Sunday, 30 August 2009

Healthcare reform in the USA: Biggie Size it

For weeks I have been putting off writing about the health care reform debate in the US. This is an issue that has interested me deeply for some time, and in the past I have done a lot of research on health care spending globally, some of it for a course on Medicine, Ethics, and Law, and some out of personal interest. A recent discussion in a stream of comments on a Facebook status update finally sparked the writing of this post.

In response to an anti-insurance rant by an American friend of mine comparing insurance giants to Big Brother, someone else commented "...I might become Big Brother. If I'm paying, it is going to totally hack me off to see the 250 pounders on their scooters buying sodas, ho hos, cigarettes and beer. I'll be following them through the store, 'nope sorry honey, none for you!"

Now I won't even get into all the moral complexities brought into play when well-off Americans (such as the commenter) complain about the unhealthy lifestyles of the millions of uninsured poor whose real incomes have not budged since the 1960s even as the economy and prices have grown, who are effectively the economic and social victims of the deregulation that has brought prosperity to the middle classes, and the associated fast-fooding and automobile-dependency of the American lifestyle; the fact that Mississippi is both the poorest and the fattest state in America (the fattest nation in the world) should give you an idea. (Yes, I am saying that the rich got rich on the backs of the fat and poor they complain about.) Nor is it necessary to inquire extensively here into how those unhealthy lifestyles developed on the ground level - for anyone interested in how America came to be the fattest nation on the planet, watch Morgan Spurlock's 'Super Size Me' - it's a good start. (hint: it does have something to do with aggressive marketing strategies and corporate profit margins)

If you want to think in such inhuman terms, the simple statistical truth is that people with unhealthy lifestyles (i.e. smokers) are actually much less of a burden on the health system, because - surprise!! - they die younger. It just so happens that a grossly disproportionate amount of money - even here in the UK, on the much-maligned NHS - is spent on the last few decades of life for those who, due to their extremely healthy lifestyles, get past 65. And no, there are no 'death panels' on the NHS, contrary to what has been reported in the American press. (As an aside, if obesity is the complaint, cigarettes have the added benefit of reducing the burden even further, given that tobacco is an appetite suppressant and most chain-smokers are highly unlikely to be obese. ) So in all fairness, the fat-asses my interlocutor complained about might be equally if not more justified shoving cigarettes down her throat to save the public the expense of keeping her alive well into her 70s and 80s...

But thank God that most people in countries with national health insurance schemes don't think that way, and neither does anyone follow fat-asses through the store and tell them what to eat, nor do old people get cut off when they get past a certain age.

The cost of end-of-life care and old-age care for that matter is disproportionately high anywhere, except where a policy choice is made to have so-called 'death panels', but I have not heard of such a country. Conservatives like to point to well-publicized cases of, say, the NHS refusing to fund a particular trial of an experimental cancer drug or something of the kind. You think that HMOs on private insurance don't refuse to fund treatments? Of course they do, all the time, and even more so - I can confirm this from experience as a patient on both sides. And think of the economic incentive - the only difference is that with private insurance, such decisions are made first and foremost for the sake of corporate profit margins rather than the public interest or absolute budget limits. In a national health care system - no profit margin means more money to spend on health care.

And whether you're insured privately or on a national insurance scheme, you always have the option to pay for treatments not covered on the insurance out-of-pocket - but that's got nothing to do with what system you're in. In fact, if anything, in such cases you'd be better off being in the UK, than in the US, where no price caps and sparse market regulation mean that treatments paid out-of-pocket would cost several times more.

The disproportional cost of old-age care is even greater in the US. When I last looked at the WHO statistics on public health spending, the US government's per capita health spending - the public funds spent on healthcare - was higher than in any European country besides France. Public health spending in the US is basically Medicare and Medicaid. What that means is that Americans are already paying more than most Europeans in taxes and other public spending per capita to fund a government-run healthcare system - but they only benefit from that money if they are over 65 or very poor and fulfill certain criteria.

One major reason as mentioned is that caring for seniors (i.e. the Medicare program) is very expensive, and the more so the older they get. But another reason is that the US healthcare system is way overpriced - i.e. no price caps - drug companies can charge whatever the hell they want, which is why congress tried to pass a bill a few years back to buy drugs from Canada, from the same companies, the same brands.

Factor into the public spending all the out-of-pocket costs (even Medicare isn't totally 'free'), the private insurance spending which is even greater per capita, both insurance premiums and co-pays, and you get a health system that is priced way above what its actual performance deserves, taking into account the standard of living and price index, which are greater in many European countries.

Do you get a better healthcare system for all that money? Don't think so. Last time I looked at WHO's health performance indicators, the US was middle-range, sharing the same infant mortality rate as Cuba - one of the poorest countries in the word, but one which alleviates that poverty with a health system that performs well beyond its means. I can't imagine what the NHS would be like, or the Cuban health care system for that matter, if they spent the amount of money per capita that the US already spends on Medicare and Medicaid.

Yet another reason for the high cost of healthcare in the US is precisely that it is too cumbersome compared to single payer healthcare systems. That is the argument against private insurance and in favour of something like the NHS - which precisely has the benefit of making things simpler, cuts out a lot of bureaucracy and paperwork. (Again, I can confirm this from experience as a patient on both sides)...

