Universal Health Care

Universal Health Care is a very good thing, an idea rooted in fairness and basic human rights, the idea that people should have access to decent medical care no matter their income or social standing. It’s a fundamental measure of a society, how it takes care of its people. Universal health care in the United States would transform society and possibly generate a large fiscal payback in a short time, as people with small problems see a doctor before they become big problems. I’d like to see that.

I also think it’s impossible. The wealthiest nation on earth is also the one least prepared to have the government play a role in health care. It comes down to a fairly simple chain of reasoning.

  1. Health care in the United States is far more expensive than anywhere else. Remenber HMO’s? That was an attempt to reduce the overall cost of care, but in the end doctors and patients alike joined in the hate of them.
  2. As much as insurance companies suck, they are the ONLY force in the United States with an interest in keeping health care costs down. They are regularly castigated and challenged for saying ‘no’. Lawsuits abound. The general public pushes constantly to limit the power of the insurance companies to say no, even to radical treatments that cost an arm and a leg and have little chance of success. Thus we have the most expensive health care in the world. It is also the best, precicely because there’s not cost/benefit analysis.
  3. So if insurance companies are the only force keeping health care costs down, just imagine if the US government were in the insurance business. Even if they could hold the line on costs, there’d be a thousand lawsuits against the government active at any given moment. People who were told ‘no’ for an expensive treatment with little chance of success — but wait! That was the government saying no! Goddammit, no one in Washington is going to tell me I can’t have that buttock transplant!

Alternately, the government can require private insurance companies to insure everyone who asks for it. Still, Uncle Sam will have to pitch in for people who can’t afford a reasonable premium (I am one of those people). Once again it comes down to saying ‘no’, and insurance companies will pass the bill along rather than rack up legal costs.

Another reason universal health care works where I am now: doctors don’t drive fancy cars. They make an honest living and do all right, and they don’t (yet) get kickbacks from the pharmaceutical and medical technology corporations.

Just to be clear: I WANT every US citizen to have access to health care, me included. But it’s not going to happen until the core problem is addressed: health care in the United States costs far too much already. Someone has to learn to say no and mean it before care can be extended to everyone. Alas, the United States government really sucks at no.

6 thoughts on “Universal Health Care

  1. Insurance companies aren’t the only ones who say “no.” But when the patient says “no,” nobody listens. I said “no” repeatedly and loudly, when Gerald was born, but the doctor insisted that I was experiencing more pain than I could stand (it was less than menstrual cramps), and she pumped me full of drugs that I didn’t want, which resulted in fetal distress.

    Then when she called for a C-section, she turned off the drugs so I could sign the forms. She didn’t tell me that turning off the drugs had also brought the fetal distress to a halt until after I had signed all of the forms so I couldn’t call off the procedure.

    Even with insurance, there were complications that caused major medical and financial hardship for several years, and I’m still suffering physical disabilities.

    BTW, I seriously disagree about US health care being “the best in the world.” It’s not. It’s only the most expensive in the world. Consider this: In the UK, the Cesarean rate is 7%; in the US, it’s 30%. The US infant mortality rate is about the same as the UK’s, but the US maternal mortality and morbidity rate is about four times the UK’s.

  2. In the U.S. we love to love doctors and we love to hate insurance companies. And polling shows the average citizen believes insurance cos are to blame for skyrocketing health costs. However, experts say it is not the case, it is actually doctors and hospitals that are to blame for the rising costs.

  3. Wow. That sounded like a commercial spot for The New Right Agenda. As a former actuary, a victim of shitty American medical care, and self-insured, I have to take objection:

    We don’t have the best medical care in the world. True, some very wealthy people come from other countries to see our very highly-paid specialists, but medical care as it’s provided to your typical American more or less sucks (depending on whether you’re more or less wealthy, or more or less working for a large corporation).

    An insurance company with a 75% loss ratio (meaning “only” 25% of premium goes to overhead, not benefits) is considered stellar in the business. Single payer would see an immediate 25-50% drop in costs (less the cost of the new bureaucracy, which would be more efficient than a lot of smaller ones, even if it is the damn gvmt).

    One reason our care is so expensive is the dearth of GPs. Universal coverage, emphasizing preventative medicine, would require more GPs who make less money (and do more good) than most specialists.

    Much of the run-up in costs is due to lawyers/malpractice, technology, and procedures with a high cost-to-benefit ratio (which are either mandated, or used as sales tools … try not covering late-life quadruple-bypasses for smokers when the guy making the buy decision for a fortune 500 company is an obese type-A smoker). Properly done, the government could say “this class of services will not be covered by the public pool … but there’s nothing to prevent you from getting this care yourself if you can afford it”. In response to your likely objections:
    – Like ALL government services, taking away an expensive benefit from a few (heart/lung transplants) can allow a huge benefit to many (vaccinations). Yes, some individuals will die as a result of this policy, but many people now die due to lack of coverage and expensive/terminal illnesses
    – As it is, for people in my position, it’s only the rich who get this kind of care anyway … the premiums for that kind of coverage would bankrupt me

    Some of the rest of the cost inflation is hospitals charging far more than actual costs for fixed-price services, to make up for their losses in emergency-room treatment (much more expensive than a general admission to the hospital) of the un/underinsured.

