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November 02, 2007
Ten Reasons That American Health Care Needs Reform
This began, actually, as a blog post. I was digging through the latest cross-country survey from the Commonwealth Fund, and summarizing it for the site. Around 800 words, I realized this would be too long for the blog. Around 1,500, I realized it should be a web article, if for no other reason than the data was really, really important. If you're at all interested in the health wonkery, read this piece.
November 2, 2007 | Permalink
Comments
I'd really be curious in actual details on this line:
There is no other area of American life where we collectively accept such a bad deal.
Education?
(You mention universities, but I think you make the same mistake there, that Republicans typically do about health care. Sure Harvard, Yale and Stanford are unquestionably the best, but they are for the most part, for the rich. Our elite health care institutions are similarly better than any others as well. The point for both the health care system and education system, is not what is best for the elite few, but overall.)
Legal system?
Government services?
This isn't an argument that we shouldn't reform health care. But I think its fair to say that health care is more scrutinized than other parts of society, and I just haven't seen data that would allow you to make the statement above. Show me comparative outcomes data and financial spend data in these other areas that doesn't show a similar picture, then you'd be onto something. (From what I have seen on education, we have similarly poor outcomes compared to other nations.)
Posted by: wisewon | Nov 2, 2007 2:13:11 PM
I'm not sure that the data you're citing is the "deal closer" you might be making them out to be - survey data for international comparison is in many ways beside the point; the problems with healthcare in this country are pretty well quantified, the numbers widely disseminated (at least among people with interest and understanding). It's what the numbers mean that gets disputed, and the hard part, as you kind of obliquely touch on in your opening, is that many of us generalize the American healthcare system from our own experience (that really, is what Giuliani does from his prostate story, and it won't, I think, help him in the long run); in fact, because of the wide number of options and systems in place, our healthcare systems resists generalities. The problems are specific, and specific to certain groups, populations, and types of care.
Moreover, I'd question the point that Americna doctors are the least renumerated on qulaity standards... only because my impression from doctors and others that I've spoken to is that a lot of the emphasis on best practices and standards of care is a recent development. And a lot of the moves to incentivize best practice renumeration come from the private sector, because best practices are meant, in theory, to reduce cost.
And all of this, really, touches on some of the deepest problems we have - because for common ailments, we do know a lot of what works best... it's just that we, as patients, don't love to hear it. The fact is, a lot of common pediatric needs, for instance, can be handled by a non-doctor in a walk-in setting, or over the phone; but because our society has placed such high confidence in doctors and hospitals, we resist the common-sense things that would make a lot of care less costly - underlined in statements like "I want a doctor." "I want MY doctor." "I want to be seen in a hospital." There's a change in thinking that needs to happen that isn't just around insurers and costs and the like; and survey data doesn't so much illuminate the issues as underline them. That's why I still think "healthcare reform" really needs to be more than "insurance reform." How we pay for things is a big deal... but why we have the problematic systems we do in America... is about a lot more.
Posted by: weboy | Nov 2, 2007 2:38:12 PM
Ezra: great article. I've got a number of conservative/libertarian-minded friends who I believe are wobbling in their opinions as their own families get hit with the insanity of our system -- it'll make for handy emailing. Thanks.
One note: you've got a minute typo in your fourth bullet point, fourth line -- after the word "result."
Posted by: Jasper | Nov 2, 2007 2:45:26 PM
weboy has it. We need to get more providers on line, both by making it easier for people to become doctors and nurses and by re-examining the state-granted monopolies that permit the medical profession to restrict supply when it sees fit. Without more supply, the only real "fat" in the system that can be cut is insurance company profits and that is not nearly enough since we need to address not just cost but also efficiency, effectiveness and safety.
Re quality of care: to today's docs cut corners because they are motivated to by compensation arrangements that have changed in the last generation, because they are overworked generally, or both? Do they make more mistakes because they are rushing, they are poorly trained, or both? If we don't look at these things we will mostly just re-distribute the (currently inadequate) care to different people.
Posted by: applecor | Nov 2, 2007 3:15:14 PM
"it's just that we, as patients, don't love to hear it"
And you think this is worse in the US than in the rest of the world? Nope, sry, but I don't believe for a New York minute that this is the reason for the US' less then stellar healthcare numbers.
