Health Care Changes

Changes in health care have been a hot topic just lately – very hot and very heated in fact. Sometimes it seems as though the discussions have shed far more heat than light on the subject.

I’ll see if I can shed a little more light than heat, though I don’t claim to be an expert on the subject. I will express my opinions and try not to upset too many people, too much. Although given the topic, if I don’t upset anybody, I probably have not said anything worth saying.

Speaking of heat, some liberal commentators, (and not just Jimmy Carter), have claimed that racism is behind the vehemence of some of the right wing response. At first, I tended to agree, but after looking closer, for the majority, I don’t think that is the case.

There are a number of people who seem to believe very strongly that government, whether federal, state, or local, does not really represent them, is not concerned with or looking out for their interests, and they frankly fear and mistrust government and any sort of government program.

They do not agree with Franklin Roosevelt who said, “Let us never forget that government is ourselves and not an alien power over us.” Some people will not negotiate change, because compromise is surrender and change is bad. Unfortunately, this is a grim prognosis for any needed changes.

Let’s start with some things that most of us should be able to agree on. First, the United States has some of the best health care available anywhere. We have many of the best doctors and the best facilities in the world. As Americans, we have available to us the best medicines, the best equipment, and the most advanced treatments that can be found. We can all agree that we don’t want changes to our health care system that would jeopardize that.

The vast majority of Americans are covered by some form of health insurance, and the majority are happy with what they have. We probably don’t want to lose that either.

But not everything is perfect, and the system we have certainly has room for improvement. About 46 million people, or about 15% of the population has no health insurance coverage. Now, arguably at least some of those are healthy and feel no need for health insurance, but many others are not.

One study, and I cannot vouch for either the methodology or bias of the authors, rated the United States against 18 other western industrialized countries in preventable deaths. The US placed the worst in that study with 109.7 preventable deaths per 100,000 people. You can compare that with France which was the best at only 64.8 per 100,000 people. The authors concluded that the lack of access to health insurance by some Americans contributed to that result.

Similarly, if you look at the C.I.A. World Factbook, you will find that a number of countries including France, the United Kingdom, Canada, Japan, Sweden, and even Cuba have lower infant mortality rates than we do.

According to an AARP study about 90,000 Americans die each year from infections they contract during a hospital stay.

Since, as a country, we spend almost 1-1/2 times as much as any other country per person on health care, should we not be able to do better than this?

A study in the American Journal of Medicine found that 62% of the bankruptcies in the United States were largely due to medical bills, and 78% of the people with a medically related bankruptcy HAD health insurance.

Think about it. What that means is that the average middle income, working American might only be one serious illness away from financial ruin.

For what it’s worth, there are few, if any, medically related bankruptcies in England , France , Germany , Japan , or Canada – each of which has a universal health care system.

We can argue the merits and demerits of the various national health care systems, but that discussion could be endless. Each system, whether ours or any of the ones I’ve mentioned has its strengths and its weaknesses.

Further, I don’t think we want to simply replace our system with any of the other systems. But that does not mean that we cannot improve our system of health care. And it does not mean that we cannot learn some things from what they ARE doing right.

I’d like to be able to discuss in depth, the plusses and minuses of the health care proposal, but at last count, I think there were four different bills in the Senate, and additional bills in the House of Representatives. Each of those bills seems to be revised almost daily, and some are literally over 1,000 pages long. So we could spend the rest of the month looking at different proposals and still not be comprehensive. I can try to discuss some proposals and see whether they are really part of the bills under consideration, and throw out some ideas to think about.

As I said, most Americans like the health insurance that they have, and I think we can agree that Americans should be able to keep the health insurance they have, if they want to. No one should be forced into a “one size fits all” plan. At this point I do not believe that any of the serious proposals would require Americans to give up their current insurance.

I’ve said that we have many of the best doctors and facilities in the world, and I think we can agree that we do not want to lose those. We have those, because the doctors have the freedom to establish practices and manage them without undue interference. We can probably agree that we do not want to force doctors to become government employees, nor force health care facilities to become government facilities.

Many other countries with excellent national health care programs, have built them around private medical practices and facilities. There is no reason we cannot do likewise. Again, none of the major proposals aim to require doctors to become employees of the government, or health facilities to be government owned.

We have the most advanced drugs & treatments available in the world, and we certainly don’t want to lose those either. I don’t know about the medical equipment industry, but the pharmaceutical companies have agreed to price concessions as a part of the health care proposals under consideration, and have signed on to back those proposals. Based on that, I think we can safely say that we should still have access to the best medicines available.