    The government is the one body who can *legislate* “No”, and they’re pretty lawsuit-proof when they want to be. And just by offering universal coverage, they say that the bottom line isn’t their main concern, it’s providing coverage … so when their review board decides “medically necessary” it’s based on cost-benefit, not profit-loss, of any single procedure. And don’t tell me (who has two folios full of medical bills and documents) that the government would introduce *more* bureaucracy. One huge win: unified medical records … a big deal for both providers and the covered (there is no complete file on me anywhere … I can’t even get doctors to give me my own records), as well as the “insurer” (who can fully decide the health status of someone without relying on their word).

    “preexisting condition” is now unofficially defined as “sought treatment for something similar in the last 10 years from another insurer”. I’m trying (in vain, so far), to switch coverage right now. The fact that I’ve been paying premiums continuously for over 10 years should mean that I have a right to seek treatment for injuries suffered during that period. That’s only true as long as I never change insurers, and it is the nature of insurance pools to get progressively more expensive as the people who don’t drop coverage are those who have expensive conditions that prohibit moving carriers, raising rates, knocking the healthy out of the pools, coda.

    Truly portable coverage (that’s really only possible with universal coverage, or some new laws) would also mean people wouldn’t be trapped at crappy jobs because of the difficulty of changing coverage.

    The government does insure millions of people already … they run Medicare. And the main complaint? Hospitals say the payments are too small. But the government is such a gorilla, that no one will turn down Medicare patients. Contrary to the story that some people have sold very successfully, the government can do certain things very efficiently (cf social security as the prime example of the difference between reality and the public perception as sold by someone with a vested interest).

    However, if you were right, I would agree with you :) -b.

  4. Thanks for that rebuttal. If nothing else it gives me hope that I’m wrong, which would be a good thing. I don’t know new right or old right, or the agendas thereof; I just know that Republicans are Not Right.

    You mention that what the American medical system needs are more general practitioners. In the era of the HMO they were called Primary Care Physicians, and as time passed it became harder and harder to find doctors willing to fill that role. If I could be convinced that we had a system that encouraged GPs that would go a long way toward changing my tune.

    Is it really true that ‘no one will turn down medicare patients?’ That runs counter to my (admittedly anecdotal) understanding of the current state of affairs. My impression was that medicare patients were having an increasingly difficult time finding places that would accept them.

    Bureaucratic unification of health care would be a tremendous boon to all concerned, except insurance companies who routinely deny claims for bogus reasons knowing that a certain percent of those rejections will not be appealed. If their records could be easily reviewed by others, that would be a good thing. Just the idea that if I have trouble in Yonkers my medical files from San Diego will be available is comforting. (Not so comforting that my well-known medical history would affect the insurance rates of my family.)

    The loss ratio indicator is interesting, and I’d really like to see that plotted over time. I’ve read that for a long time now (since before the Ford administration but I don’t know how much before) insurance premiums have tracked extremely reliably to t-bill rates. When interest rates are high, an insurance company makes its money off of government securities. When interest rates are low, they profit through fees, which would be reflected in the loss ratio. (In an interesting aside, when t-bills stay at a historically low level for years on end, insurance companies might start to look to mortgage-backed securities as an alternative. It’s possible this could create an unhealthy demand.)

    But it all comes down to *no*, and you say the government can legislate it, and can create a health care system based on cost/benefit. Man that would be great. I just don’t see it.

    As for preexisting conditions, I’m pretty sure that right now it is not in my best interest to have my blood pressure measured. It may be that my only hope of getting insurance is to return to the high-tech workforce. Which really makes me hope that we find a way to pull off universal health care.

  5. This post has become quite topical again, hasn’t it? I’m now inclined to be less pessimistic about universal health care than I was when I first wrote this. Along with a good counter-argument in the old comments section, this article provides plenty of examples of places that do better than we do. I was interested to find out that the US wastes far more on claims processing costs than any other nation.

  6. As I may have mentioned before, the very best health care I got was in the U.K. through the British National Health system. The very worst was in the U.S., under an employer-provided insurance plan that rewarded medical care providers for performing more services than were needed — and I was also a victim of defensive medicine (or it might have been more like, “the customers always ask for this, so therefore you must want it too,” even when I said “no”), the after-effects I still have to deal with even though I don’t have insurance so I hope things don’t get so bad that I have to get treatment.

    A recent study compared the two cities in the U.S. with the highest per-capita medical costs (McAllen, Texas) and the lowest (El Paso, Texas). Both cities are in the same state, so people couldn’t blame state policies for the differences in costs. Both cities are on the Mexican border, so people couldn’t blame high costs in McAllen on a population of illegal immigrants freeloading on American taxpayers and driving up costs — in fact, El Paso has considerably more illegal immigrants than McAllen.

    The difference was that patients in McAllen were demanding more medical services, and getting them, whether they were needed or not. Then medical providers in McAllen started providing more care as standard practice, without even waiting for the patient to ask for it. Things spiralled. In El Paso, patients generally accepted what the doctor said was necessary and didn’t ask for more.

    I do like a lot of features of the current proposed health care plan, although I worry about the provision that says either my employer or I must pay for my health insurance or I’ll have to pay a fine. Yes, there’s a provision for financial assistance for people who can’t afford the premiums, but if the formulas used to calculate what a person can “afford” are anything like the calculations currently used to determine need-based college scholarships, I’m going to go bankrupt.

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