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It is time for every American citizen to tune in to the healthcare debate. Inform yourself and then seek to inform and persuade others. The issue is huge and the outcome is unclear. Millions of our neighbors have no health insurance. Healthcare costs rise every year and there is no end in sight. Bankruptcy through medical catastrophe is commonplace. The rising cost of care means that fewer people get jobs and fewer people with jobs get insurance.
President Obama is right. We cannot do nothing. As scary as change is, and as problem-fraught as some of the proposals for change are, we simply cannot stay with the status quo. We have an obligation to those with whom we share our soil, and if we are wise, even those of us who now have good insurance realize that our own security hangs in the balance.
Unfortunately, fixing our broken system will not be easy. It certainly isn’t as easy as electing the right person. It doesn’t matter if that person is Obama or McCain or Max Baucus or Mitt Romney, or fill in any name you like. Providing healthcare for those who need it is a difficult and complex problem. Solutions will not be cheap, they will not come without sacrifice, and they will not always be comfortable.
The progress medicine has made in the past fifty years is miraculous. Consider heart surgery. Consider the cholesterol-lowering (and very expensive) statin drugs. But getting heart surgery or getting statins [now] costs a lot more than visiting a doctor’s office and hearing of your (quite limited) treatment options [then]. Medicine costs more than it has ever cost because it can do more than it ever could. That doesn’t mean that we can afford to pay for everything we know how to do. That’s the ugly truth. Every compassionate soul would like to see statins in the pocket of everyone who needs them and a transplanted heart in the chest of everyone who requires one. But we can’t pay for it all.
Realistically, what we can pay for is excellent preventative and routine care. We can ensure that non-emergency care is not handled in the emergency room. We can ensure that doctors make an excellent (yet not extreme) wage to ensure that we all have access to a good doctor when we need one. We can pay for medical school for those willing to be general practitioners and for those willing to serve in underserved communities. We can mandate evidence-based medicine and offer the drugs and other types of care that have proven to be cost effective.
We will have to have a two-tier system. Universal healthcare will necessarily be basic. Those with greater resources will have to be allowed to pursue greater care. We can tax them to help support those who are less fortunate. We can also tax the wealthy and healthy. But when President Obama claims that healthcare for all Americans can come without sacrifice to most of us, we need to laugh. Providing for our neighbors and ourselves will cost us, but we should do it anyway. Remember, doing nothing guarantees disaster. With so much wrong, we can surely hope for something better.
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20 Responses to “American Healthcare”
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Trick question: could you please tell us what you consider an excellent but not extreme annual (before tax) salary for a doctor?
There are many alternatives to Obamacare. I agree that the system needs change, but I am opposed to any expansion of government power over my life–and once the government is in charge of my health, they can tell me what to eat, how to live, etc.
Reform is needed–deregulation, tax reform, and breaking up of monopolies. But government control is not the answer
Brilliantly put.
I completely agree that something has to be done about healthcare. It has been ignored for too long.
What is an excellent, yet not extreme salary? (Notice that the whole premise of this question completely sets aside our status quo, hopelessly broken, fee-for-service model). This is something that should be determined through societal debate, just as with the issue of what forms of care we will pay for given our limited resources. Also, some trial and error will be required. Salaries must be set high enough to attract talented people to the profession–and to general practice (as opposed to specialties) specifically. Inducing more physicians to choose general practice will ultimately bring significant cost savings. Also, salaries must be set high enough to ensure that the waiting time for various forms of care is kept to an acceptable minimum.
[We must avoid the pitfall of putting the finger of blame on overpaid physicians and then pointing to the bogeyman of unacceptable waits for service in the Canada and the UK. Either we hire enough physicians and pay them well enough to retain them or we accept the waiting times. Getting people the basic care they need means tough choices].
If I were going to start that societal conversation regarding physician salaries I would have to just pick a number out of a hat and go from there. How about paying general practitioners whatever the 85th percentile of national income is and specialists the 90th? I have no idea how much money that is and what the average figures for physician pay are now. That would be the next data point I would seek in considering the right answer to this question. Is 85% enough to attract people or is it ridiculously high? I’ve no idea.
