T.R. Reid’s book: The Healing of America: a global quest for better, cheaper, and fairer health care, is timely material for deliberations of how we might manage to craft a health care system for all the people of our nation — instead of an insurance system for some, and a death sentence for others. Reid’s paramount point is that we need to consider health care for all citizens as a MORAL issue! We need to keep this in mind as we contemplate the rest of his data.
Reid explores at length the health care systems in other countries, including personal experience during periods of residence abroad. He uses the “test case” of seeking physician advice concerning some minor shoulder pain and mobility issues stemming from an ancient injury. Responses are illuminating. Whereas his U.S. physician is quick to suggest an expensive and somewhat risky surgical shoulder replacement, other doctors suggest various alternatives before jumping to surgery. It is no wonder why we have the most expensive health care system by far … along with one of the worst outcomes.
Reid categorizes health care systems into four basic categories, and of course hybrid mixes thereof.
- There is the Bismarck model, originally from Germany, where regulated private non-profit insurance plans cover everyone, and people visit private physicians. Employers and employees share the premiums. The government assures that those without employment coverage do not fall through the cracks.
- There is the Beveridge model, originating in post WWII Britain, financed by the government through taxes. The National Health Service is the single payer, with physicians being private, and hosptals nationalized.
- The National Health Insurance model, a la Canada, is a hybrid of the first two.
- The Out of Pocket model is the third world model. Those who can afford care get it: others suffer and die.
The U.S. has the craziest health care system: no system! For most of us for-profit insurance companies run the show. Care can vary from Cadillac to nearly worthless, as they play games to minimize “loss” and maximize returns pay shareholders and executives first. We also have the National Health Insurance (Medicare), and the Beveridge model (veterans, TriCare). … We even have the third world Out of Pocket model for the “have-nots.” Ironically, with increasing reliance on high deductible plans, coverage caps, and exclusions: this is effectively what we have even for many who have “insurance!”
Reid’s survey leads me to this conclusion: in every nation that provides effective health care with better outcomes at lower cost than the U.S., the standard care is provided without for profit health insurance. Either the government fulfills those functions as a single payer, or insurers (happily) provide the standard package (and with guaranteed coverage), competing on the “extras” — things like private rooms, super swift payment, … and more spa coverage! Even Switzerland, the supposed citadel of capitalism, wisely converted their system to a not-for-profit insurance basis — ironically at the very time that Clinton’s efforts for reform in the U.S. were being shot down by carpet bombing of “Harry and Louise” commercials in the early 1990s.
When we have for-profit insurance providers (with coverage linked to employment) as a significant portion of our (fragmented) system, there is an irresistible temptation for the insurance companies to aggressively seek to shift costs to someone else, whether that be some government plan (e.g. Medicare, as we age), the insured themself, or the plan from the person’s next employment. In a society where job mobility is accelerating in a breathtaking manner, there is likely to be an opportunity in 2.3 years or so to “dump” any adverse risks. (Then the new insurance company can exclude “pre-existing conditions!”) Needless to say, this risk-shifting scenario provides little incentive for preventive care, in contrast to rational systems where there is a continuity. Whether the provider is a government agency, or not-for-profit insurers with universal coverage, when the payer is in for the long haul, it has an incentive to reduce future costs (and provide better outcomes!) by taking care of the little things – such as preventive medicine. (In Britain, for example, physicians, media, and even signs on buses, encourage people to visit the clinic for their “flu jab,” or other preventive care. In the U.S. the only reason many insurance plans cover any prevention is as public relations or a marketing tool.)
It is also worth noting that in most of these health care systems, the primary care physician is respected as the one who coordinates care and facilitates prevention. This contrasts to the U.S. system where we have 2/3 specialists.
I would recommend that every member of Congress (and those in the Administration) read this book. Then they can refuse the gobs of cash from the Ins Co’s … and maybe craft us a sensible system of health care in the good old U. S. of A.! … Whatever we do we will need universal coverage (the big pool), and a removal of the profit-seeking and cost-shifting motives which distort our current environment to the point of imminent collapse.
Of course, we’ll have to overcome that streak of American exceptionalism whereby we insist upon doing nothing as others have done it, but only as we have “invented.” We didn’t invent the health care anti-system we now have; but we could invent one that uses the best of the experience of others to determine what might give us a real system with effective outcomes at much lower cost.
As we can see, it will be very difficult to change the system due to the financial power of the Insurance-Health complex. It will take true moral courage. Of course, if we fail, we’ll all go broke together!