Tuesday, June 16, 2009

The Public Health "Option"

As I write, Congress and President Obama are working to craft legislation that will change the face of health care in the United States forever. The changes that they are proposing are not good ones, and they will not benefit us. When I say they are going to change it, I mean they are going to take it and turn it completely upside down. They are right about one thing; our health care system needs reforming, but you don’t burn down the house just to fix a leak in the roof. Right now all we have is a leak in the roof.

We currently enjoy the greatest and most advanced health care system in the world. We have the world’s brightest and best trained doctors, state-of-the-art medical facilities and an existing insurance infrastructure capable of providing for most everyone. You’ll hear figures thrown around that about 47 million (the number is actually 45.6M) people in the U.S. are uninsured. Do you know what actually goes into that figure? Let’s break it down:
  • 21% or 9.7M are non-citizens
  • 18% or 7.9M are between the ages of 18 and 24
  • 39% or 17.6M make OVER $50,000 per year
  • 20% or 9.1M make OVER $75,000 per year
One in five are non-citizens?!? That means they’re either illegal or they’re just here temporarily (in most cases). Why do we even count them? Regarding the crowd that’s between 18 and 24, they largely choose to go without health insurance. It’s not that they can’t get it. They’re simply healthy young people without families and they choose to pay for it out of pocket. Finally, a full thirty nine percent make more than $50,000 per year! If you make more than $50K per year you can surely afford health insurance. As for the 20% of people making over $75K, don’t even get me started.

Does this “47 million” number that the politicians love to throw around sound nearly as bad now? There are, no doubt, people who don’t have insurance and need it. However, are we going to ruin it for 245 million other people with this terrible fix? There are many other ways in which we can reform the system in order to assist those that need help.

Let’s talk about this public “option” that congress and Obama are currently pushing. At first, and only at first, will this be an “option.” Soon after launching, it will essentially become required, and the government knows this. The “option” that they are touting is simply a slow but sure path to an inevitable system of government run health care. Here’s why…… the private sector cannot compete with a government sponsored system. You see, the government has this little tool called “taxation” that it uses to manipulate us to do what the politicians want. The government also has no concern for profits or efficiency. This means that it can charge less than it actually needs to operate and tax the heck out of any private plans that people choose to keep. This will force people into the government sponsored system and force the private health insurance companies to charge more. As they charge more, an increasing number of people will be forced into the government system. This is the "crowding out" effect that you may have heard about.

Consider this scenario: Let’s say you currently get your health insurance through your employer, which most people do. The government puts out a public “option.” They say that you still have the “choice” of private health insurance and that they are introducing the public option to make the market more “competitive and efficient.” Then the government requires every employer to offer health insurance to its employees, or it starts to tax them on their private health plans (currently employers and employees enjoy a tax exemption on employer-sponsored health care). Under the first, business owners (probably against their will) will start to opt for the public "option" to give employees, because they'll be forced to do so to cut costs. Thus, the employees are left with ONLY the public “option.” Does this sound like much of an “option” to you?

Folks, both Canada and the U.K. have tried this system, and they systems have FAILED! Heck, WE have tried it (Medicare and Medicaid) and they ARE FAILING! If you know something doesn’t work, would you try it again? NO! Then why are we letting our government do it? The man who used to run Canada’s nationalized health care system has gone on record saying that the system has failed, and they now need to rely on the private sector. They have four and a half month waits for MRIs! Lindsay McCreith, the man who was on the wait list for the MRI, decided to go to the U.S. for the scan. They found a malignant brain tumor. He returned to Canada and was told that he would have to wait months for the emergency surgery. WAITING MONTHS FOR EMERGENCY SURGERY!!!! Are you kidding me?!? Read here about a woman who came to the United States to get a tumor removed. She was on a waiting list in Canada, and when the American doctor saw her he said that she was only weeks from dying. How would you like to be on a waiting list while you are dying? Do you want the government to be deciding who lives and who dies? That’s what happens under government run health care.