Frank, we agree on the point that there are alternatives to the plans that Obama has proposed. However, I would hope for more radical change than what Obama has suggested, and you apparently hope for less.
You said that you are “opposed to any expansion of government power over my life.” If you are not committed to the availability of basic healthcare for all Americans, that position might work. Although expanding government power sounds ugly, I think it is the only way we can achieve something beautiful: basic healthcare for everyone. While “deregulation, tax reform, and breaking up monopolies” might help lower the cost of care, we would still be left with millions of Americans without healthcare. I think we can and must do better.
Of course there are better and worse ways of expanding government power. Obviously, we need to tread carefully in the matter of health and personal liberty. Many insurance plans offer incentives (small presents, modest cash prizes, etc.) for desirable behavior: quitting smoking, exercising, etc. They do this because the incentives actually save them money in the long run. Are you uncomfortable with such incentives?
One problem that I see with the healthcare/insurance in our country is this: Doctors and hospitals inflate their prices for services because they know insurance companies will only pay a portion of it. Then they write off the difference as a loss in their taxes. The problem is that the people who don’t have insurance get stuck paying the really high inflated prices.
For instance, when I had one of my children at the hospital I had no anesthesia, no overnight stay, the nurses periodically came in and adjusted my monitor belt, I did have an IV in case I needed pitocin after the baby was born. The doctor came in just in time to catch the baby and gave me a few stitches. My point is that there was very minimal care on the part of the hospital. The total cost for just the birth was around $10,000 and how much did the insurance pay? $2000. In comparison the fee for my certified nurse midwife is $3600; and that is the complete package of prenatal care AND birth. If you walked into the hospital without insurance you would have to pay at least $10,000. This just seems wrong to me.
I admit I am not the most informed but this is my solution. It would make sense to me to have insurance with a high deductible (but low monthly payments) for the big emergencies…car accidents, surgery, etc. the things that specialist need to deal with. Then get the general practitioners out of insurance. Most people pay a copay when they go to the doctor anyway and for a little more than a co-pay, maybe $30 or $40 a visit, I think a doctor would make pretty good money. Especially if several shared an office suite so they can share a secretary. Without having to deal with the insurance paperwork and maybe have some kind of protection from malpractice suits so their malpractice insurance was lower their overhead would be a lot less.
Now for people who can’t afford the $30 to take their child in for an ear infection check. That is another can of worms. I really don’t like the idea of people getting things for free from the government. I cringe when I see the schools handing out free breakfast and lunch during the summer. I think it is great they want to help kids who are hungry, but the kids and/or parents should have to do something for it besides just showing up. They could help with school or park clean-up or something- I don’t care if it even is a fair trade, as long as they are doing something in return. Personally I would like to see taxes be lower and have people pay a portion of their children’s schooling simply because when you pay for something you take it more seriously and appreciate it more.
First, on the salary question, there was a great article in the New Yorker a while back about the huge difference in healthcare savings from having salaried (rather than partnered-in, profit-sharing) doctors. http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
Otherwise, I think your post is all spot on. I will add one thing, which has to do with entrepreneurship – how many small businesses are there that might have been started by someone with a great idea, but stayed in the idea stage because the would-be entrepreneur would have no affordable health insurance? Our totally inadequate public healthcare system stifles the economy. Business is risky enough without having to risk your health along with it, which you might have to do if you can’t afford the astronomical cost of individually purchased health insurance.
Yes, it’s all nice to say, “keep the government out of my life,” – but then do you feel that way about roads? Roads are a basic infrastructure, a public good that allows all of us to be more productive, and the free market isn’t good at handling them because individuals’ purchasing decisions are just too self-interested and narrow. Imagine if we had a healthcare infrastructure in place that allowed all citizens to have a basic sense that they wouldn’t be allowed to fall through the cracks in the event of a major illness. How much more productive could we be as a society? And like roads, it’s just not going to happen if it’s left up to individuals who, again, are just too self-interested and narrow in their views to know the broader impact of their spending decisions.
