The best healthcare in the world

I have had only a few personal experiences with European-style healthcare, and they were a long time ago. A Swiss doctor gave me my pre-college physical. A British doctor looked at my adolescent face and prescribed skin cream. What I remember most--and what totally amazed my parents--was that the consultations and meds were free.

I thought no more about the differences between European and American healthcare until, middle-aged, I began working for a U.K. publisher. I was watching TV news one evening when a political ad came on. Cue the scary music, the dark screen. Do you want our healthcare to turn into a big ghastly mess like American healthcare? asked the portentous announcer. If not, by all means vote Labour. Save the National Health System.

Hmmm, I thought... I'd always heard we Americans have the best healthcare in the world. Is this any way to scare Britons?

Apparently, and it's a good way to scare Germans, Italians, the French, and any number of other Western Europeans as well.

Rachel's baby gets his
broken leg set in France

Want to know why? Read Rachel Stone's account of her family's experiences with healthcare in Scotland, Italy, France, Germany--and the United States.

"It should be within every person’s ability to take care of their health, and that of their children, without going bankrupt," Rachel writes. "I think the free market has had a fair shot at making that happen, and lost."

Ah, but Europeans pay awfully high taxes, don't they? Yes, but not because of their healthcare systems. The American government already spends a little more on healthcare than three of those four countries, even though, in addition, Americans fork over much more out of pocket.*

When you add government expense to private expense, American health care is 65% more expensive than France's and 100% more expensive than the U.K.'s. And for that, what do we get? Read Rachel's story. Here's the link again.
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*In 2006, the last year for which comparative data is available, the U.S. government spent $3074 per capita on healthcare. That's $135 more than the U.K., $265 more than Germany, and $880 more than Italy. Granted, though, it's $159 less than France. 

However, government expenditure is only part of the story. No country that I know of pays for 100% of healthcare; some of the funding comes from private insurers, and some comes directly from patients. In America in 2006, for example, our nongovernmental healthcare expense came to $3640 per capita. That's what we paid, on average, beyond the $3074 we had already paid in taxes.  Compare that with Germany's additional expense, $860; France's, $823; Italy's, $651; and the U.K.'s, $422.

(Data is from the World Health Organization.)

Rationing is not a four-letter word

This morning a friend wrote on Facebook about his expensive medications. He's grateful that Obamacare will make them more affordable. "I do have a twinge of bad conscience," he added, "about the cost of my health care coverage." Maybe death panels are a good idea?

Before cutting end-of-life care, I wrote back, we need to control costs. Otherwise "we are going to have to--gasp!--ration care, or soon only the very rich will be able to afford care at all."

A friend with osteogenesis imperfecta--and who has a child with the same condition--immediately jumped in. "Tell me more about what you mean when you talk about rationing care," she wrote. "As someone who requires fairly regular doctors' appointments just to function well, the idea makes me nervous."

The idea of rationing makes everybody nervous. Though one Merriam-Webster definition, "to distribute equitably," is what the propaganda poster above is trying to communicate, most of us think first of Collins's definition: "the process of restricting consumption of certain commodities." Hey, I need all of my office visits, surgeries, MRIs, echocardiograms, and prescription drugs. If my substandard aortic valve starts malfunctioning again, I don't want any bureaucrats telling me I'm  allotted only one surgical intervention.

OK, breathe deeply. Let's look rationally at that word rationing (the two words do have the same root, which has to do with "reason").

1. American healthcare is already rationed. That is, not everyone can have all the healthcare they want. My insurance is very good, but it doesn't cover eyeglasses, adult orthodontia, or cosmetic surgery (darn!).

A lot of people can't even have all the healthcare they need. Healthcare providers tend to be more abundant in areas of high population density and high average income, so people who live in rural areas may not be able to see a top cardiac electrophysiologist in the middle of the night when their tachycardia acts up. If they live in health professional shortage areas, they might have a hard time finding a general practitioner.

2. American healthcare funding is also already rationed. The government rations the amount it reimburses Medicare and Medicaid providers. Insurance companies ration reimbursements to healthcare providers. Before the Affordable Care Act kicked in, some insurers also denied valid claims from people who were getting too expensive, or else they dropped those people's insurance altogether.

The bottom line always wears a dollar sign. If you have enough dollars, your access to healthcare is limited only by your imagination. I doubt if there is any form of healthcare that Bill Gates (net worth: $66 billion) couldn't afford. Americans whose yearly income is in the lowest 20% (less than $27,000), however, can afford almost no healthcare without insurance--and a quarter of them are uninsured.

