The state of US health care
Nov. 6th, 2011 08:31 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
snousleOne of the most insidious propaganda campaigns going on right now - and a disturbingly effective one, too - is promoting the idea that single-payer systems in other countries have "failed" while the US is has the "best healthcare in the world". This is a plain, transparent lie, and because it's so easy to beat it into the ground, I am going to do so right now.
Measured by technical prowness, the US is almost certainly the best bet for those people that happen to have six-figure slush funds to put into their own health care through the private system. For that 99% of the country we have been hearing so much about lately, the ones that don't have that kind of spare change, the situation is a little different. There are so many sources to cite it's hard to list them all, but if you're a little on the nerdy/analytic side, a great place to start is the site gapminder.org, where you can configure your own charts, like this one, which tells pretty much the same story as any other source: the US has slightly worse health outcomes than most industrialized nations, but at about twice the price. Even as a percentage of GDP, the US spends about twice as much overall as comparable countries.
When it comes to subjective measures of patient satisfaction, the US also lags - see here and here, and for those of you who are worried about liberal media bias, here's something from Fox News saying the same thing.
What really shocked me was that the US already spends more in tax dollars alone than other countries:
That's from this article. Think about this for a bit. We already have a socialized medical system - one that is more socialized than other countries in the sense that it already consumes a slightly huger chunk of tax revenues than it does in, say, Canada or the UK. But to actually use it, we have to pay again. Either payment system alone should be enough to pay for decent medical care, but we have to pay twice.
That, I'm afraid, is "failure" on a grand scale. It is possibly the greatest waste of money in all history, and it is an outrage. And, as the article suggests, the right-wing take on this truly is denialism; there are no outcome- or satisfaction-based statistics I know of that contradict this picture, only heart-wrenching tales of grandma not getting her MRI when she wants it.
Let's be clear: running an effective health care system means saying "no" to a lot of people, and that is going to result in a whole lot of drama and dissatisfaction. The amount of money one could justify spending on health is literally unbounded, particularly as technology advances. If we can grow new hearts for a million dollars a pop, what elderly person wouldn't want one? Who wouldn't feel they have a right to one if it saves their life? It makes me clench my teeth whenever health care is framed as an entitlement; this path leads to ruin. Instead, it must be approached as a cost-benefit analysis, with the benefits measured in quality-adjusted life years (QALY).
There are a couple of ways to approach this. One is to say "no" in the easy cases, by shuffling them off to the side and hoping they die cheaply. Another is to say "no" in the hard cases, in dramatic situations that call for emotional demands for treatment, but where the treatments are unjustified because they don't provide the same QALY improvement as you'd get treating someone else. (In neither case do I oppose letting people pay out of pocket for procedures that the state doesn't cover.)
Unfortunately the US is caught in the reactionary, emotionally-driven mode, where preventative care is neglected and measurements of effectiveness are tossed out the window. The medical industry has capitalized on this and is quite good at the use of fear, self-dealing, and fantasy accounting to extract as much money as possible from patients. (I call it blackmail, and is a very good argument against letting private interests control medicine in the first place.) It is not clear if the political structure of the US even makes it possible to run a rational, evidence-based health care program. Obamacare might or might not be a step in the right direction.
BUT THE LIES HAVE TO STOP before there is any hope of progress.
This post is based on comments in a previous post.
Measured by technical prowness, the US is almost certainly the best bet for those people that happen to have six-figure slush funds to put into their own health care through the private system. For that 99% of the country we have been hearing so much about lately, the ones that don't have that kind of spare change, the situation is a little different. There are so many sources to cite it's hard to list them all, but if you're a little on the nerdy/analytic side, a great place to start is the site gapminder.org, where you can configure your own charts, like this one, which tells pretty much the same story as any other source: the US has slightly worse health outcomes than most industrialized nations, but at about twice the price. Even as a percentage of GDP, the US spends about twice as much overall as comparable countries.
When it comes to subjective measures of patient satisfaction, the US also lags - see here and here, and for those of you who are worried about liberal media bias, here's something from Fox News saying the same thing.
What really shocked me was that the US already spends more in tax dollars alone than other countries:
That's from this article. Think about this for a bit. We already have a socialized medical system - one that is more socialized than other countries in the sense that it already consumes a slightly huger chunk of tax revenues than it does in, say, Canada or the UK. But to actually use it, we have to pay again. Either payment system alone should be enough to pay for decent medical care, but we have to pay twice.
