A healthcare system that works - is it too much to ask?

[William Blake, Pestilence, c. 1780-84]

Most of my Facebook friends are proclaiming the evils of the AHCA, the new GOP healthcare bill. I agree with them that it is at best deficient and at worst cruel, and I hope it never becomes law (Senators: do your job!).

But I fear that my AHCA-hating friends—as well as those who proclaim the evils of the ACA (Obamacare)—are ignoring the bigger picture. Whether we hate Trumpcare more than Obamacare or Obamacare more than Trumpcare, we all need to consider three things:

1. While a lot of people were helped by Obamacare, some people were hurt by it. We won't be able to fix American healthcare until we listen to their concerns.

A British friend of mine opened up a Facebook discussion about the GOP bill, inviting her American friends to comment. She got plenty of comments from supporters of Obamacare (including me). She also got comments like this: “The cost of premiums have risen dramatically, while the actual coverage is diminished.”

People posted that, under Obamacare, their healthcare insurance costs rose “by double digits,” “massively,” “astronomically,” “by 40% overnight.”

They told about huge premiums—$9000 a year for a single person, $19,200 for a family—with deductibles almost as high as the premiums. “One middle-income person could easily spend $20k before being reimbursed,” someone wrote.

Many family physicians relocated, people said. Insurers shut down, care became less accessible, and confusion reigned. “I’ve spent literally dozens of hours on the phone fighting for care that was promised and then roadblocked,” one man wrote. “It’s a mess.”

These commenters may not know that the average cost of health insurance premiums actually rose considerably less after Obamacare went into effect than in the preceding decade.

They may not realize that the low-cost insurance they had before Obamacare probably did not cover the full cost of catastrophic illnesses, would have gotten increasingly expensive as they got older, and would have bumped them if they ever put in a major claim.

What they do know is that they can't afford healthcare insurance and often can't even find healthcare providers. That's a national disgrace. They need compassion, not lectures about the virtues of Obamacare.

The second thing we all need to remember is this:

2. If people are suffering under Obamacare, they are likely to suffer even more under Trumpcare. We won't be able to fix American healthcare until we recognize that change does not equal improvement.

Under the current GOP plan, some people will be able to save money. They can choose to go without insurance altogether, or they can buy a cheap plan that will help them with minor problems but leave them high and dry if major problems strike. Young and healthy people and people with limited incomes may find one of these options attractive. They may not realize that being uninsured or underinsured could cost them their homes, their credit rating, and even their lives.

Under the current GOP plan, Medicaid, one of the most successful plans for insuring the poor, will be cut back. Once again people will go to hospital emergency rooms for primary medical care (the most expensive possible approach), or will skip it altogether. Insured people may not care if uninsured people die prematurely, but they should at least worry about public health if inadequate healthcare leads to uncontrolled epidemics.

Under the current GOP plan, since a fair number of healthy people will choose to be un- or under-insured, premiums for the rest of us are sure to rise. Even if everybody chose to be insured, premiums would rise, because the GOP still believes, against all evidence, that competition among healthcare providers will contain costs.

Only one group of Americans will be sure to benefit from the GOP plan. "While the Affordable Care Act raised taxes on the rich to subsidize health insurance for the poor, the repeal-and-replace bill passed by House Republicans would redistribute hundreds of billions of dollars in the opposite direction. It would deliver a sizable tax cut to the rich, while reducing government subsidies for Medicaid recipients and those buying coverage on the individual market" (Scott Horsley, NPR, May 4).

Yes, I believe that Obama improved America's healthcare and that Trump will make it worse—but that's not my point. American healthcare was badly flawed before Obamacare, is badly flawed with Obamacare, and will be badly flawed under Trumpcare. It's not all that important to know which system is the very worst. What's vitally important is to come up with a system that works.

3. Our choices are not limited to Trumpcare and Obamacare. Why can't we scrap both plans and come up with something really good?

There are so many models we could choose from, if only we'd pay attention to healthcare systems in other nations.

Do our legislators know that the U.S. spends far more per person on healthcare than Australia, Canada, Denmark, France, Germany, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, or the U.K.—and yet in every one of those nations, people live longer, have less infant mortality, have fewer seniors with two or more chronic conditions, and have less obesity than we Americans do? And that they achieve these results in spite of the fact that in 10 of those 12 nations, more people are daily smokers than in America, and that in all 12 nations, the population is older?

Do our legislators know that in the U.S., for every dollar spent on healthcare we spend only 56 cents on other social programs, whereas in the other 12 countries, for every dollar spent on healthcare they spend between $1.00 and $1.88 on social programs? (You can check these statistics and learn even more fascinating facts about healthcare in other nations here.) Read my post about how healthcare (primarily intervention after a health problem has occurred) is more expensive but less effective than social services (primarily services that may prevent health problems) in keeping a nation healthy. Why are we doing things backwards?

Why aren't our legislators studying the healthcare systems of these 12 nations?

Why don't they notice that the other countries vary widely in how they finance healthcare—some by single payer, some by private insurance, some by a combination—but they all limit what providers can charge?

