I am mostly in agreement with Danny’s post but I have a few other thoughts to add. First I would like to identify what I think are some facts about the state of America’s healthcare system that cannot largely be disputed no matter how you feel the problems we face should be solved. First, healthcare in America is too expensive and the rate of growth of prices outpaces inflation and shows no sign of slowing. Second, 50 million, and possibly more people don’t have health insurance to buffer them from the high cost of care. Third, there are cultural, economic, and social patterns in this country that will make it very difficult to reform healthcare and improve the level of public health in this country. One is Americans’ tendency to overconsume healthcare (moral hazard) and thus drive up its price. Another is our love affair with food and tendency to live sedentary lifestyles, which is why obesity afflicts approximately 23-25% of the population (some rates are higher in southern states). Subsequently Americans become susceptible to chronic diseases like heart disease, stroke, and cancers and thus must consume more healthcare than if they were healthier. Obesity is on the rise, especially in children, and thus it seems like chronic diseases may plague the next generation of Americans to the same if not a greater extent.These are the sobering realities to face, and both Republicans and Democrats are trying to invent ways to deal with these problems, most notably to control costs and cover the uninsured. In short, the Republican model is to increase competition within the free market by creating interstate competition of private insurance agencies, increasing protection of doctors from frivolous lawsuits, rewarding doctors for good health results (to decrease their overuse of procedures), and place decision making power for healthcare in the hands of the patient. The democratic model is more focused on creating a single-payer healthcare system, perhaps similar to that of the UK in which all citizens are covered and in which the supply of healthcare is controlled by the government. While I largely agree with the Republican model, its biggest weakness is that this system does not guarantee coverage for every American. Prices could theoretically drop, but poor families or those with special circumstances could be left out of coverage. I am also critical of the democratic model because I do not think government should be given the power to make decisions about people’s health. As a future physician, I think this should be left first and foremost to the patient and also to the doctor. This model would also drive up every cititzen’s tax burden. Moreover, it would reduce the quality of care for people who are able to afford private insurance, complicate the patient-physician relationship, decrease compensation and motivation for doctors, and negatively impact people’s health (in the UK people cannot see specialists or undergo specialist procedures until they see their primary care physician first and are often placed on 6-12month wait lists for scans, procedures, and surgery).
One solution that is not as drastic as a single-payer system is to make public-funded healthcare optional and to have it subsidized by both the state and the government so the financial burden is spread across institutions. Also, allow people to keep their private insurance. Another option, which would be similar to the way Singapore runs their health system, is to create universal coverage but have the government only fund a certain percentage of healthcare. This way no one would be without insurance and people would still have to keep a job to healthcare would not become a welfare-like system. These are just some thoughts on how to increase coverage. Whatever intervention the government decides to put into law, whether it ends up being from the republican or democratic part, will not “solve” the healthcare crisis because while everyone will be covered, our system may become less efficient and lower in quality. Moreover, cultural, economic, and social mindsets of Americans will most likely persist and our health as a country may not improve. The problems with American healthcare are numerous, complex, and may not be solved by any sort of intervention, be it government funded or created by the free market.
Joe, I would like to elaborate on several of your points. I will be analyzing several of the problems with the democratic model of health care.
ReplyDeleteIn my opinion, I believe that the decrease in compensation and motivation for doctors is the most pressing issue within the democratic model. Amongst all jobs requiring a professional degree, doctors are the most important. Medicine is the only profession in which employees are dealing in life and death situations every single day. This makes their jobs extremely tedious and difficult.
Lowering the salary of doctors is going to scare away potential medical students, who would discover an easier and more financially rewarding career path, such as in banking. By further lowering the salaries of medical professions, this is going to increase corruption, something that goes hand in hand with government bureaucracy. The motivation to spend thousands of dollars on medical school, to only receive a modest salary, will further diminish the not only the number of doctors, but also the quality. The government will solve the shortage of doctors by lowering the standards on obtaining a medical license, thus allowing unqualified people to attain degrees/licenses and practice medicine, overall driving down the quality of medicine.
Another main point is the downright corruption and unpleasantness that come along with government run systems. Getting a new drivers license is a lengthy and foul process. It takes hours to get a simple card, a hunting license, a birth certificate, etc. etc. Now imagine that the government is in charge of getting a patient a CAT scan, complete with review and an opinion of a qualified radiologist. That would take months and many problems cannot wait that long.