:-/
Posted by: Gray | Nov 2, 2007 3:19:38 PM
"We need to get more providers on line, both by making it easier for people to become doctors and nurses"
People don't chose a job because it is easy to get in, but because they think they will make more money with it than with other alternatives! Also, if supply of doctors and nurses will grossly exceed demand, this will start a cycle where the wages are so driven down until nobody will want to chose such professions anymore. This already happened on the nurse market - most of them are immigrants now, I read. And if by saying 'making it easier' you mean lowering the hurdles on qualification, the results may be desastrous.
Posted by: Gray | Nov 2, 2007 3:25:49 PM
Gray - I'm not saying that... well, actually, I'm not sure what you're saying I said. What I said was that we have a lot of statistics demonstrating that there's a problem... and the problem is complicated. Parts of it, yes, have to do with how we pay for healthcare and that needs reforms. But we also have to change how we think about healthcare, as patients. No one thing causes our healthcare problems, if only because we don't have one problem... we have a lot of them. And I do think that when you talk to Americans, as opposed to, say, Europeans about the health care they expect and how they expect it to be delivered... you do, yes, find that American expectations are much different. That alone isn't the problem. But changing our notions about doctors and hospitals, really, is part of what any solution will need to really work.
Posted by: weboy | Nov 2, 2007 3:36:23 PM
Let's grant your assumption, Gray (although considering the hardships doctors face, I doubt it's true that it's all about the money). "Making more money" needs to take into account the cost of medical education, doesn't it? And with Baby Boomers aging, do you think supply exceeding demand is a realistic fear? The reverse seems much more likely (and more problematic).
Either there are too many nurses or not enough - which is it? I say not enough. If people shun nursing it because it is a hard job with limited autonomy in many cases. Part of what I advocate is giving nurses more responsibility so that patients can be treated with minimal or no doctor intervention for routine matters.
Posted by: applecor | Nov 2, 2007 3:37:38 PM
I think alot of people in America avoid going to the doctor as much as possible for as long as possible until it is too late.
This is in part due to a lack of healthcare and the high cost of premiums.
So many are over charged and given unnecessary tests just to bilk insurance companies.
There's also the risk that you will end up in a situation where your insurance won't cover you due to a preexisting condition and after many months of tests and doctor visits you'll get stuck with a monstrous bill you cannot pay.
Not to mention the over prescrption by doctors of various drugs which just end up costing more money and in many cases cause side effects worse than the original reason for going to the doctor.
Posted by: PoliShifter | Nov 2, 2007 3:43:47 PM
We subsidize unhealthy living and treatment (public hatlh care - or better "sick" care!). We tax healthy living and prevention. This, I fear, accounts for more than half of the economic and social challenges.
The other problem is that given international and national demographics - a government health care plan which transfers between generations is not sustainable.
But these economic dynamics (market vs control approach) are better understood and over-discussed compared to the ecological and health arguments involved.
Even the left understand by now that governments must help individuals to become as independent of higher powers as they can. If they cannot achieve this - the higher powers will not have any money to help those who need help. Subsidizing prevention and taxing treatment would be one good start. We have to reverse the current perversions!
No no no Mista! You can fool some people sometimes but you cannot fool all da people all da time...
Posted by: Hugo Pottisch | Nov 2, 2007 3:48:06 PM
NUMBER 1 REASON: IT'S NOT A SYSTEM!
Posted by: Patton | Nov 2, 2007 3:57:03 PM
We need to get more providers on line, both by making it easier for people to become doctors and nurses and by re-examining the state-granted monopolies that permit the medical profession to restrict supply when it sees fit. Without more supply, the only real "fat" in the system that can be cut is insurance company profits and that is not nearly enough since we need to address not just cost but also efficiency, effectiveness and safety.
Exactly what I have been hammering Ezra on. Fix the problem of high costs and not focus so much on the bandaid of wealth-trasfer insurance schemes to finance the overpriced services.
Maybe you'll be better received with the same message than I was.
Posted by: El Viajero | Nov 2, 2007 4:04:29 PM
FYI
Hospice Beats Hospital
http://www.overcomingbias.com/2007/11/hospice-beats-h.html
Posted by: Floccina | Nov 2, 2007 5:23:44 PM
Applecor-
You made two points that completely oppose one another. You state that you think medical mistakes happen because physicians are "poorly trained". Yet you want to give people "more authority" that have less training. Or you state "make it easier to become a doctor or nurse", which by definition means you are taking a less qualified applicant than you would with higher standards. There is no way around that. It is hard to expect better quality by putting those with less qualifications in charge. We do that more than any other country gaining the results you would expect from such a policy. More physicians is not going to drive down costs especially when you add 47 million people to the pool, costs will increase by adding more physicians ordering more care because you will never get wait times to zero no matter how many physicians you add. Which means full dockets and increasing the amount of interventions ordered by 2 for every physician you add. Physician reimbursement is only a fraction of what we spend on healthcare the vast majority goes to hospitals but it is talked about much more than the latter.