3. The challenge is to find an approach to rationing--i.e., allocating--public funds so as to make healthcare more, not less, widely available to all.

One way to do this is through policies that increase healthcare resources and distribute them more evenly throughout the country. Other developed nations do this in many ways, such as offering low-cost medical education so physicians aren't burdened with debt; limiting legal liability so insurance payments don't drive doctors out of business; using single-payer or streamlined private insurance systems so administrative overheads don't force medical clinics to double or triple their costs; and putting cost ceilings on medications and medical equipment.

At the same time, we need programs that reduce the need for expensive health repairs by keeping people healthy in the first place.  Adequate prenatal care, for example, can reduce expensive pediatric care for pre-term babies; and a healthy diet can prevent many cases of diabetes, heart disease, and cancer (note to Department of Agriculture: corn subsidies aren't helping).

But there are always more healthcare needs than healthcare funds ... even after we've increased healthcare resources and reduced the need for repairs. How do we ration our resources so that there is indeed "a fair share for all of us"?

Not by insisting that Bill Gates's healthcare must be no better than mine. Heck, his house and surrounding structures comprise 66,000 square feet, just a tad bit bigger than mine even including the basement. I'm guessing he eats in better restaurants and buys nicer clothes than I do too, and I expect he travels first class. That's what "rich" means.

So yes, rich people will get better healthcare than poor people, and people with good insurance will get better healthcare than people with barebones insurance or (heaven and the U.S. government forbid) no insurance at all. However, poor people also need shelter, food, clothing, transportation--and healthcare.

4. We need to get rid of our hypocritical notions about equality--which we aren't practicing anyway--and start thinking in terms of adequacy.

What if we had, say, a three-tier healthcare system? 

The foundational tier would be publicly funded; the patient would pay nothing. If you need basic medical care--an immunization, a routine diagnostic service such as a mammogram or a blood test, meds for a cold or a urinary tract infection--you go to your local pharmacy or public-health clinic and get it done. Such an approach can be wonderfully efficient, cutting out whole layers of bureaucracy.

The middle tier would be funded by private, not-for-profit insurance, which everybody would be required to carry (publicly subsidized if they can't afford it). This would include all other necessary health care--and yes, someone would have to draw lines between what is necessary and what is not. Not every possible treatment would be available to everyone who wanted it. This is rationing, to be sure. We're doing it now.

But if we've done a good job of allocating healthcare resources and reducing the need for repairs, we should have more money to go around rather than less. (For examples of how this is  being done elsewhere, see my August 29 post, "Four Countries That Already Meet the Republican Platform's Health-Care Goals.") My Facebook friend would still be able to meet her fairly regular doctors' appointments. In fact, if our reforms increased the number of physicians to a level similar to Western Europe's,* she might find it easier to get in.

The top tier would allow for unnecessary, but pleasant, healthcare. It would be funded by individuals either out of their own deep pockets or through for-profit insurance policies they've purchased. It could include things like private hospital rooms, private-duty nurses, the very latest designer drugs, face lifts, and hospitals with wood paneling and marble floors (sorry, CDH: I love you, but you do go overboard).

We Americans are smart. We could find a way to provide necessary medical care for everybody. Perhaps someday, when all our present Members of Congress have finally passed away, a totally new set of lawmakers will figure out how to do it. But first we're going to have to realize that rationing can be a tool used for the common good, or it can be a buzzword used to scare people who haven't noticed that haphazard rationing--our present nonsystem--is the cruelest approach of all.
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*In the United States, there are 26 physicians for every 10,000 people. By contrast, there are between 27 and 35 physicians per 10,000 people in France, Germany, Ireland, Luxembourg, Portugal, Spain, and Sweden; and there are between 36 and 42 physicians per 10,000 people in Austria, Belgium, Denmark, Iceland, Italy, the Netherlands, Norway, and Switzerland.

Our nonpartisan American runaway train

Art by Stephen Slade Tien
via Wikimedia Commons

I freely admit what you already know: I am a wonk. So when the book I'm reading, The Moral Measure of the Economy, laid out a bunch of fearsome statistics going up to 2005, I was compelled to update them. I'm not going to bore you with all the stats. I'd just like you to notice one thing that seemed odd to me. Maybe you can tell me what's going on.

We all know that the gap between rich and poor is getting wider. What I didn't know was that, whatever the forces may be that are driving rich and poor apart, they don't seem to be related to one party or the other.

