Daniel Roe
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Poster: Daniel Roe @ Sun Jul 26, 2009 7:04 pm
This is a draft I posted to reddit that seemed to go over pretty well, so I decided to post it here.
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I am a 3rd year medical student seeing patients about 50 hours a week. I am also a libertarian. The news these days, as you can imagine, has been a bit of a distraction.
Back to Reality
With health care, the first thing you have to accept is that there is literally not enough wealth on the planet to give everyone the best and most convenient healthcare possible. There is medical technology out there so advanced and on the bleeding edge it makes NASA look like a 7th grade science class.
Even if we had the money, there are other things we'd much rather be spending our money on than our health. It ends up the case that health care can never be cheap enough, fast enough, or good enough.
Think of it this way--The following is what I want from my health care:
* Fast
* Effective
* Cheap
Now pick two.
What We Get For Our Money
People look at this system and say that it's way too expensive--that it's bleeding money from every orifice and needs to be patched up by government.
People use life expectancy as evidence for this. Since we're not number 1 (or even number 10), surely this means that our system's results are inferior.
However, using life-span as a measurement of health care is wrong.
Americans, as we all know, are fat. Only about 1/3 of Americans are not fat. Moreover, 1/3 of Americans are not only fat but obese. This fact alone has some huge effects on health care costs, but when you factor in the general lack of health in America due to lack of diet moderation, exercise, and weight control, that's when things get a little heavy (pun intended. deal).
Complications from weight excess, bad diet, and exercise deficiency dwarf even tobacco in morbidity and mortality by several fold. Heart disease is the number 1 cause of death, 8% of Americans have diabetes (+90% of which is type 2), CVA and stroke are up there too. Not to mention the fact that nearly all cancers have increased morbidity and mortality in the obese. This lack of self-maintenance of health has cascading effects on nearly every biological process in the body.
Death is cheap. If people would simply just up-and-die from every heart attack or diabetes exacerbation, it'd save the system a lot of money. However, as our life-expectancy indicates, people don't die from these diseases much in our country. Only a few years of life span is shaved off our average. This is an amazing feat: to actually bolster our abysmal lifespan with the might of our economy.
When people point out that 15% of our GDP is spent on healthcare, I'm actually surprised at how little that is.
Insurance Companies
Nothing would make me happier than to tell you that just removing profit from the insurance companies would make things cheap. I'm a libertarian, but I'd support it if it were just that simple a sacrifice. The problem is, that's totally wrong.
You would be hard-pressed to find a medical insurer in the US that makes more than 7% net income. Up until the past few years, 5% was an astronomical profit and insurers were hovering at cost.
People like to blame insurance companies for the high cost of care. Would cutting 7% off your medical bills be all that earth-shattering?
In a recent interview with Bill Moyers, one former executive at Cigna stated the hideous practice of trying to disqualify high-cost beneficiaries by technical flaws in their paperwork. Indeed they did do that, but it doesn't actually happen that often.
People decrying our system seem to think that nobody with an expensive and potentially deadly disease gets healthcare. If that were true, my health insurance as a fit, healthy young student with no prior conditions wouldn't be $2,000 a year. More than enough people dying of horrific diseases in this country are covered. I know, some of them are my patients and family members.
Insurance companies pay 97% of all claims. (by the way: Many of those claims are made with the health care practitioner knowing full well that they wont be reimbursed, but do so anyway)
HMO Vs PPO
If you saw Michael Moore's Sicko, you know about HMOs. One of the not-so-subtle implications of Mr Moore's movie is that insurance companies to this day still manage care. He even took footage from 10-year-old congressional committee meetings that made a convincing case against managed care.
The problem with this is: we don't have managed care anymore, and we haven't for some time now.
You can look up the "HMO Act" yourself, but basically this act of congress under Nixon made HMOs the standard of American care until it expired in the mid 1990's. HMOs fell by the wayside and PPOs took over. That, combined with a decline in healthy lifestyle, is why health care costs skyrocketed.
HMOs (AKA Managed Care) basically tells doctors straight away which procedures are allowed to be used for each set of symptoms. If you have a cough, you may be able to get a chest x-ray, but you can't get a kidney function test (even though you can have kidney ailments that are involved with cough, they're just rare).
If you had a devastating illness, HMOs did an okay job of covering you most of the time. It's by no means perfect, but remember: it was cheap!
The HMO tells you which doctor you can see (the doctor had to agree to work under the plan), and tells the doctor what they're permitted to do.
In contrast, if you come to a doctor's office with a PPO backing you, it's basically a free-for-all.
One thing I will say for HMOs is that they were cheap, and they provided most of what you want out of a health care plan.
Since the advent of PPOs, it has become very hard to even find a company willing to sell you a HMO plan. When you find a plan, you have to jump through several hoops to qualify. However, even now, HMO's usually cost 30-40% less.
Because HMO's so tightly managed care, they became vehemently opposed by Americans. When the HMO Act came up for renewal, it was voted down by congress and lead to the extinction of the practice.
HMOs Vs Single Payer
Single payer systems are managed care, by definition.
The single payer manages what physicians can do for their patients, puts conditions on care (eg "Quit smoking if you want your arteries fixed"), and sets prices.
When countries allow the single payer to compete with private insurers, some patients and doctors choose not to participate in the single payer program at all. This is why many systems do not allow private competition.
Latest Health Care Plan By Obama Et Al
As far as I can tell, the new health care bill on the table now is going to make it illegal to not have healthcare.
On top of that, through some pretty crafty measures, it will force most Americans into changing over to an HMO-style plan.
Even if I weren't a libertarian, I'd probably still say that forcing people to buy health insurance is about the most fascist thing this government has done in a long time.
More Health Care = Less Personal Responsibility ?
It's no coincidence that the people who put the least amount of effort into maintaining their health are usually those who have the best healthcare.
I know libertarians are up in arms over medicare, but the fact remains that these patients get superb care. There's a reason why the medicare program is on a rocket-sled to bankruptcy, and it's not that they pay out too little. Medicare pays more per capita than any socialist system in the world. They get everything they want from motorized chairs to unnecessary joint replacements. No private or public managed care system hold a candle to Medicare.
It's true that there's a lot of red tape and that doctors routinely get paid less (or are unexpectedly denied payment)--a lot more than a PPO. However, recipients still live like kings on the plan.
It's no wonder, therefore, that the obesity rate in the elderly is higher than any other demographic, with a close second being the poor (who get coverage under Medicaid).
Yes, it's harder to take care of yourself when you're old, but it's a mistake to think that these people are incapable of diet and even a modicum of exercise. Proof of this is simply by comparing our elderly obesity rates to those of other countries.
It really doesn't matter who pays for it, having a lot of health care makes you lazy about your health. The government directly subsidizes the poor and the elderly, but employer-provided health care is also indirectly subsidized. Basically, government made it more lucrative to both sides to give more reimbursement in the form of health insurance than wages. Just like with wages, employee health care reduces profit, which reduces corporate tax. In addition, it is currently untaxed by the labor tax (aka the personal income tax), nor is it taxed by FICA or Social Security. In fact, employers didn't start providing employee care until government started heavily taxing other forms of employee reimbursement (wages).
Torn
As a libertarian, I'm mortified by the prospect of government manipulating care. However, as a future physician, I can't shake the feeling that maybe having managed care will bring back personal responsibility for health in the US.
It's very conflicting, but in the end, you just can't argue in favor of slavery, even if it will make people safer from themselves.
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