Now that we have touched on a couple of easy ones, why don’t we get to a topic that has generated a lot of heat. There has been a lot of talk of “Death Panels”, with some prominent politicians and commentators claiming that the health care proposal under consideration set up death panels which would review elderly people and decide who among them should live and who allowed simply to die. Well, as we noted, there is not one proposal but several, second most of the proposals are works in progress, not finished legislation. None of them of the health care bills set up ‘death panels’.

There was a proposal, which has since been removed, about a subject on which people are deeply divided. It would have paid for voluntary consultations for elderly people about end of life medical decisions. To show how divided we are about that, a survey by USA Today asked if it is better to keep a terminally ill person alive as long as possible regardless of the expense, and 40% of Americans agreed, while 48% said that the costs should be weighed.

This is really a personal or family decision and not everyone feels the same way – some people have living wills where they specify what may or may not be done to keep them alive, if doing so will only prolong their death, rather than making them healthy again.

According to statistics published by the Center for Disease Control & the US Department of Health & Human Services, the average remaining life expectancy for a 65 year old person in the US is 18.7 years as of 2005. So when someone goes on Medicare, they will incur medical expenses for about 19 years. So what portion of Medicare medical expenses do you think goes to people in their last year of life? Perhaps about 1/19th or about 5%, maybe more say 10%? It is actually 27%.

We really are talking terminally ill people here. No reasonable person would say that people should be denied care because of expense if that care would cure them. What is reasonable, though? How do we decide? To a large degree, it has to be a very individual decision. Some decisions might be easy – we probably don’t provide a liver transplant to someone with advanced coronary artery disease, diabetes, and COPD. But regardless, we are dealing with human beings – someone’s mother, father, son, daughter.

Have I depressed you enough yet? The problem is that we speak of health care in the abstract, but we are really dealing with people’s lives. While we perpetuate a system that allows people to die unnecessarily for lack of health, then that system is killing human beings. Perhaps in what we attempt to do, we should take into account the medical maxim – first, do no harm.

One argument that I’ve heard is that a major problem for health care providers and with health care reform is tort reform. Some claim that outrageous malpractice settlements push up malpractice insurance premiums driving some doctors out of their practices and pushing up the cost of health care for everyone. Certainly some specialties have real problems – obstetricians & surgeons face some of the largest expenses.

But according to the Congressional Budget Office, medical malpractice costs amount to 2% of direct health care spending. Still that could be somewhat understated, since doctors may sometimes order unnecessary tests to forestall claims of malpractice. Then again, how many times have each of us heard of people who had diseases which were not uncovered until those additional tests that the doctors might not have wanted.

Tort reform usually means capping awards for punitive damages, which seems to make sense until you or a family member is injured, maimed, or killed due to the negligence of a doctor. Mind you, we all know that the vast majority of doctors are not negligent or remiss in their practice of medicine. But we also know that there are some doctors who are occasionally so. Those who are drive up the costs for the many who are not. Is tort reform the answer? Part of it, perhaps, but there may not be an easy answer.

Perhaps a larger cost for the average doctor than malpractice insurance is the administrative cost of filling out and submitting insurance paperwork. I have not seen any comprehensive studies, but I have seen estimates that the average doctor’s practice will spend $70,000 per year, just filing insurance forms. I would have to think that if health care reform could push down those admin costs that would provide savings to all of us.

Then again you also have insurance company overhead. For the average insurance company, overhead is about 20% of premiums, while about 80% goes to covering medical expenses. Medicare in comparison spends about 3% on administrative expenses and about 97% on medical care. I have also heard that is not completely comparable, but should we not be able to save something there?

A study in the 2003 New England Journal of Medicine estimates that 24% of total health care expenditures in the US were for administrative costs. Their estimate was that 71% was unnecessary, when compared to administrative costs for the Canadian national health care plan. Their dollar estimate in 2003 was that the waste amounted to $286 billion each year. That is far more than most of the proposed plans are expected to cost.

There is a lot to consider with the health care proposals that are on the table. It is far more complex than screaming about socialized medicine, communism, or death panels. It is far more complex than we could possibly cover this evening. We are not likely even to all agree on a solution, but if we can start to agree that there is a problem, and come to some agreement as to the nature of some of the problems we face, maybe we can begin to work toward some sort of resolution – not a resolution that will make everyone happy, but still a resolution.

I will end with a paraphrase from Franklin Roosevelt, “But while they prate of economic laws, men and women are [dying]. We must lay hold of the fact that economic laws are not made by nature. They are made by human beings.”