Here's what the book says:

In 1985, the average income of the top 5 percent of families was 13.5 times as much as the average income of the bottom 20 percent. In 2004, the top 5 percent made almost 21 times as much as the bottom 20 percent.

So I looked up the Census Bureau table that gives this information (it's here; go to Table F-3 and click "All Races" for the Excel file), and I calculated the ratio for each year since 1966, and I made this chart. The short silver bars at the bottom represent the average income of the bottom 20%. The long green bars represent the average income of the top 5%. See the gap widen ...

Here's what seems odd to me:

• From 1966 to 1981, the ratio is pretty stable: seven years of stable Democrats, nine years of stable Republicans.
• In 1982 the gap starts to increase. It gets steadily larger through eleven Republican years.
• In 1993 the gap suddenly jumps from 1:16 to nearly 1:20. From then on, through ten Democratic years and eight Republican years, it never goes below 1:18. Since 2000, it has always been nearly 1:20 or higher.

Something is causing our nation to become more and more unequal (in opportunity as well as in income, as Joseph Stiglitz points out in The Price of Inequality: you can read an excerpt here). Whatever it is, neither Democrats nor Republicans have effectively dealt with it.

Economics is a complicated science: 

     - is our rising inequality a failure of understanding? 

Tax hikes, even for the rich, are hard to get through Congress: 

     - is it a failure of will?

The princes of Wall Street, Wal-Mart, and multinational corporations are doing just fine: 

     - is it a triumph for their lobbyists, who spend more and more every year?

And if we find it distressing, who are we supposed to vote for, anyway?

Good government, bad government--"everybody's confused"

Before beginning the next paragraph, please click here and listen to Mavis Staples and Jeff Tweedy performing "Only the Lord Knows." If you haven't already bought the whole album - it came out two years ago - you really should. Especially during this acrimonious election season. (I commented on it here.) Mavis and Jeff knew what was coming in 2012...

I pick up the paper, I put down the paper,

Turn on the TV, I get confused.

People on this side say the people on that side,

They lyin', say they lyin'--everybody's confused.

OK, now imagine taking a dozen or so suburban Catholics--some of them staunch conservatives, others committed liberals--and making them talk to one another about public policy for two and a half hours every Wednesday evening during the two months leading up to the election. Give the group a sexy name, like "Living Solidarity: Government, the Federal Budget and the Common Good" (such a name keeps a group's size manageable). Ask them what they think the government does well, and what it does badly. Try to keep them from killing each other.

Actually things went surprisingly smoothly at my parish's adult-ed group last week. The moderator told us repeatedly and in manifold ways that we must be polite to one another, and we were, even when talking about government successes and failures. And then we learned that one of our assignments would be to strike up a two-minute conversation with a stranger, each week on a different topic. This week's homework: "Ask someone you don't know: What is something you appreciate that government does? What is something you hate about what government does? Be specific."

Oh, right. If someone standing in line behind me at Trader Joe's tried that on me, I'd ask him to watch my cart while I dashed back to the produce department to pick up more broccoli rabe. No way am I going to let some political nut turn my peaceful shopping expedition into a shoot-out. And no way am I going to turn myself into an agent provocateur either.

So I put my questions on my Facebook page, Madame Neff's Salon, and discovered that some people hate speeding tickets while others appreciate them. Other than that, here are the answers I got:

What is something you appreciate that government (federal, state, or local) does?
Emergency services like fire, police, and ambulance. The Post Office, which--unlike FedEx, UPS, or the Pony Express--is required to serve all areas of the U.S. Schools. A good legal system. Enforcement of laws and rights: property rights, religious rights, right to protest, freedom of speech. OSHA. The FDA drug review. Health care. Programs that help poor people and those who experience disasters. Programs that guarantee clear air, water, safe food, safe buildings, etc. Roads, transportation,some communication. A state program for at-risk children that offered subsidized physical, occupational and speech therapy for our son. Medicare.

What is something you hate that government (federal, state, or local) does?
Picky laws: Prohibiting plastic bags. Outlawing marijuana. Banning large sugary drinks. Banning smoking outside. Subsidies to private enterprise (tax breaks, funding research and development, etc.) without demanding repayment or a share of profits. Unnecessary war. War without the approval of Congress. The salaries of elected or appointed government officials. Torture.

