Monday, February 18, 2008

What a mess we have made of health care!

Why can't we just face the truth? For a variety of reasons, we have wrecked our health care system under the guise of a free enterprise, market-driven approach. Somehow we believed that using the market would result in better health care, that is, better care to more people. After close to 30 years, the results are shameful:
  • We spend more money on health care per capita and a higher percentage of gross domestic product than any other developed country and yet on several key measures such as infant mortality and life expectancy we rank embarrassingly low.
  • 40 million Americans have no health insurance and thus basically no way to cover the expenses of maintenance health care let alone of serious illness.
  • Lack of access to preventive and ordinary care means that more routine illnesses present in more advanced and often chronic form by the time the health care system is accessed.
  • Those of us who have health insurance live with an illusion of security since HMO's achieve their business success by restricting access to care.
  • Increasingly the ability to pay determines the amount and quality of health care one can receive. Those in the top two percent of U.S. incomes can afford whatever health care they desire. The rest of us must often forgo needed treatment because we cannot afford it.
  • What was once a totally not for profit sector has become dominated largely by for profit companies, both health care and insurance companies. Profit companies legitimately seek a reasonable profit. Unfortunately in health care, profits are resources that are not spent on providing health care.
  • While a large proportion of drugs are based on research funded by our tax dollars through the National Institutes of Health, drugs prices in the U.S. are higher than in other countries. We are the source of subsidies at the research and the retail level.
We have taken health care out of the realm of a social goods (similar to fire and policy protection, education, highway construction and maintenance, air traffic control to name a few) and moved into the realm of market goods. This has clearly resulted in a fundamentally flawed health care system. Even attempts to use the insurance model to cover everyone will continue complicity with the profit market model and thus perpetuate the problem.

Why cannot we just do what common sense tells us: Just as public education through the 12th grade, health care should be available to everyone regardless of health history, ability to pay, legal status, etc. As with education, those who desire a different alternative and can afford it would be able to access health care through a market model but no one would be denied quality care because of ability to pay.

I am lucky to live in Rochester NY. New York requires that hospitals be not for profit corporations. While many ancillary services--imaging is a good example--have moved out of hospitals into profit making corporations, the fundamental structure of care remains a not for profit one. In Rochester, the largest health insurer and HMO is a Blue Cross entity that did not transform itself from a not for profit to a profit seeking organization. Now named Excellus, the leadership and board of this non profit insurer did not think it wise for the long term health of their clients to become a profit seeking company. While there are clearly health care issues in Rochester, we have not experienced the horror stories so typical in the operation of hospitals and HMO's in other parts of the country where health care has become a business.

If it is too extreme and perhaps impossible to return to health care system that is not viewed as a business, what can we do to at least begin to get our money's worth out of our private and public expenditures. Here are three possible suggestions:
  1. Change the current law that prevents Medicare from negotiating prices with drug companies. The Veterans Administration is allowed to do this as well as the HMO that covers federal employees. Doesn't it make sense to permit this for those on Medicare who opt for the drug coverage?
  2. Simplify the Medicare drug coverage by eliminating the confusing insurance middlemen. If Medicare can pay health care providers directly, it can easily pay drug providers directly. This would eliminate the money diverted to insurance company profits.
  3. Require that everyone have health insurance coverage and then create incentives for people to use the health care system as often as needed. This will, over time, result in more preventive care which will reduce expenditures in the long run.
These are steps that we can take to move away from the disastrous experiment of converting health care into a market-driven business. Markets are effective at allocating resources for many activities but health care is not one of them. Our experiment has made a few people very wealthy and left the rest of us paying more for health care and getting less.

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