Virtue and Vices in U.S. Health Care System
A couple of weeks ago, Michael posted a brief set of observations about the strong health care system in the Netherlands, implying a superiority over the U.S. system that is common from both domestic and foreign critics of American health care.
Since my wife’s diagnosis with breast cancer a couple of months ago, I have had frequent and intense personal exposure to the U.S. health care system. I feel this gives me the perspective to offer a few observations about its virtues and its vices, both of which tend to undermine the simplistic memes that often dominate the health care debate. I am not going to get into pointless nationalist debates about whose system is “better”, but rather I want to encourage all involved to see the inevitability of tradeoffs and the impossibility of magical solutions.
Virtues: Speed and pervasiveness of access to high quality care for the well-insured. Until this summer, I didn’t know so many different types of scans even existed, let alone that the multi-million-dollar machines that do the different kinds of CT, PET, MRI, and other scans existed each in multiple different forms within the same medium-sized city. Access to specialists was similarly dizzying, with multiple practices available for all of the many different kinds of referrals. The longest wait time was two weeks. This kind of pervasive availability results from extensive investments by competing providers and is thus not available when profit-making incentives are stripped out of a system, as in even the best nationalized, single-payer systems. There is a good reason that the wealthiest people from Canada and the U.K. wind up seeking care in the United States as their only option for avoiding stringent rationing and even outright unavailability of some high-tech tests and treatments in their own country.
Vices: Price. All the wonders I cite above is really only available to those who not only have health insurance, but who have the right health insurance. Andrew Enthoven, who Michael credits with the creation of HMOs, was in fact a RAND Corporation analyst who’s exact innovation was the infamous “co-pay” that requires individuals to share the cost of the health care they use in order to provide a disincentive to overuse. But for those with a serious medical condition, the co-pays can add up very quickly. Only those with an unusually excellent plan that has a relatively low annual cap on out-of-pocket expenses can avoid very serious impacts. And the raw cost for those without insurance can be crippling — one very partial accounting I saw for a single month’s worth of the treatment process approached US$50,000. Those who do not have access to these gold-standard health plans may find the wonders of U.S. health care just as out-of-reach as if they were in a rationed nationalized system.
What are the implications for these observations on the eternal debate over health care in the U.S.? Mostly that advocates should dispense with the illusion of easy solutions or romanticized models from other countries. Any increase in access funded by the government will either require a massive increase in costs paid or a significant decrease in availability. There is no free lunch at the cutting edge of technological health care and slogans about social justice won’t produce MRI machines to feed demand in the absence of profitability. Yet, refusal to increase access makes those wonders merely theoretical for a huge proportion of the population, probably more than two-thirds. The miracle of high-tech capitalist health care has a dark side in the neglected masses who die needlessly within sight of its unrivaled glamor.
European systems have largely chosen the option or prioritizing access to primary care over access to advanced care while the U.S. has heretofore chosen to prioritize advanced care over broadening primary care. Modifying the U.S. choice while avoiding the killing of the golden technological goose is a challenge with which no health care plan I am aware of has yet seriously grappled.
Excellent post, Jason, and I’m sorry to hear about your wife’s diagnosis. My thoughts and prayers are with your family.
We’ve recently experienced a series of much less serious illnesses, which included an outpatient surgical procedure for my husband. Even though the scope of the problems is much less than what you’re experiencing, I’ve had similar revelations on the high cost and what that would mean to a family without good health insurance coverage or of lower means to pay even the copay and deductible portions.
The observations about high cost get lots of play in the health care debate from the Democrats’ side. The countervailing observations about the availability of high-tech tests and treatments usually gets ignored in favor of romanticization of the Canadian or European single-payer systems.
The scans that my wife had to wait mere days for would require weeks or even months or years to get in Canada or Europe. And with some kinds of diseases, those kinds of delays can be fatal to the patient. Yet such points are usually excluded from our debates about health care. I had a friend in the U.K. in the 1980s who was required by the government to suffer in crippling pain for 4 years because she was too young to meet the government regulations rationing hip replacements. And I read somewhere that the total number of MRI machines in the entire country of Canada is less than 1/2 the number available in the medium-sized American city where I live (total population less than 10% of Canada’s).
I actually do have experience with a socialized health care system in the U.S. military. The experience was horrifying, both in the availability of care (trying to get an appointment was so impossible that any condition required an emergency room trip to be seen at all — we usually preferred 3AM trips, as it reduced the wait time to only 4 hours) and the quality of care (contrast the private room my wife gets now with the 50-person open-air ward I had in the military). Recent findings of grotesque conditions at British hospitals show that my observations on this are on-point.
Yes, and the bottom line is basically as you described in the post; ALL systems involve rationing and the only question is whether a central administrator decides on how to ration the available service or whether the rationing occurs according to ability to pay.