I like to make my own health care decisions. I also don't mind working for it. Keep reading over the next few weeks for some fixes to the leaks in the roof that we currently have. There are many, but they can be amended, and it will only make our health care system better. The fixes will also allow more people to afford medical insurance. Let’s not burn the house down.

8 comments:

  1. Patrick, you are wrong on a lot of these factual points, regardless of our opinions about whether or not their should be a public health option.

    First explain this statement: "We currently enjoy the greatest and most advanced health care system in the world. We have the world’s brightest and best trained doctors, state-of-the-art medical facilities and an existing insurance infrastructure capable of providing for most everyone." Flat out wrong on every count. Best trained because they went to more years of school? You can't measure that because you there's no cross-country comparison of medical education. Most advanced? On what indicator? In that we have the equipment so that we provide more complicated surgeries and run more tests than every other country? And clearly, the last statement is false, because if the insurance industry is capable of providing for most people, why aren't they? Why are we one of the least healthy of industrialized nations? YOU may currently enjoy the American health care system (which is, I think we all agree, not as good as it could be at this point) but there are a lot of people that don't. And, taking that point, leave out VA and Medicare/Medicaid and it's a free market system. Since it seems like you think free markets fix everything, why isn't it already the best it could be? Regardless of what you've heard, I have seen some BOMB hospitals in places like India and the UK, with way better and more efficient technology than we have here doing the SAME procedures. When you talk about great access to health care here in the US, clearly you've never sat in the now-defunct Charity Hospital ER waiting room in New Orleans at 3 am. It's got a reputation, google it.

    To me part of it is about disparities, assuming a ceiling effect of perfect health. Assuming we'd like everyone to be at 100% health, right now the US picture looks more like our population ranges from 10-99%. In countries like Sweden and Norway, the picture is more like 70-95%. This indicates a failure to me on the part of the US system.

    I will now give you a reason to care about insurance options for non-US citizens. Let's take it as a fact that they are here, whether they should be or not (that's about immigration laws, not health care reform). When our immigration laws don't permit us to give them driver's licenses, it makes it hard for them to a. get a job where they could have insurance through their employer or b. purchase it on their own. On top of having to take more dangerous jobs (like construction - no workman's comp when you're paid in cash) whenever they or their families get sick where do they go? That's right, the emergency room, because the emergency room can't/won't turn them away (see also, Charity Hospital, New Orleans). So while you - somehow better than them as a US citizen with insurance - have fallen off the ladder and need immediate attention, this non-US citizen has come in with a fever and a cough (plus they're in dangerous jobs that make them more likely to need ER services). The cost of treating this in preventive care (as in, he gets to make an appointment with a primary care physician and see the dr. tomorrow) is HUGELY lower than giving him antibiotics in an emergency room, not to mention your wait time is lower when you have a "real" emergency. When emergency room costs go up because patient volume goes up, the hospital has to charge more per visit/procedure, which gets transferred to the insurance company which in turn gets back to you. So you're the one currently paying for the non-US citizen's health care anyway. It would be cheaper for you AND for him and would place less burden on the system through the public health option.

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  2. Listen I take your point and understand that people in this country still think that Obama wants to "socialize medicine," and I still think your fears are irrational because I'm not exactly sure what there is to be afraid of. More people will see doctors- the horror! You'll still have to pay for health insurance - close to the same as what you already pay! But let's talk about the VA, Medicare and Medicaid systems. What do you mean they're not working, they ARE working! Not saying they're perfect, but their model is proving to work and here's how: The doctors aren't minions of the state. They see patients, some of them whose insurance happens to come from the government. In fact, YOUR current doctor might even see those lowly Medicaid patients, would you know the difference? Does it affect your care? In these systems, at a minimum, there is a basic guarantee of care.