If I got back in line at Trader Joe's, broccoli rabe in hand, and still had to answer the questions, I'd probably tell the pushy stranger that I really like--or would like--excellent public education, universal health care, Social Security, interstate highways, food security programs, regulations to protect the environment, regulations to keep financial institutions honest, family health-care leave, paid maternity leave... well, by the time I got to that many points here in Republican DuPage County, I expect my interlocutor would have scooted into another check-out line, as far from me as possible.

But if he stayed to listen, I'd also tell him that I really hate the way our government--federal, state, and local--promises so many of these good things but then refuses to fund them. On a more personal level, I hate the way so many Americans think we should have more services but lower taxes. Read, for example, Greg Sargent's article in the August 2 Washington Post, "Americans hate government, but they love Medicare, Social Security, and environmental regulations."

I'm looking forward to hearing my classmates' opinions. I think we can manage not to throw overripe fruit at one another, especially if we keep in mind Mavis and Jeff's call to humility:

What to do, what to do now?--

Only the Lord knows, and he ain't you.

Listen to them!

MORTALITY by Christopher Hitchens

Before yesterday, I had read no books by Christopher Hitchens. I had read about him, to be sure. His name kept popping up everywhere.

 "I wouldn't walk around the block to hear Christopher Hitchens take cheap shots at Christians," writes Stephen Prothero in God Is Not One. Prothero, a professor of religion at Boston University, calls Hitchens one of the "'Four Horsemen' of the angry atheist apocalypse" (along with Sam Harris, Richard Dawkins, and Daniel Dennett)--fundamentalists all, but by another name.

And yet Hitchens's books are extremely popular, as are books by the other Horsemen. "If you want to know why the 'new atheists' ... sell so many books," says theologian and former bishop N.T. Wright in Simply Jesus, "the answer is that they're offering the modernist version of the good old-fashioned theological term 'assurance.' They are assuring anxious ex-believers that the nightmare of small-minded and stultifying 'religion' is gone forever." In other words, they offer to save us from fundamentalism.

Writing Hitchens's obituary in Christianity Today, an evangelical (though not fundamentalist) magazine, Douglas Wilson takes no offense:

This [propensity to attack sacred cows] was all part of Christopher's very public rhetorical strategy, not a function of an inability to domesticate a surly temperament. He was actually an affable and pleasant dinner companion, and fully capable of being the perfect gentleman.

Angry fundamentalist, savior from fundamentalism, nice guy... who was Christopher Hitchens really? In a New York Times review of Mortality, Hitchens's just-published posthumous book about his slow death from cancer, Christopher Buckley muses: "What discrepant parts were in him: the fierce tongue, the tender heart."

It was Buckley's review that prompted me to put Mortality on hold (now there's a great idea...). I won't sum up the book here; you'll do better to click this link and read Buckley's heartfelt appreciation. I'll just say that Mortality, like life, is short. It consists of a Foreword by Graydon Carter,who worked with Hitchens at Vanity Fair; seven essays that Hitchens wrote for that magazine; an eighth chapter of "fragmentary jottings" in the manner of Pascal's Pensées; and an Afterword by Hitchens's wife, Carol Blue. You can read the whole thing in an evening; if you're a fast reader, you can read it twice.

But why read a book about dying at all? Maybe because you're a Hitchens fan (I'm not), or because you love the way he writes (I do), or because you hope to gain wisdom (you may).  I guess I read it because mortality has been much on my mind of late. Stage four cancers, fatal strokes, hospital infections, dementia have attacked family members and friends, some in their 90s, some--like Hitchens, like me--in their 60s. I looked at mortality myself last year (and blogged about it here). I wanted to hear what Hitchens, the gentlemanly curmudgeon, had to say. I wanted to know how he felt, knowing his time was nearly up.

In chapter one, Hitchens reacts to learning he has stage four cancer (as he later notes, "the thing about Stage Four is that there is no such thing as Stage Five"):

I can't see myself smiting my brow with shock or hear myself whining about how it's all so unfair: I have been taunting the Reaper into taking a free scythe in my direction and have now succumbed to something so predictable and banal that it bores even me.

Hitchens never allows his dying, however predictable and banal, to bore his readers.

52 years later, is the church threatened or threatening?

In 1960 when John F. Kennedy became the Democratic candidate for President of the United States, a lot of people panicked. The ironically named "Citizens for Religious Freedom," a group of some 150 evangelical and mainline Protestant leaders, issued a manifesto declaring that, in the words of the Reverend Norman Vincent Peale, "Our American culture is at stake." With a Catholic at the helm, they feared, the pope would call the cards.

