The Colonoscopy Chronicles-a Baby Boomer’s Guide to Colonoscopy-has so far focused on some of the medical nuts and bolts issues related to colon cancer screening, and colonoscopy in general. So today’s posting will be a bit of departure, as I will take this opportunity to editorialize about the healthcare topic of the day-Healthcare Reform. I propose that healthcare reform is necessary, and long overdue. I firmly believe that Congress will pass some form of reform, and it is my hope that it will be the reform that we want and need. Who would have thought that this would have been such a political tinderbox? Well, when you stop to consider it, perhaps it was predictable that healthcare debate would generate a visceral response from Americans. For one thing, many Americans earn their livelihood from the healthcare industry. It is estimated that healthcare comprises about 17% of our economy, thus it stands to reason that about one of every six Americans’ paychecks come from healthcare.
Another reason for the spirited debate that has occurred is that those Americans who are covered by healthcare insurance in one form or another fear, understandably, losing that coverage, or having their coverage seriously altered. Most studies have indicated that those who are covered are generally happy with their coverage and would not want to see it replaced. This is despite the fact that there is widespread agreement that there are serious flaws with the status quo.
Let’s face it, when those of us with health insurance receive the estimate of benefits letter from our insurance company, we see the initial charge by the provider or institution, and then we see how our insurer has negotiated a more favorable rate for us, and finally we see how much of this negotiated rate the insurance company will pay, and how much we are responsible for. This last number, our ultimate patient financial responsibility, is generally a far cry from the initial charge. This fact is not lost on patients, and the last thing they want to see is that they are now on the hook for the total charge. This potential hit to the pocket book is bound to provoke a powerful reaction.
Another reason people are loathe to see anything that compromises their health insurance coverage is the fact that most covered patients have significant choice in terms of choosing their doctor, and are afraid that this freedom would vanish under healthcare reform.
Finally, most of us have had either personal experience or have had a loved one experience a catastrophic injury or illness. We all know that without coverage we or someone close to us would have been devastated financially, on top of the effects of the illness.
So yes, it is completely understandable that those who currently have health insurance in one form or another are willing to fight to maintain the status quo-or at least some semblance thereof. American medicine-despite the potshots it takes in the media-has much to be proud of. American research in medicine and pharmacology has produced advances that were practically unthinkable. To put things into perspective, when I was a medical student in the early 1980’s, AIDS was first recognized. Within a matter of only a few years, the virus responsible for AIDS was identified, and treatments developed. Now, what was once a uniformly rapidly fatal disease has been transformed into what is largely a controllable chronic illness-all within an approximately 20 year time frame. This is not to say that we have cured HIV. I also recognize that there are huge numbers of patients that cannot afford antiviral drugs in order to keep the virus in check. But the point is, that the speed and effectiveness with which medicine has advanced is remarkable. Death rates from cancer are declining in America, and people are living longer than ever.
So, why does healthcare in America need reform? First of all, there are vast numbers of Americans who do not have healthcare insurance. While the estimates vary, most would agree that approximately 10-15% of Americans are not covered. What is not exactly clear is why these patients have no coverage. Most certainly, some of them simply cannot afford medical insurance due to a low income, but yet are not eligible for Medicaid-the government healthcare for the indigent. Still others are not able to afford healthcare insurance, not because of a substandard income, but because they have a pre-existing medical condition that makes their insurance rates impossibly expensive. Finally, there are many who can afford health insurance, but simply choose not to. Any meaningful reform in healthcare would have to address all of these underlying reasons for lack of healthcare insurance. Those who truly cannot afford insurance due to low income should get some form of subsidy. Those who have pre-existing conditions should not become healthcare pariahs. Those who can afford insurance but choose not to must be mandated in some way to purchase it.
In addition to reform ensuring that all Americans are covered, it must address the issue of runaway costs. Clearly, the rise in healthcare cost has oustripped rate of inflation. The reasons for this are complex, but certainly include massive profits by health insurance companies. When the insurers offer patients fewer services at a higher premium each year, and pay healthcare providers less each year, it doesn’t take a math genius to see that it is a recipe for steadily increasing profits for the insurers. United Healthcare, just to cite one example, earned nearly 5 billion dollars in profits in 2008, while Aetna earned about 1.5 billion in 2008 profits. No one begrudges them an opportunity to turn a profit, but the insurers must be regulated so they cannot cherry pick the healthier more profitable patients and refuse to cover the higher risk individuals.
Another reason for spiraling costs is the litigation-crazy society in America, and the constant threat that doctors will be sued for malpractice for any sort of negative patient outcome. Beleaguered doctors, fearing lawsuits, often resort to ordering tests that they know are unlikely to be fruitful just to cover the remote possibility that something could have been missed, or to mollify patients. This wasteful process results in huge, essentially worthless, healthcare expenditures. Reforming the malpractice laws could result in a system that no longer promotes this futile spending, yet still protects patients. Yet the current healthcare reform bills that are being proposed do nothing to promote malpractice reform. The trial lawyers have too strong a lobby, and they are not about to allow this source of windfall profits to slip through their fingers.
Finally, healthcare should be reformed because, despite the steadily rising costs, we really do not get our money’s worth-partly for reasons mentioned above. In addition, there have not been uniform standards for measuring outcomes and quality. Consumers deserve to know if their healthcare provider follows evidence based medicine, and deserves to know how they perform on a series of universally accepted benchmarks.
There you have it-it is hard to argue against the principles of universally available healthcare this is cost-effective, and promotes quality. The dilemma is in choosing the best path to get there. The reality is that these noble principles will be completely distorted once Congress takes out their toolbox and goes to work drafting a bill. The incredibly powerful special interests who donate millions of dollars to the politicians will really be the ones crafting these bills, and crowding out the interests of the public. The lobbyists that represent the hospitals, the pharmaceutical companies, and the insurance companies will see to it that their interests will be the first priority, and then let the chips fall where they may. They will come out the true winners in whatever reforms come about.
The losers? You guessed it-first and foremost John Q. Public. Sure, on the surface it may seem that there are some gains for the average citizen, but this will come at a gigantic cost in terms of higher taxes and higher public debt. The other big losers will be physicians. As the least powerful link in the healthcare food chain, their interests will be overshadowed by the big bullies on the block-big pharma, insurance, and the hospitals.
What about the “Public Option”? On the face of it, a public option sounds attractive: provide a competitor for the private insurers to let free market forces drive down prices for the consumer. As many have aptly pointed out, it would be one thing if this competition was fair, but it would hardly be a fair fight since the government run option would have gigantic competitive advantages-being subsidized by the taxpayer. What we really need is proper regulation and oversight of the existing private health insurance market. Private profit driven companies will not necessarily do the right thing for society-their principal responsibility is to the shareholder. But that doesn’t mean that every industry needs a government run competitor to force private industry into compliance-that’s what laws are for.
For example, automobile manufacturers knew full well that installing seat belts and headrests in automobiles would prevent injuries and death in car accidents. While the moral imperative would have been to install them, they did not, since it would cut into their profit. So what should the response of government be-to open up a government run automobile manufacturing company and produce cars with seat belts and headrests? Of course not!! Rather, the answer was to federally mandate that these safety measures be implemented by the existing manufacturers.
Creating a public option would entail the creation of a new entity that would bloat the already massive Washington beureucracy and cost the taxpayers beyond their wildest dreams. If the true aim is to achieve universal coverage, with cost reduction, and quality assurance, we can and should do it without a public option. For all of our sake, let’s hope Washington gets it right.
Here’s to good health!
The Colonoscopy Chronicles
Wednesday, October 14, 2009
Posted by Doctor Mike at 9:00 AM