When I was stationed in Denver, the rationing system was even more arbitrary and random than by a central administrator. Basically, here is how it worked: They only scheduled appointments two weeks in advance. So if you wanted an appointment, you had to repeatedly speed-dial the appointments number at 7am (when the appointments line opened, it was actually closer to 7:15 on most days, but you had to start at 6:50 just to make sure you were pounding on the lines) exactly two weeks before your hoped-for appointment. You had to hope you could break through the busy signals (the appointments center had exactly 1 incoming phone line) and beat the hundreds of military retirees who were competing for exactly the same times. There was supposed to be a preference for active-duty military, but in practice the system was strictly first-come, first-served. If you didn’t get through, the emergency room was your only option, with zero regard to the severity of your condition.
It was essentially the same as calling in to a radio show contest for a coupon to the Ground Round.
My own experience with "statized" (i.e. socialized healthcare on the state level) healthcare has turned me off to the whole concept completely.
First, they want to know your whole life’s history practically, and then don’t you dare even think of trying to save for your retirement, as any money you have at all decreases your eligibility for the program.
Then there’s doctor availability. State-run systems are notorious for negotiating (read: dictating) prices that no doctor wants to receive for their services, so you end up having to travel a town or two over just to find a specialist (or even a PCP sometimes) that will see you.
Yea, yea, I know that any national healthcare system wouldn’t have income limits, but I’m guessing the issue with doctors would still stand, unless they’re legislatively forced to participate. That’s not going to happen in the U.S. Way too authoritarian a measure.
Still, I’d like to see a system made that doesn’t rely on ridiculous income limits that provides affordable healthcare to those who might make too much to be eligible for free healthcare, but way too little to be able to afford private insurance. My own state has started a system like this, except that they currently have a ridiculous thing where if you’ve had any insurance in the last six months, you’re not eligible!
Sorry about your horror story Jason. If my profess my utter ignorance of military matters, why aren’t military retirees going to the VA.
The hospital my brother was born in was recently named by ConsumerReports as the most "conservative" hospital in the U.S. (that is, doctors instead of supplying hundreds of additional treatments for people with life threatening illnesses are much more likely to let things take their natural course). Studies have shown that conservative hospitals, whose costs are a lot lower, have about the same life expectancy as more activist hospitals. The long and short of this is that more is not necessarily better. Additional treatments could make a person better, but might make them worse. In fairness, having health care specialists at your beck and call is not the same thing as conservative treatment, but my central point is people may simply not be informed enough to make a decent choice about their health care, and must usually rely on the doctors to make the important decisions of care. As such, I think health care provision makes more sense as a public service than as a business. Health care innovation and finding cures for deadly diseases maybe a different story altogether however, but I’m sure there would be many ways to integrate CME and medical schools with private sector enterprises designed to find cures for these diseases.
My only objection to this is that it appears to imply that countries with socialized health care utterly lack private health care plans. While that may be the case in some countries, it certainly isn’t in ALL of them. In Spain there is a healthy private health care market, in addition to the nationalized system. The wealthy in Spain generally do not touch public hospitals. What IS undoubtedly true is that you don’t get off paying taxes for public health care just because you don’t use it. Inevitably the rich subsidize services they do not use. The same could be said in both countries for education; the wealthy help pay for schools their children will never visit (along with the childless).
Michael Merritt, I’m sorry about your experience, but I assure you that it needn’t be like that always. It sounds like part of the problem was that the system in your state wasn’t truly universal, so a great deal of effort (and money) goes into making sure only eligible people use it. In Spain the king himself could walk into a doctors office and as long as he had proper ID he’d be attended to.
It’s not all flowers and birds singing in universal health care systems of course. One of the main problems is the wait for specialists, which is notoriously long in Spain (also in Canada, as I understand it) especially for gynecologists and the like. Of course, the greater tax burden associated with universal health care (and it does mean bigger taxes, there is simply no way of getting around it) means that there is less "extra" money for private care, if you decide on that, though it could be that some countries offer limited tax breaks for people who decide on private care.
All of this is hard, but I think a necessary price to pay for providing what should be a right, the right to basic health care. Though I’ve used this analogy (and argued about it at length) before, I think it’s worth repeating; the US charges people for universal public education, whether they use it or not. It’s usually inferior to private education, and most people have to pay for it even if they don’t use it, but it’s the only way to ensure the right to a basic education for the population.
Some national systems specifically ban private health care supplements as "unjust". One such system is Canada. Britain does not ban it yet, but puts limits on it and is considering a ban. That is the reason I specified Canada and the U.K. in my post, also because those two systems are the ones most often romanticized by advocates of single-payer health care. I said nothing about other countries.
