I have seen excellent diaries on the need for universal health care. Although I am not a specialist in the field of medical insurance, my background in the group insurance industry has led me to do a lot of thinking about how we pay for medical care, and what we get for it. I have come to believe that a single-payer system is our best option.
This option is not without risks, however. In this diary, (My first), I want to highlight some things that I think are good in the American health-care system, which we need to be careful not to loose.
These are:
- High-end health care
- Medical education
- Fraud prevention incentives
- Choice of Doctors
- The ability to experiment with plan designs
Details on each of these after the break.
- High-End Health Care
At the high end, the American health-care system is unsurpassed. As the opponents of health insurance reform frequently remind us, rich foreigners come to this country to get high-end procedures done, for which they would have to wait a long time in their own country if they are even available there.
Why should progressives care about treatments which are only available to the few? Because today’s high-end treatment becomes tomorrow’s routine procedure. I call your attention to The Work of Human Hands by G. Wayne Miller. This book discusses the advances in neo-natal heart surgery at Boston Children's hospital.
This story is personal to me. A young relative of mine was born with congenital heart problems. He was at a very good hospital, but not Boston Children's which was the best in the world. I remember visiting him at the neonatal ICU. A frail infant in his crib attached to a respirator is a sight that stays with you. It is not a place you would want your child to be for any length of time. The doctors at the hospital caring for him said his condition required difficult surgery and they advised waiting until he was 2 or 3 months old before operating.
His parents got a second opinion from Boston Children's, where they looked at his x-rays and said they routinely did his surgery at 1 month of age. His parents switched hospitals. He had the surgery. He is now significantly older and indistinguishable from his peers. This would not have been true if he had been born 5 years earlier. He is a living testament to medical advances. Here is the link to the BCH web-site where they no-longer even talk about neo-natal surgery as innovative. Now they are working on pre-natal surgery.
I am sure that the other hospital now also routinely performs the surgery on one month olds. Medical innovation advances with experts who pioneer new techniques and procedures, which then spread to everyday practice. Our current system provides good incentives for these pioneers, and we are the world's superpower when it comes to medical advances. I do not want to lose that.
- Medical Education.
Medicine works on an apprenticeship system. Would you like to have an unknown disease and be treated by a rookie doctor with no one watching his back? Of course not. That’s why they have teaching hospitals where young interns and residents are supervised by attending physicians. There are plenty of problems with this system and the long hours it demands of the young doctors with the consequent risk of mistakes caused by fatigue. We may be able to improve it, yet we surely cannot do without it.
How is this training paid for? According to 1997 Senate Testimony on Graduate Medical Education by Bruce C. Vladeck, Ph.D. (from the department of Health and Human Services)
Historically, when hospitals were paid charges or costs by all payers, the costs of medical education were shared by all payers. However, as managed care companies and other insurers negotiate with hospitals for lower payment rates, hospitals increasingly rely on Medicare to help finance medical education
But as Medicare is being asked to pick-up a larger and larger share of the cost of medical training, there are pressures for Medicare to reduce costs, which is placing strains on our ability to train the next generation of doctors. The danger is that policy-makers designing universal care will emulate the private plans' cost containment strategies, and teaching will suffer. I’d prefer to see education covered by direct grants rather than hidden in payments for treatment, but it must not be forgotten.
- Fraud Prevention Incentives
Experts estimate that medical fraud costs taxpayers $60 Billion/year (Washington Post, June 13, 2008). As this article points out, government programs are frequent targets for fraud. Meanwhile, the Health Insurance Association of America said in 1999 that
health insurers save $11 for every $1 they spend fighting fraud – an average of $5.5 million per company in 1998.
While insurance company bashing is a popular dkos sport, I personally know that the people I work with take great pride in paying claims dollars to people who need them. I will not dispute that there are some bad actors in the insurance industry, but there are also physicians and claimants who try to get money they do not deserve. In some cases, as noted in the Washington post article linked above, the fraud is committed on a scale of hundreds of millions of dollars.
There have to be incentives in the system to combat fraud and abuse. If we pay too easily, then the predators will have a field day and we will fail to control costs. The free market does a good job since companies that decrease claims costs can decrease premiums and sell more insurance. If we move away from the free market then we have to find other incentives.
- Choice and supply of doctors
Those of us with good medical insurance take for granted that we will have a good choice of providers. I recently decided that I did not like the bedside manner of my cardiologist and switched. It was easy.
People with restrictive networks of doctors may not have the same choice, but insurers do compete to establish broad networks.
Of course the uninsured do not have much choice at all.
If we "fix" the system in a way that leaves us unable to choose a doctor, or that makes the best and the brightest leave the profession, then we will not have met our goals.
- Tinkering with Plan Designs
We know that a lot of the health costs faced by the country can be reduced if people take responsibility for their own health. Incentives built into premiums and copayments can make a big difference in changing behaviors.
I am a type 2 diabetic. I was first diagnosed 9 years ago, went on a strict program of diet and exercise, lost 40 pounds and brought my blood sugar under control. Over the years, the strict diet became looser, and I stopped exercising as much. After a while, the looser diet became truly bad, and I stopped exercising completely. I stopped seeing the doctor, because I wanted to avoid what he had to say. I told myself that as long as I was keeping my weight down, I was O.K. Classic denial. My company got me back to the doctor. They made a rule that if you hadn’t had your cholesterol and blood sugar checked in the last year, you would pay more for insurance. They offered free screenings at work so no one had an excuse not to get tested. I got tested. The results were horrific. I am back to seeing the doctor, eating better, and starting to exercise again.
Whatever plan we come up with has to have room to experiment with ideas like this. If we don’t allow the plan to grow and change over time by discovering and promoting new best practices, it will stagnate. A good strategy needs a built-in mechanism for course correction over time.
So, as I said at the top of this diary, I am for a single-payer system, although I am prepared to accept any universal system as better than our current mess. Barack Obama, has a lot to learn about health care financing, but I believe that he will take the time to listen and learn. He has said that he will sit down with employers, medical professionals, economists and insurers as well as ordinary people to try to design a system that will work. I do not pretend to have all the answers, but now I have shared some of the questions that I see ahead of us.