    The way I understand it, the public health plan extends those options to more people. In the NHS in the UK, the government provides a basic safety net of government insurance. If you're poor and need a liver transplant, you probably will be low on the list. You'd be low on the list here too. If you can afford it, however, you can have private insurance which allows different tests, different procedures, and different doctors. If you can't though, there is still a pretty decent safety net for you. Taken another way, does your current HMO/PPO limit your choice in providers? Mine does, but somehow (!!) I've managed to find good providers within my network without feeling like basic freedoms have been infringed upon. But I thought the free market gave me unlimited choice?

    Ezra Klein said something that I 100% agree with: "Socialism and capitalism exist on a continuum. Some things in America are very capitalist. TV purchasing, for instance. Some things tilt more towards socialism, like the military. I think we need a larger safety net and a bit more regulation of the market, which is to say, I'd like us to move left on that continuum. It does not mean I'd like the government to take over the means of production."

    The current system is not working. Past efforts at reform, to fix the leaks, have exacerbated the problem to the point where HMOs are so big they might as well be the government. It's been leaking too long, and we need a bigger change.

    --Sorry for two posts - I was over the character count :)

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  3. Sarah is passionate and I applaud her for that. So am I - I am a cancer survivor. I have been keenly focused on health care for many years...I have all the stats too and can match every stat that Sarah has and MORE. The fact is you simply cannot deny the overwhelming antidotal stories from many Canadians and Europeans about the difficulty and frustration of their system. I have spoken personally to many of these folks in the last three months. There are many chilling stories. You don't hear stories from US citizens to nearly the same extreme. If you suffer a major disease over 55 or 60 years of age, your chance of dying is enormously greater than in America. There is little dignity in their senior care. So of course, their costs are going to look much less in the land of "free" health care where do you pay for what you don't get. You cannot deny the fact that different age groups in those countries are treated differently (i.e. what Obama calls "comparative effectiveness"). It is a total shame - and we should be ashamed of ourselves for ever pointing to a system that has little dignity as the "example." We are better than that! You cannot deny that Europe has virtually no infrastructure, commercial or government, for health research and development, innovation - there is simply no incentive to do so. Just look at the INC 500 and Fortune 1000 at all the wonderful job being created and progress being made in the health sector. Take away the incentive in America for innovation and you place the entire health of the world at risk. Despite her criticism of our system, you cannot deny that we currently subsidize most of the world's health innovation and even pharmaceutical costs (yet, we get no credit or mention of our benevolence from the "do gooder" crowd). Give me three examples of equipment or medicine that came out of Europe that had a meaningful impact on health outcomes? You cannot sell something where there is no market to do so. You cannot deny that there has been a brain drain of medical talent from socialized medicine countries. You cannot deny that the primary single payer systems we have in the US (medicaid, medicare are terribly inefficient). Many believe that by turning over the other 50% to an already ineffective system, it will magically make it efficient. You don't solve a problem by destroying what is good in order to fix what is bad. The commercial market does not work optimally and needs reform, but we do have the platform already to have a good system that provides broad access and quality care. Both parties need to set aside the special interests they are held hostage to and fix the problem.

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  4. Anonymous, you mention that if you have a disease as an elderly person in the US you have a higher probability of surviving than you do in Canada or the UK. I find this statistic a little dubious given the longer life expectancy in the UK and Canada (we'd have to check the life tables), but I'll give you the benefit of the doubt. On this logic, this is an interesting point, since at 65 in the US you qualify for Medicare. In some sense, you've made my point - the US government is capable of providing quality services to a population of patients.

    Anonymous, I think we should separate health care delivery and drug discovery. The pharmaceutical and insurance industries are different and complicated entities. Having worked in a leukemia lab in the UK, I know our research was funded by a private pharmaceutical company, similar to many labs at research instutions in the US. Assuming there will always be patients, pharma will always have an interest in funding research. But from what I've read, speaking of percentages, that in the US, most of the research in this country is supported through the government's NIH grants, not pharmaceutical companies.