Unfortunately, it often fails to do even that because there is no mechanism to ensure that the government monopoly in education actually produces it. The only actors within the education system that are organized and hold political power are the teachers’ unions and their incentives are often to AVOID addressing any problems in the system (if those problems might mean the loss of jobs for some of the union officials). Similarly, some “universal” health care systems in fact fail to provide truly universal care due to the inevitable corruption and malfeasance that results when the government holds a monopoly on something and there are no mechanisms to hold administrators responsible (ex: Cuba, Venezuela).
This is a myth that groups like Heritage and Fraser Institute push as fact. Here is a response with actual data and studies.
http://content.healthaffairs.org/cgi/reprint/21/3/19?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=phantoms+in+the+snow&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
My observations came from first-hand personal experience, Rudi. I do not appreciate your accusing me of affiliations that I do not have as a way to score cheap partisan points against groups that you apparently do not like. You should either demonstrate that I have an affiliation with Heritage or Fraser or you should retract your slander.
I thought my post quite balanced and I tried to be fair in it. Your using it as an excuse to retreat to hardened ideological talking points while extracting my post out of context to accuse ME of partisan talking points is both hypocritical and dishonest.
Jason;
I’m sorry about your wife’s situation. I’ve always had opinions about health care (hey, I’m a doctor) but when I was teaching residents I would always emphasize that they could not solve system issue via the individual case. They needed to advocate for the patient. So I won’t point out the plusses and minuses of our system in your wife’s case. I will only reiterate something you said:
Vice: Price…
I would only rephrase that as "cost". Every system has to deal with that and how it will be paid.
Jason, I wasn’t attacking you, just the point that non-elective care is worse in Canada and that large numbers of Canadians cross over the border for CT and MRI tests. I agree that your post is balanced, I just question the rationing and availability meme. I only addressed your last sentence:
My link to healthaffairs.org disputes this assertion with a study of Canadians in the Michigan and New York areas. From the study/report:
The availability of these advanced tests is more a function of rural versus urban. Access to the Rochester Clinic in urban Minnesota versus care in say rural Wisconsin or the UP of Michigan.
Please accept my apology, I wish your family well during this crisis.
Claudia: Sorry, I made it sound like everybody was on it in my state. That’s not the case. It’s actual my state’s brand of the Medicaid program.
However, my state did recently start up a program for low income adults. That’s the one where you have to wait six months, which brings up the question:
If you’re already low income and have to wait six months (for non- exceptional cases), that seems like an unnecessary barrier to getting it, since people might need healthcare now, not just six months from now.
For example, I’m about to start a job on Monday that doesn’t provide healthcare for six months. I want to use this new plan in the meanwhile, since I can’t afford going on my own right now. I have two chronic conditions that need regular testing and medication that costs over $200 a month. Does making $26,000 a year mean I have to wait six months to use it? Hopefully I’ll find out soon when they tell me if I’m eligible or not.
That’s my problem with some of these programs. The amount of red tape can be staggering.
I should also note that I just lost a health plan offered through my school.
While Rochester has a population of about 180,000, it cannot seriously be called "urban", as it is 100 miles away from the true city of Minneapolis-Saint Paul. And the proper name of the major hospital there is the Mayo Clinic, not the Rochester Clinic. Also, the medical care in Rochester is an exception in any country and not useful as a basis for comparison.
My observations about rationing of health care in Canada were admittedly anecdotal, but I think they have an unusual degree of credibility since I have family members in northern Minnesota who have personally met Canadians coming across the border to seek care not available to them in Canada.
It should also be noted that, for quite a while the State of Minnesota offically ordered their employees was to order their drugs from Canada. Also, Minnesota’s health providers have been paying into a fund to increase the availability of affordable healthcare — but, "Minnesota Care" funds have been diverted and the program reduced — much to the outrage of the medical professionals.
I mistook the Mayo Clinic for the city is located, but it still is within the urban areas compared to northern Minnisota the the UP of Michigan. The report I cite give data to the use of scanning tests and shows that only a very small number actually leave Canada for this service. If hundreds of Canadians go to the US for scanning procedures versus 10,000’s that get this service in Canada how is the access meme proven? In another survey the treatment is elective, not immediately life threatening.
http://www.oecd.org/dataoecd/31/10/17256025.pdf
In this study two surgeries are elective and non-life threatening, knee replacement and cataracts. The other two are cardiac surgeries, CABG and PTCA, but the conditions are not critical. If a patient had a serious heart attack, then these surgeries aren’t elective and even in Canada immediate surgery is the norm. Traveling across a border for a knee replacement is not a serious case.
Great quote for an open market system period.
That happens here now - read - uninsured are covered by those who are insured.
Yes the Canadian system is so great - they are offering private insurance for those who are frustrated with the basic level of care.