Posted by: Dingo | Nov 2, 2007 5:24:01 PM
adding more provders and fixing the cause of the problems doesn't generate trillions for governemnt coffers though. The democrats obsession for fixing healthcare has nothing to do with fixing healthcare it's them getting control of the trillions that come with it. Global Warming is another example, Kyoto wouldn't clean the air or reduce pollution it would just move it to poor countries but allow trillions in new taxes. The New Deal is about to collopse, when SS and Medicare fail to deliver their promised benefits to the post baby boomers people will blame the Democrats, if they can't find the money to fix or delay the day of reconning they are doomed.
Posted by: Nate O | Nov 2, 2007 5:42:39 PM
To actually decrease the rate of cost growth you have to increase reimbursement. Decreasing reimbursement certainly doesn't do it, we've been trying that for the past two decades. Physician's get paid less to do a knee replacement today than they did in 1976. Difference is they would do one or two in an OR day in the 70s. Joint surgeons now will do 8-14 knee replacements in a day. The result is a mushroom cloud of expense across the board.
Posted by: Dingo | Nov 2, 2007 5:45:35 PM
There is an opportunity for economic growth in healthcare, just as with green technology. There will be a 1 million nurse shortage by the start of the next decade. You can't tell me that adding 1,000,000 americans trained here, not imported immigrants, with jobs of 50-80,000 a year will not be a benefit for us. People want a living wage. Here is our opportunity.
Posted by: Dingo | Nov 2, 2007 5:48:33 PM
I promise this directly relates to your deep need to take over everyone lioves because politicians can do so much better then people making their own decisions.
But here's a short story, totally true. The best minds in government designed the school lunch program. YEAH! The best minds found that kids aren't eating enough fruits and vegetables. YEAH, GOOD JOB!
The best minds devised a great government plan. Government subsidized lunches will now include a vegetable and two fruits. GREAT JOB! YOur guys are good! We need more money to pay for this great food that helps kids, BOOM! There you go, its for the children, will 100 million do?
Kids go to lunch, I sit with my child across from four children eating subsidized lunches. They have a Banana, a small salad and Kiwi friut. GREAT JOB! I sure hope were paying those government brains alot of money!
Kids eat their taco, drink their chocolate milk, or juice and eat their ice cream treats. One tried biting the kiwi fruit, said yuck and spit it out.
HMMM, Hey big brains, this ain't working so good, I feel a bit queasy??
Bell rings, kids line up, dump their trays into the big garabage bin, bananas untouch, kiwi gone, salad history, all in the trash bin.
Hey wait, big government guys, what happened to your great plan? The great idea, the planing, the big bucks. Now the fruit and vegey are in the trash that we just paid for?? What gives??
Well, we never thought the kids would act like kids, not in our big government planning book.
Anyway, were working on more fruit for breakfast now, good day!
True story of what happens when how big government central planning meets the reality of the 7 year olds.
Posted by: Patton | Nov 2, 2007 5:59:44 PM
"""We need to get more providers on line, both by making it easier for people to become doctors and nurses and by re-examining the state-granted monopolies that permit the medical profession to restrict supply when it sees fit"""
Luckily, the British NHS has a fixed for that problem. They simply hire Islamic radicals from the Middle East. Not the best plan, but I imagine they wouldn't possibly lie to a patient about his or her condition....I mean we would give them drivers licenses and all.
Speaking of driver's licenses. When I've travelled overseas, no country ever offered me a drivers licenses, I allways used an international license. Why can't Hillarys' illegal aliens bring their International Licenses??
Posted by: Patton | Nov 2, 2007 6:11:15 PM
Thanks, Ezra, great summary.
The comments here are an indication of why problems don't get acted upon. There's always a Patton in the Senate or House who wants to look at school lunches instead of health care. Or someone who wants to attack some part of the 'system' - likely because of an individual history topic, or that's their favorite target. You don't see Patton attacking the insurance companies. Funny, isn't that?
Posted by: JimPortlandOR | Nov 2, 2007 6:52:58 PM
"We need to get more providers on line, both by making it easier for people to become doctors and nurses and by re-examining the state-granted monopolies that permit the medical profession to restrict supply when it sees fit."