    You've asked me for three examples - "Give me three examples of equipment or medicine that came out of Europe that had a meaningful impact on health outcomes?" I'll give you more.
    1. Louis Pasteur was from France and is considered the father of modern microbiology.
    2. The Aravind Eye Hospital in India - which has performed something like 12% of all cataract surgeries ever performed in the world - ever - through a unique model of technology and health care delivery, bringing sight back to literally millions of Indians.
    3. Watson and Crick discovered the double helix shape of DNA in the UK.
    4. More recently, scientists at the Sanger Center in Oxford were the first to sequence a human chomosome, which led to the complete sequencing in the Human Genome Project.
    5. John Snow - the founder of modern day epidemiology traced the roots of cholera through London and changed how we look at communicable diseases.
    6. Recently, scientists at the London School of Tropical Hygiene and Medicine were able to keep mosquitoes with p. falciparum from reproducing. This has the potential to be the biggest impact on malaria we've seen to date.

    I could go on, but in terms of discoveries that contribute to health, both pharma and government have an interest in curing patients(/voters). That's why most major research institutions are funded by a mix of government and pharmaceutical grants. A more interesting discussion would be doctor's incentives in pay-for-performance plans, which insurance are pushing for.

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  5. Thanks Sarah. My question was to name three European health care innovations, either equipment or medicine, in the last two decades. I did not see mention of even one. You mentioned one advanced technique in India, and it is great example. But, India's public health system is not like the European model, and it is heavily discriminatory based on the caste system, so I don't think you are suggesting the US move to that, right? At least two others you mentioned were hundreds of years old, long before socialized health care in Europe when their was a "wild west market" with little to no regulatory controls (those two example work more in my favor than yours). Watson and Crick were in the 50's long before the current model. Two of your mentions are contemporary. My understanding of the Sanger Institute is that it is funded by the marketplace through charitable donations. I may be wrong, but I don't think the London School has actually produced a medicine yet, while their studies are very encouraging. Sarah, the fact is there are few actual medicines and/or medical equipment/devices coming out of Europe. there simply is not a robust market for them to make a profit and recoup research costs. If that free market incentive is removed in the US, then the entire world health care system will be at risk. I am amazed that anyone would desire that inevitable outcome. Please tell me that is not what you want? One of your points is wrong and I would ask you to think about it some more. it goes to the law of markets and supply and demand. You said as long as their are patients, pharma will always have an interest in research. That is not correct. As long as there is a return on investment, Pharma will be interested in research. They are not charities. The example you cite in the UK involving a pharma company is almost assuredly because there is a market, most likely the US; A pharma company cannot survive on the European market alone. Our generous subsidization is one of the three main reasons why American health care is higher than European models. The second is our cost of care towards end of life is substantially greater (that is a dignity issue and the Europeans should be absolutely ashamed that they have an age discriminatory based system). The third goes to lifestyle, which skews the life expectancy number. An unbiased researcher cannot fairly compare US life expectancy with Europe because of the lifestyle differences. Obesity is a huge problem in the US, among other things, but lifestyle issues belong first in the public health debate, not in the insurance debate. And, it is a debate we should have. The free market insurance system can be a facilitator to better public health, if the US would encourage, through incentives not penalties, lifestyle changes. Currently insurance companies in some states cannot incent patients on a group employer sponsored policy who live healthier lifestyles with lower premiums, rebates, etc. The other issue goes to national policy. For example, the Depart of Agriculture which dictates standards to school cafeterias and food production and labeling standards has destroyed the family farm and organic farming (it is slowly coming back) and allowed the de-nutrification of our food supply. This department, largely controlled by Democrats for decades and their crony staffs which are not political appointees, has done more to damage public health and run up health costs than any single organization in the US. Another example of government control run amuck.

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  6. Anonymous, you and I are saying the same thing -when I said pharma will have an interest as long as there are patients, I meant patients as consumers, sick people that will buy drugs. So as long as there are sick people, there will be a demand for people to treatments. And plenty of drugs have come out of Europe, everyone is making discoveries. Patent laws are different in the US and there are different regulations so they go by different names. Best example I can think of off the top of my head - discovery of the virus that causes AIDS happened simultaneously in a French lab by Montagnier and at the National Cancer Institute in the US by Gallo. They share the Nobel Prize. Btw - the National Cancer Institute is a US government institution. That's a pretty big innovation shared by a. a European scientist under a more regulated system and b. the big bad scary US government - NOT private research.