That, I'm afraid, is "failure" on a grand scale. It is possibly the greatest waste of money in all history, and it is an outrage. And, as the article suggests, the right-wing take on this truly is denialism; there are no outcome- or satisfaction-based statistics I know of that contradict this picture, only heart-wrenching tales of grandma not getting her MRI when she wants it.
Let's be clear: running an effective health care system means saying "no" to a lot of people, and that is going to result in a whole lot of drama and dissatisfaction. The amount of money one could justify spending on health is literally unbounded, particularly as technology advances. If we can grow new hearts for a million dollars a pop, what elderly person wouldn't want one? Who wouldn't feel they have a right to one if it saves their life? It makes me clench my teeth whenever health care is framed as an entitlement; this path leads to ruin. Instead, it must be approached as a cost-benefit analysis, with the benefits measured in quality-adjusted life years (QALY).
There are a couple of ways to approach this. One is to say "no" in the easy cases, by shuffling them off to the side and hoping they die cheaply. Another is to say "no" in the hard cases, in dramatic situations that call for emotional demands for treatment, but where the treatments are unjustified because they don't provide the same QALY improvement as you'd get treating someone else. (In neither case do I oppose letting people pay out of pocket for procedures that the state doesn't cover.)
Unfortunately the US is caught in the reactionary, emotionally-driven mode, where preventative care is neglected and measurements of effectiveness are tossed out the window. The medical industry has capitalized on this and is quite good at the use of fear, self-dealing, and fantasy accounting to extract as much money as possible from patients. (I call it blackmail, and is a very good argument against letting private interests control medicine in the first place.) It is not clear if the political structure of the US even makes it possible to run a rational, evidence-based health care program. Obamacare might or might not be a step in the right direction.
BUT THE LIES HAVE TO STOP before there is any hope of progress.
This post is based on comments in a previous post.
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no subject
Date: 2011-11-07 08:03 am (UTC)I can't pull things up for you right now because of my limited connectivity, but give me two weeks and I will show you why the root of the problem is not the payer system, but the cost of malpractice insurance on health providers. While you're researching, you might compare the cost providers have to pay to protect themselves in the U.S. to those in the "higher rated" countries. The malpractice insurance industry has justified their exorbitant costs ($75,000/year for a GP, $250,000/year for an OB/Gyn) with stories of "jackpot lawsuits" that get a lot of press but in actuality are very rare. We need tort reform and malpractice insurance reform urgently, and legislation requiring providers to lower their costs to reflect this (because they tried it in Texas and the docs kept the savings). Then you'll see the cost of health care drop dramatically, and with it, the cost of health coverage for the average Joe.
no subject
Date: 2011-11-07 01:02 pm (UTC)no subject
Date: 2011-11-07 05:21 pm (UTC)An interesting report, because it's from a group that generally promotes tort reform, concludes that "medical malpractice claims and premiums have almost no impact on the cost of health care. Medical malpractice premiums are less than one-half of one percent of overall health care costs, and medical malpractice claims are a mere one-fifth of one percent of health care costs." These people have an agenda of their own that might influence their take on it but given their goals I would expect their bias to go the other way; even allowing for great exaggeration it's still orders of magnitude away from explaining the 2x greater cost of medical care in the US.
Another report from NBER address the question of whether rising malpractice premiums affect the type of care delivered, possibly making it more expensive due to unnecessary tests. Cross-state comparisons say "not much".
Time had a fairly good article listing numerous reasons for high health care costs; malpractice is listed as a factor, which it is, but one of many.
no subject
Date: 2011-11-08 04:29 am (UTC)I really like that Time article, I think it sums it up nicely.
Don't get me wrong, btw. I could support a single-payer system if we could just do it right. Incorporating all the changes suggested in that article, and eliminating the incentives that hospitals (not so much physicians) have for keeping people as repeat customers.
Having said that, however, the danger lies in the budget incentives inherent in the public sector. For example, if a private company comes in under budget for a given year, they are rewarded with bonuses (typically). If a public agency comes doesn't use their entire budget, what happens? Their budget is reduced for the next year. So public agencies are incentivized to exceed their budgets so they get a bigger one next year. A reward for going over-budget. Until that kind of nonsense is stopped, I can't see a public health care system ever working in our country (even if we could get the people to agree to the necessary tax hike).
But good catch on the malpractice premium effect on health care costs...I stand corrected on that.