Fifty-two years ago today, Kennedy gave a memorable speech to the Greater Houston Ministerial Association. Telling the group of Protestant ministers that he believed in an America where "no religious body seeks to impose its will directly or indirectly upon the general populace or the public acts of its officials," he promised that

whatever issue may come before me as president — on birth control, divorce, censorship, gambling or any other subject — I will make my decision in accordance with ... what my conscience tells me to be the national interest, and without regard to outside religious pressures or dictates.

The speech probably gave him the edge he needed to win the presidency.

Fifty-two years later, six of the nine Supreme Court justices, 28% of the members of Congress, and both vice-presidential candidates are Catholics. Not everyone is happy with recent Catholic-supported efforts to limit access to abortion and contraception, but nobody seriously suggests that the pope is ruling America. In fact, it's the Catholic bishops who are panicking. "Across America, our right to live out our faith is being threatened," they warned parishioners in a recent bulletin insert.

Church and state have had a rocky relationship at least since the fourth century CE, when the emperor Constantine legitimized Christianity and gave the keynote address at the Nicene Council. Should religious lobbying groups help to make public policy? Should public policy exempt religious groups from otherwise universal requirements? Yes, and yes, says the United States Conference of Catholic Bishops. No, and no, says Americans United for the Separation of Church and State.

The answers are not always clear. An enormous amount of spin (from all sides) has muddied the waters. If you are at all concerned that, in America today,

• the state has too much power over religion, or
• the church has too much influence on the state, or
• church and state are altogether too cozy with one another--

I recommend reading two short articles on this anniversary of the Houston speech.

First, read the speech itself. It is beautiful literature. Historically significant. As relevant today as in 1960. Still powerfully moving.

Then take Emily C. Health's perceptive quiz, "How to Determine If Your Religious Liberty Is Being Threatened in Just 10 Quick Questions."

Romney's plan covers preexisting conditions - for the rich and the lucky

"You shouldn't have let his health insurance lapse."

For just a moment I thought Romney was actually moving toward the middle. On Sunday's Meet the Press he said he wouldn't get rid of all health-care reform. One thing he planned to do, he said, "is to make sure that those with preexisting conditions can get coverage.”

And then later, of course, his campaign clarified: He would make sure that those with preexisting conditions would be covered if they had continuous insurance coverage. In other words, he would continue to enforce the Health Insurance Portability and Accountability Act of 1996. Well, whew.

Yesterday Washington Post blogger Ezra Klein asked, "Who would be left out of Romney’s preexisting conditions plan?" Answer: "About 89 million Americans."

If you have a pre-existing condition, are covered by a good insurance policy, and qualify for and can afford a COBRA policy, you'll be OK for 18 to 36 months. After that you're on your own.

But people buy COBRA policies because they are out of work, and COBRA's rates are steep for the unemployed: about $500/month for an individual and nearly $1400/month for a family.*

If you have a preexisting condition and can't  afford COBRA, you could lose or be unable to get health coverage under Romney's plan:

• if you're the nonemployed wife or child of a man who retires or dies or loses his job
• if you stop working for several months to care for an aging parent or an ill family member
• if you lose your job due to serious illness or injury
• if you are unemployable due to mental or physical disabilities
• if you take an unpaid maternity leave
• if you're looking for your first job and you are not covered by your parents' insurance
• if your company decides to stop offering a health-insurance benefit
• if the only company who will hire you does not offer a health-insurance benefit
• if your company goes out of business, and it takes you longer than 63 days to find a new job

I understand why preexisting conditions must be tied to continuous insurance coverage: you can't have people signing up for insurance only after they've had the diagnosis or the accident. And indeed, preexisting conditions are tied to continuous insurance coverage in Obamacare (to use the Republicans' preferred term), in socialized medicine (to use another term they favor, even though they usually use it erroneously), and in those developed nations who finance health care through private insurers.

The difference between Romneycare and all those other plans is this: With the other plans, everybody has continuous insurance coverage. With Romneycare, you can have continuous insurance coverage if you can personally afford it, if you are able to work, and if you're lucky.

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*In 2010 an individual policy cost $429 a month and a family policy cost $1170. Those are the latest figures from the Kaiser Foundation; since health-care insurance rates have been rising between 8 and 9% a year for several years, it is reasonable to assume that the average Cobra policy now costs about $505 (individual) or $1377 (family) per month.