2015, there will be one big change that will help to raise quality of care
and lower costs. Doctors’
pay will be determined by the quality of their care, not how many people they
treat. By 1/1/2017, if
any state can come up with their own plan, one which gives citizens the same
level of care at the same price as the PPACA, they can ask the Secretary of
Health and Human Resources for permission to do their plan instead of the
PPACA. So if they can get the same results without, say, the mandate, they can
be allowed to do so. Vermont, for example, has expressed a desire to just go
straight to single-payer system. Later, in 2018, all health care plans must now
cover preventive care (not just the new ones), and a new tax on “Cadillac”
health care plans (more expensive plans for rich people who want fancier
coverage). Finally, in 2020, the elimination of the “Medicare gap,” or doughnut
hole, will be final.
So that
is the current state of Healthcare in the US. I have to say that Obamacare is
certainly better than nothing. However, in an effort to satisfy the AMA and
Insurance companies, Congress, like they did with Medicare, just expanded the
customer base for private insurance. As I quoted above, just because you can
make a profit on something, doesn’t mean you should.
My plan
is drastically different. I would create a nationalized insurance system,
similar to the one in Canada. Operationally speaking, this can be accomplished
by simply making Medicare apply to all citizens. Why do this? First of all, I
don’t care about insurance companies. I don’t care if they make a profit. I don’t
care if they survive at all. I think that making a profit from people’s health,
especially the way we do in America today (not focusing on preventative care,
limiting benefits for those with life threatening conditions, making people
chose between living with bankruptcy or rolling the dice with death, and
jacking up prices across the board because Americans can “afford” it) is no
different than selling guns to warlords or doing business with Nazi’s. You are
part of the problem, not part of the solution. The insurance companies won’t
all go under, of course. There will still be companies offering “Cadillac”
plans to the very wealthy; and if people would like to opt out of the
nationalized health insurance, for idealistic or whatever reason, they are
welcome to. The program would not be forced on anyone, and there would be no
mandate for insurance. However, the tax increases would apply across the board
and there would no longer be deductions for health benefits or costs.
On this issue, people are deeply divided. Those without insurance, or who cannot
afford it, (which admittedly is a group of which I am a member) are generally
for it. Those in opposition have offered many compelling, but in the end, not
deciding arguments against. The one I hear most is “Universal health insurance
does not necessarily mean universal access to health care. In practice, many
countries promise universal coverage but ration care or have extremely long
waiting lists for treatment. Those countries that have single-payer systems or
systems heavily weighted toward government control are the most likely to face
waiting lists, rationing, restrictions on the choice of physician, and other
barriers to care.” As I said above, the Canadian example is often used. However,
this is comparing apples and oranges. I will cover this issue more in depth in
my upcoming book, but to use broad strokes. We have more doctors per capita
than any other nation on the planet. People come from every different nation to
go to our medical schools, because our education system is second to none. If
there is any place in the world to have heart, lung, or any internal surgery
done- it’s here. The same goes for most treatments of other diseases. We have
more diagnostic equipment available than any country as well. The wait times
for diagnosis or treatment will increase no more than under Obamacare, when the
same 45 million uninsured enter the medical marketplace.
But don’t Canadians flock to America for treatment, due to their broken
system? The most comprehensive study on this topic, it employed three different
methodologies, all with solid rationales behind them, was published in the
peer-reviewed journal Health Affairs. The authors of the study started by
surveying 136 ambulatory care facilities near the U.S.-Canada border in
Michigan, New York and Washington. About 80 percent of such facilities saw, on
average, less than one Canadian per month; about 40 percent had seen none in
the preceding year. Then, the researchers looked at how many Canadians were
discharged over a five-year period from acute-care hospitals in the same three
states. They found that more than 80 percent of these hospital visits were for
emergency or urgent care (that is, tourists who had to go to the emergency
room). Only about 20 percent of the visits were for elective procedures or
care. Next, the authors of the study surveyed America’s 20 “best” hospitals, as
identified by U.S. News & World Report. Only one of the 11 hospitals that
responded saw more than 60 Canadians in a year. And, again, that included
both emergencies and elective care. Finally, the study’s authors examined data
from the 18,000 Canadians who participated in the National Population Health
Survey. In the previous year, 90 of those 18,000 Canadians had received
care in the United States; only 20 of them, however, reported going to the
United States expressively for the purpose of obtaining care.
Another
argument I hear is that Canadian doctors are coming to the US for the
profit-based incentive. The Canadian Institute for Health Information has been
tracking doctors’ destinations since 1992. Since then, 60 percent to 70 percent
of the physicians who emigrate have headed south of the border. In the
mid-1990s, the number of Canadian doctors leaving for the United States spiked
at about 400 to 500 a year. But in recent years this number has declined. So
when emigration “spiked,” 400 to 500 doctors were leaving Canada for the United
States. There are more than 800,000 physicians in the United States right
now. In 2004, net emigration became net immigration. Let me say that again.
More doctors were moving into Canada than were moving out.
Above I
said, and they will be needed, that tax increases will come. Right now, the
average per household expenditure on healthcare is $20,000 annually. There isn’t
good data, at least that I could find, on the distribution of health costs
across the population. This is different from the distribution of health
spending, which is driven by illnesses (and is highly variable). While
certainly the wealthier pay more, and the poor pay less, this is an astonishing
figure. Taking that the average income for a household in the US is
approximately $43,000 a year, healthcare costs would attribute for just less
than half of income. Compared to this number, a tax increase of a few percent
(progressively graduated based on income) that eliminated this expenditure is a
net win for individual citizens. Also, keep in mind that around 60 million
Americans are covered by Medicaid and another 50 million by Medicare. Using
these rough numbers, and an approximate total population of 350 million, just
under a third of Americans are ALREADY covered under a government run insurance
program, with another 45 million who are uninsured or drastically underinsured.
The system just doesn’t work as it’s designed, and we need a drastic change to
both provide universal coverage, and control costs.
In summation,
the issue comes down to this: you can’t compare the US to any other country
when it comes to healthcare. You can’t use examples from nations with a few
thousand doctors for a few million citizens to extrapolate outward to a country
with 350 million citizens and almost a million doctors. More importantly, you
can’t compare a country that adopts technology with the country that creates the
technology. The US is a world leader in groundbreaking healthcare and it will
continue to be. We just need to assure that our own citizens can benefit. My
system is the best way to accomplish that. More importantly, with only one
party controlling most of the insured in the country, the ability to bargain on
reimbursement will mean that costs can be controlled much better than they are
now: another benefit of the single payer system.
I encourage
comments below; I know many people have strong opinions on the issue. Like and
share so more people will join the conversation. I haven’t addressed this
before, but I encourage debate because, call me a flip flopper if you like, but
I have been convinced to change my opinions and positions based on a argument I
feel is stronger than my own. If you think I’m wrong, tell me. I’d love to
debate it. Then, in the end, our cumulative knowledge will be stronger.
©
Robert Cheek, 2013