The current system just lets too many people fall through the cracks. Tens of millions of uninsured is only one of many indications that the approach of “keep the government out of my life – let the private sector find solutions” is just not working, and it’s time for more, not less government on this particular issue.
I agree with the call for health care reform. It’s something that we really need and the best way to help enact useful reform is for people to get informed and learn the in’s and out’s of the possible legislation.
Also, contact your legislators.
Therese, Great article. I found it very convincing.
Incentives are a good thing. Nothing wrong with that.
The key difference is that an insurance company does not have the power to tax, or the power to force. It’s really all about that. Government can use compulsion.
And millions of Americans are not without healthcare. Everyone can get CARE. Nobody is being turned away from the doctor or hospital. They might have to pay for that care, and it may be very expensive. They may not be able to afford the current insurance plans. But reforms that brought costs down would make coverage more available. And there are some people who simply choose not to buy insurance. Why must they be forced to be included?
We need to get back to an INSURANCE model. Insurance exists to help with major losses. In car insurance, you don’t use your coverage to pay for oil changes and routine maintenance–just major loss due to accident or other adverse event. We need to get healthcare on a similar footing: you buy insurance for major losses, and pay for the routine on your own. I am in favor of HSAs, which allow people to save money for healthcare free of taxes. More policies along those lines: give people MORE power and more choice. Not force everyone into a government run system.
One more thing: healthcare is not a RIGHT. It is humane and charitable to want all people to have access to healthcare. But RIGHTS are things we have, God-given, such as freedom of conscience and freedom of speech. They are things we have to keep watch over, to make sure government does not violate them.
Healthcare for everyone is a nice goodie, which many people feel should be possible in a prosperous and advanced society. But it is not something that anyone has an inalienable right to.
An analysis of how Obama’s health care agenda may affect families can be found at meridianmagazine.com
It was about half way down the page today (Sat. July 25) but you could find it later by searching the archives for– Obama health care agenda
Frank, why isn’t health care a right? The Bill of Rights already goes beyond things one could call “God-given, such as freedom of conscience and freedom of speech.” It includes the right to keep and bear arms and protection from quartering troops. Why not believe that it might have included a minimal level of health care had that been imaginable to the Founders?
Therese–I’m not sure that you understood me. I was suggesting that physicians *should* be salaried. I am opposed to the fee for service model.
I think your point about entrepreneurship was excellent. People make too many life decisions on the basis of what their healthcare options might or might not be. It doesn’t make sense to tie healthcare to jobs and employers.
I like Rebecca’s reminder to focus on possible legislation. It is too easy to get all worked up thinking about the details of the ideal healthcare system. That is important, but there is actual legislation on the table right now. The opportunity to influence our legislators is right now. While I am strongly in favor of a single payer system (government pays), this isn’t even being considered. It is not something my legislator can vote for. He could, however, support a plan that included a “public option.” I need to determine whether that is something I support.
Frank, we continue to disagree. You said that “millions of Americans are not without healthcare. Everyone can get CARE. Nobody is being turned away from the doctor or hospital.” You have overstated your case. While it is true that many who are without health insurance are able to get charity care in hospital emergency rooms, many are not getting the medical attention they need. Many do not get the prescriptions they require. Many do not see the doctor, although they would like to, because they know that they cannot pay.
You note that “there are some people who simply choose not to buy insurance” and ask “Why must they be forced to be included?” The answer is simple. Because we want all Americans to enjoy basic healthcare (I’ve never suggested that healthcare is a right, I don’t find that line of reasoning helpful). People who get in trouble without adequate health insurance affect all of us. Of course, the bankruptcies caused by health crises are not good for our economy. But these cases also tug at our consciences: we don’t want to let people die or become senselessly ill because they were stupid and greedy/risky or young and thought they were invincible. If we plan to pay for their medical costs in the end, it makes sense to demand that they help carry the load along the way.
You said that “we need to get back to an INSURANCE model. Insurance exists to help with major losses. In car insurance, you don’t use your coverage to pay for oil changes and routine maintenance–just major loss due to accident or other adverse event.” I completely disagree. The problem is that people are penny-wise and pound foolish. They don’t get the preventative care that they need and then their final bills are much, much higher. If we are going to pay for the “major losses” down the road, we want to do everything we can to encourage “routine maintenance” now. If childhood immunizations are completely free, more children are immunized and they are immunized in a more timely manner. It is a very expensive mistake not to pay for prevention.