Why don't they notice that the other countries differ widely in who provides the care—some through the government, some through private providers, some through a combination—but they all provide it to everybody?

Why don't they consider the evidence that social spending prevents illness and therefore lowers treatment costs while improving effectiveness?

Why don't they imitate some system that has already been proven effective, rather than constantly trying to tweak a malfunctioning system that has never manged to keep costs down and has never provided healthcare for all?

And if our lawmakers are incapable of coming up with a satisfactory healthcare system, why do we keep voting for them?

Needed in America: a huge healthcare experiment

[Thomas Eakins, The Agnew Clinic, 1889]

So the House Republicans are having a really hard time coming up with a healthcare plan that all Republicans are willing to support. Apparently during their seven years of saying no to the ACA, it never occurred to them that they might one day be in a position to propose something better. They just never saw this coming.

Oh, they'll pass something all right. Maybe even tomorrow. The ACA, they have always maintained, is a bad plan. They are probably right: under President Obama, American  healthcare went from worse to bad. Under any proposals the Republicans have made so far, it will go from bad to worse.

If only our lawmakers read books. Eight years ago T.R. Reid, in The Healing of America, explained why our healthcare system doesn't work. He even used entertaining anecdotes and simple language that members of Congress could grasp, if they'd take the time to read it. It's unlikely that our current president would be able to focus long enough to understand it, but he could be overruled by a conscientious Congress (is that an oxymoron?).

What we Americans need is not a tweaking or even an overhaul of our healthcare system. We need a radically new-to-America approach. 

Pundits on the left argue in favor of a single-payer system. It works quite well in many Western European countries: everyone has healthcare; total costs are about half of what Americans pay; Western Europeans live longer than we do; and they tend to like their healthcare systems.

Pundits on the right argue in favor of a free-market system. No developed country has tried such an approach for at least 50 years, so they can't argue from real-world examples. They ardently believe, however, that competition would keep prices down, increase personal responsibility, and provide better care--and who's to say they're wrong?

Why don't we put it to the test? Let's have two healthcare systems. Let each state decide, by popular vote, which they want:

A. A single-payer system, financed primarily by state taxes, assuring all residents of basic, emergency, and catastrophic medical and dental care at low or no cost. Each state can decide what to do about deductibles and co-pays. Private insurance companies are welcome to offer supplementary policies for amenities such as private hospital rooms, cosmetic surgery, and excellent hospital food (joking! I don't actually believe that any U.S. healthcare system can manage good food, though a friend assures me that Swiss hospitals can, and do). States are permitted to negotiate prices with all providers, and may set caps on prices if they wish.

B. A free-market system, financed by private insurance policies purchased by individuals or corporations (to use as an employment benefit). Insurance is never required, and insurance companies are free to offer whatever benefits they choose and charge whatever they wish. States opting into this system may choose (or not) to subsidize insurance for people with low incomes. The only federal requirement is full, upfront, publicly posted disclosure of all prices--insurance, office visits, tests, procedures, hospital stays, equipment, pharmaceuticals--so consumers can easily choose among providers and provisions: otherwise the system would not be free-market.

What happens if a resident of one state goes to a different state for medical care? The person's insurance--whether publicly or privately financed--pays whatever they would pay in the person's home state, not exceeding the actual cost of the care.

After a few years of this, Americans might have a pretty clear idea of which system costs less, which one provides a  higher quality of care, which one covers a greater percentage of residents, which one operates more smoothly, which one has higher approval ratings, and so on.

I think the single-payer system is likely to work better, but maybe not. European healthcare systems work better than ours, according to Bradley and Taylor in The American Health Care Paradox, because Europeans spend a lot more on other social services than we do. By focusing on fixing problems rather than preventing them, Americans are no doubt capable of producing a single-payer system that doesn't work. Maybe, on the other hand, full disclosure of prices coupled with our entrepreneurial spirit would actually come up with something good. We'll never know unless we try.

If given the choice, would you prefer single-payer or free-market? Why?

Why single-payer healthcare funding may not work in America

Of course Obamacare is failing.

Not quite as badly as No-Obamacare was failing, so I'm still glad it exists. It's a necessary stopgap until we find a system that actually works.

But you know what? Single-payer healthcare will fail just as badly.

In 2015, U.S. spending is projected to hit $10,000.

Yes, I know that single-payer healthcare systems succeed in other developed nations. I also know that competitive insurance-based healthcare systems succeed elsewhere. But neither system will succeed in the United States, because the U.S. is the only nation on earth that refuses to keep healthcare spending from spiraling out of control. If the cost remains the same, it doesn't matter who's paying. In the long run, we all are.

Many Americans believe that a free market would drive spending down, but the American healthcare mishmash (both before and after Obamacare) is definitely not a free market. Just try finding out what a procedure is going to cost so you can choose the least expensive provider. Even the providers have no idea until they've already signed you up and run your insurance numbers. If you're computer literate and have lots of time and patience, it's possible to get approximate prices for prescription drugs, but what can consumers do about profiteers like the infamous Martin Shrekli?

And anyway, when you're being rushed to Emergency is no time to comparative shop.