    Just so I'm clear: pharma depends on the free market. That's why no one can tell them to stop researching Viagra and start researching better anti-malarials. If they found a cure for malaria, they'd have to sell it cheap - they'd never make their money back so there's no incentive. I don't think it's right, but I'm not sure what to do about it. I think pharma can have undue influence on our doctors, and I'd rather get the best treatment the doctors know of as opposed to what the doctor is getting paid to prescribe for me. I think it's problematic that pharma can sponsor the research of medical school professors, where there may be a conflict of interest preventing the next generation of doctors from learning best practices. I don't know the solution to these problems. But I do know that pharma has an interest in providing treatment, not a cure. In fact, it is in pharma's best interest to NOT find a cure for diabetes (preciesely because they're not philanthropists) when they could have ~20% of the US population using their strips 6 times a day and paying for insulin. And I don't think that's right, but I don't know the solution.

    But THAT is not the issue at hand. The insurance debate is about entry points to care: in terms of delivering health care, I find it impossible to say that we're doing the best job. If Europeans spend half what we do, then in theory our outcomes should be twice as good since we're spending twice as much. The opposite is true. If a healthy life is a success, we fail on life expectancy, infant mortality, chronic disease. Among some other industrialized nations (Australia, UK, New Zealand, Germany, Canada) the US comes in dead last on efficiency, equity, access, quality, and healthy lives. Yes, those are 5 things I'd like my health system to be good at. If the other countries are doing those things better, I'm willing to look at ways we can improve and change our system.

    You're right, insurance companies already incentivize healthier lifestyles - as in, they don't provide it to people who have pre-existing conditions like they're smokers, they have HIV or cancer, they're obese. You assume that these people will change these factors to get the insurance, but the thing is, they don't (or they can't). Unfortunately these people USE the system the most, regardless of ability to pay. Then the question becomes how can we best prevent those conditions from happening? And all the research tells us that early access to preventive care leads to longer, healthier lives. So that's what I support. Getting people to see doctors before they're on their death bed.

    You really seem impressed with the way Americans are treated at the end of their lives - and what I'm saying is, for the most part, it's not privately funded. So all I'm advocating for is expanding the access to this care to a larger percentage of the population so that hopefully we can prevent them from becoming obese, etc in the first place. Like I said, I don't support the government controlling the means of production, I do support expanding the safety net so that more people get to see doctors.

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  7. Yes, we are saying the same thing to an extent. I am still maintaining that a European type system in the US will have a radically negative impact on health innovation, which will put the entire world health system at risk. No, plenty of drugs do not come out of Europe, no where near the medical innovation coming out of the US. In your opinion, how would you rank European innovation versus US innovation? If the US is a 9 on a 10 point scale, where would Europe be? I would say a 3 or 4. No, health care companies do not incent healthier lifestyles in the manner they should currently in the US, often due to state laws pertaining to group policies - that needs to change. I do agree with your thoughts on prevention and seeing the doc before there is a problem. I am impressed, not with Medicare specifically (which is terribly inefficient), but with the fact that, philosophically, we don't ration care with our senior population, in Medicare, commercial or taxpayer funded retiree plans - that is a positive. have not heard your thoughts on the age discrimination used in Europe - do you support that? And, in general, I am just curious if you have anything positive about the US health care system and our innovations over the years? I will admit I have little positive to say about the European model, albeit there are some things about the Swiss that are impressive.

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  8. Sarah, not sure you will be able to watch these, but I thought I would give it a try ---- this is what we are fighting to protect America from:

    http://www.youtube.com/watch?v=refrYKq9tZQ

    Here is proof that the free market actually works much better:

    http://www.youtube.com/watch?v=E_KCLm9cekU

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