Ashley, I’m also not a big fan of people getting for free things they should have to pay for. But as you point out, especially when we are dealing with children, things get a bit tricky.
Education is a great example. I would much prefer everyone had to pay for their children’s education because I think parents (and then children) would value the education much more and therefore get much more out of it. And yet, though free educaton has brought its own set of problems, as a country I’m guessing we are far ahead of where we would have been without the (sort-of) free public education we have. (Obviously I’m also no expert on the impact of free education on our country. I would love to hear an expert’s take on this.)
Back to the topic of healthcare…it seems to me that countries where the government is responsible for healthcare are getting a better deal than we are. (FWIW I remember an article in the Economist comparing our country’s healthcare to other countries. I remember thinking that we were getting the worse deal. The article may be this one (http://www.economist.com/displaystory.cfm?story_id=E1_PNVRTDQ ) though I’m not sure since I read the economist but don’t have a subscription. There is a certain irony to that given my opening remark.)
The downside of offering healthcare for free (i.e. paying for it through compulsion–taxes) is the same one we have with education–you create way too many whiners that the system doesn’t do more for them while they, at the same time, take no real responsibility to make it better or opt for an alternative (obviously, you don’t fall in this category). But maybe we have to simply try to offset this problem as best we can through propaganda (in its best sense) to encourage good behavior despite the easy of whining. We certainly could do a better job of propaganda about our public schools but we do have some of it–for example much is done to encourage parental participation.
Of course, for any who don’t believe we should have free eduction, I suspect you won’t find this line of reasoning very helpful.
Pmom – I did get that you were in favor of salaries for doctors, just meant to support your point …
On Frank’s idea that people already can get care, I’ll give you a real-world example. I knew a Ph.D. student here in DC whose income from his fellowship was about $16,000 a year. He decided to forego buying health insurance because with his low income he qualified for the free public health system here in DC – the cutoff point was about $17,000, and if he earned more than $17,000 he would no longer have been eligible and would simple have had to pay out of pocket for any healthcare he got.
Meanwhile, my first salaried job in DC, working for a nonprofit, paid about $25,000 a year. I found this very difficult to live on, given how expensive the DC area was. I was able to pay for food, a small room in a shared, shabby apartment with a very long commute (of course no car), and not much more than that. Had I not had healthcare included with my salary, I would not have been able to afford independent health insurance – not remotely.
My point is that someone who lives in DC and makes $17,500 or $22,000 a year and does not get health insurance through their job will simply not be able to afford health insurance. Any illness will essentially bankrupt that person. The person’s only choice is to go to an emergency room, and then probably never pay their bill, which ends up raising the hospital’s costs, and then those costs get passed on to other users of the hospital, me for instance. And for the system as a whole, this ends up being far more expensive than just providing preventative care would have been. It’s a bad system for keeping people healthy, and it’s a bad system for keeping costs down.
This is what I mean by people falling through the cracks.
The common wisdom on the new types of insurance like HSA’s is that they weed out the sicker people, because it’s people who are fairly confident that they won’t get drastically sick who will choose those lower-cost programs over traditional insurance.
One big way that the free market/insurance model breaks down when it comes to healthcare is the “public good” problem, which has to do with the fact that laissez-faire economics is based on the premise of perfect information being available to buyers and sellers, while in reality we usually have limited information, e.g., when it comes to healthcare.
The “public good” problem is that the true cost of the good (in this case healthcare) is hidden from individuals. You think that you aren’t paying for the person who falls through the cracks, but you really are. From your limited viewpoint as an individual, you don’t realize that you might well end up paying less if you taxes went up by $10 a year to fund a more inclusive public health option, and your insurance premium ended up going down by $100 a year. (The classic example of a public good is air quality – e.g., you don’t realize the cost of poor air quality and resulting asthma is added on to what you pay at the gas pump or your heating bill.)
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