To me, it is downright scary even contemplating the fact that the government has access to my health and family health records. The physician-patient relationship is extremely important on so many different levels. The corruption within the health care system is already rampant, and with government control it would make your`s and your families medical records almost public document.
In conclusion, there is a need for reform in the health care industry in the USA. However, this should be the job of the private sector, thus not allowing government shortcomings and corruption to plague the industry. Doctors are a communities most valued members, as they are in charge of peoples lives and well being.
Frank,
ReplyDeleteThanks for your thoughful criticism of the democratic model. I agree with everything that you are saying in your critique of the democratic model of healthcare. It certainly would decrease motivation for doctors, drive down the quality of medicine, complicate the patient-physician relationship, and ultimately place the supply of healthcare in the control of the government. This is bad for the reasons you outlined, and also, because it takes the power and autonomy away from the patient. I hadn't thought about the fact that your medical records would also be privy to the government, and that is a scary thought.
For the aforementioned reasons, it is my hope as well that healthcare reform will come from the private sector. What I was trying to emphasize in my last post was that whether reform stems from the private sector or from the government, there will be people left behind and it may not solve the underlying problems in American health. In the case of reform from the private sector, people will still be left without health insurance and forced to pay out of pocket for care. Hopefully, prices will fall so this will not be as significant of a financial burden as it is today. In the case of government reform, we can eventually achieve universal coverage, all of the negative things you and I have outlined will come to pass. In either case, we will have unfortunate consequences and that is a shame, given how far modern medicine has come.
I think the one thing that can improve Americans' health regardless of how the system is reformed is an increased knowledge of how to live healthily. We desperately need lower the incidence and spread of chronic diseases (the top three causes of death in our country are heart diseases, stroke, and cancer). Much of this can be accomplished through improving our diet and lifestye. If this can be improved, I think it will alleviate some of the burden placed on our health system and improve the reputation of our nation's health to other OECD nations.
Interesting comments. First, if someone glancing at this is busy, but interested, skip my whole comment and click on the final two links at the bottom of my comment.
ReplyDelete2nd, I agree 100% with two of Joe's comments: 1. No one will be completely satisfied with any type of health reform and there will always be problems. The fact that it has taken the U.S. so long to collectively embrace health reform is a sign of the massive undertaking (now that conservatives have finally agreed to reform we can be assured the majority feel something must change) and 2. regardless of any reform, improvements in diet and nutrition will have the greatest impact on costs and health outcomes. I am a strong advocate of health policy changes such as a "soda tax." (See http://healthcommentary.org/public/item/231829 & today's NY Times editorial: http://www.nytimes.com/2009/06/03/opinion/03weds3.html?partner=rss&emc=rss).
Also, I thought the Singapore model Joe mentioned is interesting. Took a course on health care models in other countries and never came across something like that. Not sure how it would quite work, pros/cons etc. but it seems like it's combining the pros of both public/private into one? With regards to Frank's post, to sum up my response quickly: I agree with the concerns but sacrifices have to be made for reform. Benefits outweigh risks. "In practice, controlling costs invites a lot of political opposition. It means taking money out of somebody's pockets--insurers, hospitals, device makers, etc."
While I share lots of conservatives concerns, the one you described as most paramount, docs salaries, I tend to take with a grain of salt. Primary care physicians in America with the private system we have now get paid zilch. They terrifyingly struggle to maintain practices and America is in a primary care physician crisis. One of the reasons doctors, correction: specialists, get paid so much is because of the ridiculous fee-for-service payment system. More surgeries, more money!!! No quality control, whatsoever. No emphasis on prevention, whatsoever. The fee-for-service system needs to be done away with and most health policy people agree with that. This obsession the right has with maintaining the status quo even if it means driving health care costs through the sun (they are already passed the moon) and further driving quality down boggles my mind. Primary care physicians need to get paid more. AAMC agrees by trying to make medical school more appealing for primary care graduates with various incentives. Specialists even agree, lobbying to congress that while they think primary care physicians need to be paid more, they should not have to suffer. Haha, well tough luck in my opinion. Money does not grow on trees (note current recession) and more money from nowhere can definitely not be put into this joke of a health care system. I'm not some doctor-hater as I hope to be a doc and many relatives are specialists but it's just a simple reality-check in my book. Doctors are meant to treat others. Fee-for-service doesn't cut that.