Many in the general public scream "Rationing!" whenever any limitation to healthcare is suggested, no matter how sensible it may be (refusing to fund drugs with no proven benefits, for example, or allowing futile, often painful, but expensive procedures for people in the last stages of dying). It's frustrating when we grow up and realize that we can't all have everything we want, but it's rational to make sure that, when something (like money for healthcare) is in short supply, it's apportioned wisely for the common good. Americans are not rational about rationing.

Congress, as the right arm of lobbyists, has no interest in keeping healthcare affordable. They would not pass either George W. Bush's Medicare prescription drug plan or Barack Obama's Affordable Care Act until all threat of price caps was removed. Medicare is not even allowed to negotiate drug prices.

Well, folks,

• if consumers are unable to do comparative shopping;
• if we all believe we have a divine right to any healthcare that's available, no matter how expensive or ineffective it may be;
• if we will not allow our healthcare payers to set price ceilings or negotiate lower prices;
• and if our lawmakers continue to favor the lobbies who fund them rather than the people who elect them;

of course our healthcare system will fail.

It will fail millions of people who cannot afford the treatment they need. It will fail millions who pay high prices for treatment they don't need. It is failing all of us, since we pay twice as much for healthcare as we would pay in other developed countries.

Until we find an effective way to limit healthcare spending, American healthcare will continue to fail--whether it is funded by private individuals, by competing insurance companies, or by a single payer.

"We hate the government, except for the large part of it that helps us"

[Colin Woodard's map of 11 American nations]

I just got back from another nation.

According to Colin Woodard, author of American Nations (and this recent article summarizing that book's thesis), the United States comprises eleven distinct cultures. By upbringing and acculturation, I belong to two of them, The Left Coast and Yankeedom. Earlier this week, I got together with friends in The Far West. I am still scratching my head.

Some of these friends hate the federal government, especially its Democratic representatives, and particularly the Obama administration. My views about government, Democrats, and Obama are radically different from theirs, though I understand why some people fear government overreach, I accept that good Republicans exist, and I occasionally disagree with President Obama myself.

But here's what baffles me. Everyone in the group of Far West friends I saw this week is a huge fan of VA hospitals, even though the US Department of Veterans Affairs is the second-largest department of the US government, and even though, as T.R. Reid points out in The Healing of America, VA healthcare is one of the world's purest examples of "socialized medicine."

Everyone in the group is also a huge fan of Medicare, even though Medicare is a US government program that closely resembles Canada's National Health Insurance, often derided by Obamacare opponents.

When I suggested that it would be nice if everybody in America had access to healthcare as good as that provided by VA hospitals or Medicare, everyone nodded. I think they were agreeing with me, though perhaps they were just being polite.

The thing is, we wouldn't have VA hospitals or Medicare if we didn't have a strong federal government.

• The Veterans Health Administration, established during the Truman years as the Department of Medicine and Surgery, today "operates the nation’s largest integrated health care system."
• Medicare, signed into law by Lyndon B. Johnson with Harry S Truman by his side, accounts for 14% of today's national budget--and that's without including the government's healthcare programs for the poor. Add Medicaid and the Children's Health Insurance Program (CHIP) and you bring the total up to 21%.

Of the seven of us gathered around a table at El Adobe Cafe earlier this week, five get Medicare, one gets VA benefits, and one is a caregiver. My friends love these programs because they need them, and they know what their lives would be like without them. At the same time, some of them hate the federal government that makes the programs possible.

I don't get it, but I've learned that arguing gets me nowhere. Even if these people are biting the government's outstretched hand, I'm glad they're getting fed. And speaking of food, El Adobe Cafe serves some of the best Mexican food I've ever eaten. The Far West gets some things exactly right.

Gimme that old-time health insurance ...

Yes, President Obama said that if we like our health insurance, we can keep it. 

Yes, that turned out to be false for a few million people.

Yes, the President chose his words poorly. Whether or not health reform became the law of the land, there’s no way any President could have known if we’d be able to keep our health insurance from one year to the next.

And with the changes mandated by the Affordable Care Act, insurance continuity would be even more of a crap shoot. Companies would tinker with benefits and prices in hopes of keeping the cash flowing after the reforms kicked in. They would certainly cut unprofitable policies or raise their prices stratospherically, or both. This was happening long before Obama took office; surely it would happen even more as insurance companies were required to, well, insure people.

So President Obama should not have made a promise he couldn’t keep.

However, I don’t think the President intentionally lied. I don't think he was naïve about insurance companies. I think he was naïve about Americans. I suspect he had no idea that so many Americans would actually like and want to keep those individual policies that 

• cost significantly more than work-based policies 
• hire people for the express purpose of finding trivial reasons to deny payment on claims
• respond to claims by shutting down people’s policies or raising their prices way beyond affordability
• refuse to insure people with any pre-existing conditions (e.g., people who have been kicked off their previous policies because they actually had to use them)
• set limits on how much they will pay that are way lower than the cost of treating most serious illnesses

And that pretty much describes most of the policies that have shut down as a result of the Affordable Care Act.

Oh, how they will be missed.