Sunday, July 19, 2009

Health Care Reform

So, there's a pretty good chance that Congress will approve some kind of health care reform this year. The House and Senate have each passed their own versions of the bill, both, to my surprise, with a public insurance option.
I read an article about the bills in the Times yesterday, and, frankly, it's dismaying, because they're leaving the present mess standing and requiring health insurance for all. (You can read that article here; for a comparison of the bills, click the multimedia sidebar.)

If you think I'm joking about the present mess, I am not. The New Republic ran a spectacular graphic the other day showing how many businesses, government entities, and other organizations are involved. Take a look; it's here.

Opposition and fear are starting to build. The governors quite rightly fear unfunded mandates. Businesses look at the requirements for providing insurance to their employees, and you just know that many businesses will either not grow or will lay people off as they hit or try to stay under the size limits where it's required that they provide insurance.

Here's the deal: we don't need health insurance. What we need is health care. The present system, which combines employer-sponsored health insurance, socialized medicine for the poor, those over 65, veterans, and the disabled, and a patchwork of individual policies and state-sponsored programs, is insanely inefficient, inequitable, and expensive.

Any single-payer or integrated system would be better. I'm a Kaiser Permanente member and have been for 19 years now. Kaiser owns its own buildings, hospitals, and anicillary facilities; sporadic attempts at outsourcing, like giving maternal care to Alta Bates, worked badly and just lasted a few years. There's some specialization, in that, for example, in Northern California, brain tumors are treated at the Redwood City hospital and much orthopedic surgery is done at Vallejo. It's an excellent model; referrals take place seamlessly; test results are available at the touch of a keyboard; if you need X-rays, they send you downstairs and the photos are taken. Doctors are on salary instead of being paid per patient or per procedure. There are no incentives at all to provide too much care, as there are for other doctors.

The funny thing is that 25 years ago when I moved to the Bay Area, Kaiser was looked on with some suspicion. For one thing, it was the working class person's health care. The plan originated with the visionary Henry Kaiser, who wanted his workers to have decent health care available. And the membership has always had high percentages of minority and working class people.

For another, it had a reputation for not working very well, for being too controlling, for not referring, for being incompetent.

Things have changed a lot since the 1980s. Kaiser has improved enormously, while the fee-for-service system has gone insane and gotten crazy expensive.

It's time for the US to look at single payer or an integrated, socialized system. The transition would be mighty painful, but it would free up an awful lot of money in these ways:
  • Predictable financing, through taxes on all individuals and businesses
  • Ability to control costs in a rational and consistent way
  • Coverage for all
  • Simplified billing and administrative systems
Alternatively, the government could mandate that all insurance companies must provide policies to anyone who applies, at a predictable, government-determined rate, and that those policies provide nationally-consistent coverage.

I don't think the political will exists to do either of these things, and so we will wind up with a continuation of the current Frankenstein-monster system.

Now, if you think my ideas are just! terrible! and would rob people of their choices, think again: as Paul Krugman pointed out the other day, the private health-insurance system (employer-paid and individual plans) pays 34% of U.S. health care costs, while various government-sponsored programs pay for 46%. "Most of the rest is out-of-pocket spending," he says.

So, given that we're already more than half way to socialized medicine, let's go all the way while we have the chance.

Update: rootlesscosmo suggests a couple about the current situation. Click here to read an editorial by Arnold Relman. The other link is, alas, broken.


Anonymous said...

insanely inefficient, inequitable, and expensive

To which I'd add ineffective, since by all the evidence people in this country pay more than people in other countries while getting worse health outcomes. These two articles make the case for a single payer system but also a powerful case for a system that will remove the financial incentives that lead doctors to order unnecessary, and expensive, diagnostic procedures and aggressive courses of treatment. As Dr. Gawande says, how health care is paid for, while important, isn't the only issue; there's also the question of what gets paid for, and why.



Lisa Hirsch said...

Yes, absolutely. We pay for a lot of medical care that does nothing or is simply unnecessary - see the big article in the Times this past week about the high overall cost of testing for various kinds of cancers, versus lives saved, etc. I haven't read the two Gawande items yet, but I've read both his books. He's great. And I have a planned follow-up to this posting that will mention an editorial of his from about 18 months ago.

I'm going to put those links in the body of my posting and make them clickable, also.

Michael Walsh said...

Health care needs to be declared a utility, like electricity and water, since everyone needs it and consumer choice is constrained.

Utilities aren't non-profit, but their profits are regulated, and the only way to get the health industry to do what it is supposed to do is to take away the incentive to make mounds of undeserved profit.

Lisa Hirsch said...


Hamster said...

33% of Americans think the US health care system needs a major overhaul
Only 16% think we should leave it just as it is


We are the only developed nation in the world that doesn't provide healthcare in some form to all it's citizens. In fact many of us have no health insurance

Other developed nations have found their solution to heath care
How do they do it? Compare

The question is, though, do they really like their system. Or would they prefer a system like ours.


The vast majority of Americans feel that we need health care reform this year.

Both Republicans and Democrats have come up with their plans for health reform
Let's take the best ideas from each side, add in the best of systems from around the world and come up with something that will work.

No one is going to get everything they want. But at least we can fix some of the major problems.

Iinaction is totally unacceptable. And just taking something to dull the pain isn't going to really solve the problem

Paul H. Muller said...

The problem here is the Congress. Something like 65% of Americans want a single-payer system and it has just squeaked into the current legislation. Obama as President can only cheer-lead, and even though he hasn't done all he might have in this case, there are limits to what the Presidnet can do.

Something is drastically wrong when something the majority of the people want is such a struggle to put into law.

The answer is simple: return no incumbant to office. Until members of congress become more interested in getting my vote than getting campaign contributions from the insurance companies, we are going to have worse care, not better.

Lisa Hirsch said...

Hamster - yes to all of that.

Paul - "insurance companies" and "profits' are key words in why this will be so tough.

I bought the current issue of The Economist just for the cover, by the way.

rootlesscosmo - Atul Gawande's article is accessible if you click the link at his web site! That might get readers past authentication at TNY or something. So, interested parties can go to Dr. Gawande's web site and click the link on the first page.

Anonymous said...

Also note that Kaiser has quite recently further computerized their patient databases and linked them together. I've had my optometry work done at three different clinics for various reasons, and from now on they'll be able to access each others' new data electronically, which they can't for old records.

Anonymous said...

I'm opposed to mandating health care without fundamentally changing the system by which it's provided. California mandates auto insurance, yet California is full of uninsured drivers, who are invariably the ones who hit you.

Lisa Hirsch said...

Yes, we absolutely need fundamental change. Single-payer, with automatic enrollment for all US citizens, would be the ideal way to go. I don't think we'll get it, even though the alternatives are so Byzantine.