Another type of scare story cited by pro-corporate Americans (such as this blog) is that a national healthcare plan would 'victimize' immigrants and other vulnerable populations. One story cited is of an immigrant spouse of a New Zealander who is denied care due to rules that do not allow immigrants to be a 'public burden'. It is irrelevant whether the story is true or not. And let's not even discuss the blanket assumption that an immigrant in New Zealand would have access to health care through private insurance were things otherwise. The simple fact is that any American who buys this argument is unfamiliar with their own immigration system. (No surprise there, most likely they've never been through it) Under current rules, a legal 'green card' immigrant in the US is not allowed to become a 'public burden'; any American citizen with an immigrant spouse is required to sign an affidavit to this effect, declaring that they will be financially liable in the event that their spouse becomes a 'public burden' (i.e. by claiming social security).

Obviously, the issue at stake is not the humane provision of a health service for all New Zealanders or Americans, but the inhumane immigration rules which exclude non-citizens. When I signed up for the health service here in the UK, I didn't have to prove anything except my address, and even that only for the purpose of ensuring I am with the right GP for my area. Aside from my medical history the past few years, the only thing the NHS knows about me is my name and address. They don't know or care what my legal status is here - and I am not even a permanent resident, but a student now on a two-year post-study work visa. Once, a friend who lives in Italy contracted a kidney infection while on a brief visit here - she has a chronic condition - she was able to get phone advice over a 24-hour help line the same evening without even giving her name, and treatment from our GP the next morning, no fuss.

I can imagine what the next complaint would be, and I have heard that one too - 'medical tourism'. What people seem to forget is that going to the doctor is no fun for most people. I sure as hell put it off even when I should go to the doctor, even when I can do it for free. You don't need the disincentive of co-pays, let alone going to another country to get it. We're not talking government-sponsored tickets to the theater. When people go to the trouble of going to another country specifically to get medical treatment, most likely they really need it badly, and they can't afford it or obtain it otherwise. Anyone who's got a problem with that is sick in the head.

Yet another thing to consider is that it works both ways - the fact that someone visiting the UK from another country can get medical treatment here without a problem, and without charge, should they fall ill during their visit, is something we should be grateful for as human beings; just as much as the fact that I can similarly travel worry-free in some countries. If some people do abuse the system and come here for free treatment on purpose even when they could get it otherwise, or for treatment not medically necessary, there is really very little you can do about it without harming the majority of people who don't abuse the system, but it doesn't really worry me that much. You can't ever totally avoid people pissing in public parks, yet the fact that it happens is no argument for keeping them closed.

If you want to compare costs, I would advise anyone in the US lucky enough to have a health insurance plan to take a good look at their paycheck; and calculate what they pay in income tax, and add to that the health insurance premiums, social insurance, out-of-pocket costs, take it all out. And then calculate what you get in return. I guarantee that they will find that on average, contrary to the perception that Europeans pay a lot of taxes, Americans are the ones getting screwed over. Not by the government, however - but by the insurance companies and pharmaceutical giants.

Because ultimately, any health insurance money comes out of your paycheck, even if your health insurance is 'employer-funded'. The higher the insurance premiums, the less money there is for you to negotiate over. This is something that annoys me about some union bargaining strategies - in 2002, the AFL-CIO officially opposed a ballot initiative in Oregon to provide a state-wide health-coverage plan, on the grounds that the tax that would be imposed to finance it took up to 8% income tax (with as low as 2% for lower incomes) and up to 11% payroll tax. The employer, the AFL-CIO held, should bear a greater portion of the cost. But this is a bogus argument, as some local unions who favoured the plan realized - the tax money taken together would amount to much less than what is doled out on private insurance plans; in reality it doesn't matter who finances the health care on paper - whether it is payroll or income tax, the more money it costs, the less there is to negotiate over for pay rises and other benefits. The goal should be to cut health care costs, and one big way to do it is to eliminate insurance companies and corporate profit margins. The rest we can squabble over later.

Also, while medical malpractice is certainly another major contributor to the cost of healthcare in the US, that should have no impact on the extraordinarily high cost of Medicare, which is driven largely by drug prices and old-age care, which rarely involves malpractice.

Moreover, the highly litigious, adversarial culture of high payouts in damages that has developed in the US is precisely the result of a privatized system. When you pay for something, when health is a commodity rather than a public service, you have different expectations of it, even if those expectations are entirely misguided - i.e. relying on the misguided notion that if you pay doctors more they are less likely to make mistakes.

My only major criticism of Obama's health care package would be that it does not go far enough. In order to truly address all the problems with the US healthcare system without creating new ones, what needs to be dealt with is not just the cost of health insurance premiums, but the cost of health care itself - down to the root. If you simply move to a single payer system without imposing price caps (especially on pharmaceuticals), without investing in lower-cost medical education (recognizing foreign medical school diplomas would be a start), or investing in preventive care and patient education, even with all the savings achieved by cutting out the insurance companies (see Paul Krugman's article;) operating the system may prove to be simply too expensive. The system may be headed for insolvency, just as Medicare is at the moment.

Not to mention the need to address the shocking amount of disinformation and ignorance among Americans regarding this issue. As Krugman notes in a more recent piece, some Americans who benefit from Medicare don't even know that it is a government-run program.

Going back to the obesity issue, rather than complaining about it, perhaps my interlocutor should have considered whether the 250-pounders buying soda and ho hos are precisely why America needs national health insurance. Most people like them most likely don't even have health insurance, or regular access to a doctor, or anyone to tell them - before it is too late - that their enormous weight is something they should see a doctor for, that it is the product not so much of the quantity they eat, but the kind of food they eat. But bear in mind that if their lifestyles do change and their life expectancy goes up, they will cost the health care system - public or private - more, not less.

If as Morgan Spurlock puts it, "everything's bigger in America", then the healthcare plan needs to be too. America needs one super-sized biggie McWhopper of a public health insurance scheme in order to sort out all its problems.