You are an idiot. Healthcare is not a free market, which means doctors dont compete against each other and lower costs. Allowing more providers will do nothing to lower costs, in fact it will cause them to increase.
Take NYC for example. Highest doctor/patient ratio in the world, and the highest healthcare costs per capita in the world. Everybody in NYC is followed by 7 different specialists, whereas in areas with fewer doctors, they only have 1 or 2 specialists.
Healthcare costs per capita are HIGHER in big markets with high doctor/patient ratios. Rural areas with low doctor/patient ratios have tremendously lower healthcare costs. If doctors really competed against each other for patients, this would not be happening.
Healthcare hasnt been a free market since Medicare came online in the 1960s. Therefore your idea of flooding the market to induce competition among providers wont work.
Furthermore, NPs and PAs have already made their impact and there's nothing more that can be done to create competition with docs, because NPs/PAs dont compete with docs they simply add to overall healthcare costs.
An NP/PA can already open a clinic, see patients solo, order bloodwork, order imaging tests, and write scripts for anything a doctor can write for. The only thing NP/PAs CANT do is surgery. NP/PA are more numerous with a wider scope of practice than any other nation on earth.
Your "solution" to expand PAs/NPs has already been tried and has failed miserably.
Posted by: joeblow | Nov 2, 2007 6:54:17 PM
Look what are we talking about here? Its healthcare for Pete's sake, its not rocket science. And since the government will control it, were not about to let people sue us if we screw up people.
Do we really need qualified doctors? I mean, what does qualified mean really. Why can't we pay for an illegal alien to see an illegal alien doctor, who may not actually have a diploma or anything like that. Or we just issue State diplomas. Its not like they were going to get world class healthcare back in Guatemala.
We will have a captive population, where they going to go?, you see the doctor we tell you and you will like it. This isn't Burger King, your not getting it your way. If you don't like it, we will have a government psychologist there to get your mind right, a little re-education.,.
man, I'm feeling so empowered, I want to be a mwedical bureacrat, I can't wait to control these people's lives.
Posted by: Patton | Nov 2, 2007 7:04:20 PM
Ezra loves to throw out how much we spend per capita vs socialized systems. Does anyone have what the per capita spending for healthcare is in the midwest? Preferabbly in chart form, they seem to prefer those. I would be willing to bet Idaho, Oklahoma, Kansas and other midwest/western states are considerably closer to european systems. Maybe the solution is to socialize just CA, NY and MA? Those are the only people clamering for it, lets allow them to do it. Is it wrong to watch someone administer a self inflicted gun shoot wound? Even if it is I think I can live with the guilt.
Posted by: Nate O | Nov 2, 2007 10:49:28 PM
It didn't take long to solve this problem at all! This was back in 2004, sure not much has changed...
http://www.boston.com/business/globe/articles/2006/06/22/states_per_person_health_cost_leads_world_study_says/
Massachusetts has ``the world's costliest healthcare," with average annual spending above $7,000 per person
Per capita spending in Massachusetts in 2004 was $7,075, 33.2 percent higher than the national state average of $5,313. The second-most expensive state was New York, at $6,635, and the least expensive was Utah, at $4,043 per person.
We have identified the problem, and Liberals it's you! Get rid of MA, NY, and CA and where 20-30% higher, nothing to brag about but I'll pay 30% extra to not have socialized medicine. More importantly why in the world would we listen to a Liberal about reforming healthcare when they have excelled at destroying it, proof above. They aren't trying to fix healthcare there trying to get us to subsidize theirs!
Sorry it's not in a chart I don't know how to post them in comments:(
Posted by: Nate O | Nov 2, 2007 10:59:28 PM
Good luck to Ezra and the rest of you fighting for UHC. You're facing an uphill battle against powerful interests and the word "socialism".
But hold on. There's good news. With the U.S. dollar in free fall, before long the per-capita cost of health care in other countries will surpass that of the U.S. Today, for example, the Canadian dollar hit $1.07 U.S. -- up 25% this year. At this rate, by the time the presidential election rolls around, Canadians will be paying more per capita than Americans, measured in U.S. dollars. Soon Americans will have the cheapest health care in the world -- and you just have to sit on your rear ends and let it happen. Bush's economic policies have a silver lining after all. Am I missing something?
Posted by: mijnheer | Nov 3, 2007 12:13:29 AM