Also, administrative costs with the American system are incredulous. It is widely accepted this is because of the private system, the different insurers we have, etc. "Administrative costs per capita were $1,059 in the U.S. and $307 in Canada; these costs accounted for 31 percent of health care spending in the U.S. versus 16.7 percent in Canada." A public system is sure to fix this and I could provide links to show that as well.
Also, the concern about government having access to health records I had never thought of. After trying to wrap my head around it I am led to believe it is just an exceptionalist argument made with no effort to try & accept a public system. While I am not too familiar with "health care system corruption", you say that it is "already rampant." I'll take you for your word. With that said how would government make this worse? GINA (genetic information non-discrimination act) and HIPAA laws would still apply. Your health information as public information? That's pretty unrealistic and far-reaching in my opinion. I'm going to end this with a very interesting link from a frequent health care commentator on Slate. The 2nd link was just posted and adds empirical values to the bar graph shown in the 1st link in case you're someone who likes those sort of things! http://www.slate.com/id/2215825/pagenum/all/#p2 http://www.slate.com/id/2219682/?from=rss
ReplyDeleteHi Danny,
ReplyDeleteThanks for your comments on my post. I'd like to respond to your thoughts on physician compensation. I do agree wholeheartedly with you that primary care doctors should be compensated more generously. There is going to be a shortage in primary care docs in the future and with the baby boomer generation aging, we will need many more doctors to care for them.
However, I disagree with your statement that fee for service should be discontinued. Just because a doctor has a positive financial incentive to perform more surgeries does not correlate negatively with prevention and quality. Yes, emphasizing prevention and quality are very important but I belive there are other ways to do this than to eradicate FFS. For instance, some docs may order a few extra scans (CT, MRI, etc) for someone who does not need it to make some extra dough. Situations like this may qualify as the kind of wasteful spending you are describing. However, to take away incentives from specialists or surgeons who, through doing more procedures, can impact the lives of many more people than they would if the government imposed a limit on the number of procedures they could perform. Moreover, if specialists were paid a flat fee, how would that improve quality? You'd be receiving the same amount of money whether your results improve or not, and if your services are in high demand, you'd be limited to the number of patients you could see. Essentially, I think this would detract from quality and innovation of specialist and surgery fields.
What I also think is interesting, to argue against a single payer system, is the fact that socialized systems like Canada are seeking to gradually transform their health care system to make it more similar to ours. Here's the article if you'd like to take a look.
http://online.wsj.com/article/SB124451570546396929.html
ReplyDeleteInteresting article. I tend to agree with it. It's not a surprise. You also see countless stories here of Americans who choose to go overseas for surgical operations that cost 1/4 as much as they do here. I think that trend can, and does, go both ways. Nonetheless, that does not change the fact that the article's concerns of long waiting lists & rationed care are very just; I totally do not deny that. Regarding those though I'll respond in a bit. In the meantime, and more importantly:
ReplyDeletePres. Obama made the following New Yorker article required reading for all of his staff, It is long so read it when you get a chance. The President required it and it’s good/interesting.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all
I’ll just show these three paragraphs out of context from the 8000 words but their purposes are very clear:
“ It is the newest hospital in the area. It is physician-owned. And it has a reputation (which it disclaims) for aggressively recruiting high-volume physicians to become investors and send patients there. Physicians who do so receive not only their fee for whatever service they provide but also a percentage of the hospital’s profits from the tests, surgery, or other care patients are given. (In 2007, its profits totalled thirty-four million dollars.) Romero and others argued that this gives physicians an unholy temptation to overorder.”
“It’s not easy,” he said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible.
“Skeptics saw the Mayo model as a local phenomenon that wouldn’t carry beyond the hay fields of northern Minnesota. But in 1986 the Mayo Clinic opened a campus in Florida, one of our most expensive states for health care, and, in 1987, another one in Arizona. It was difficult to recruit staff members who would accept a salary and the Mayo’s collaborative way of practicing. Leaders were working against the dominant medical culture and incentives. The expansion sites took at least a decade to get properly established. But eventually they achieved the same high-quality, low-cost results as Rochester. Indeed, Cortese says that the Florida site has become, in some respects, the most efficient one in the system.”
“As economists have often pointed out, we pay doctors for quantity, not quality...Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? “