Health Care Again - pt. 2

All of the debates about healthcare, and the discussion we had in the previous article, seem to lead us back to the issue of providing healthcare insurance to those who couldn’t afford it, in order to keep people from ‘dieing early.’  But that really is two separate things, isn’t it?  Is the ACA really an effort to prevent people from ‘dieing early’ or is it an effort to make certain that everyone has health insurance?  The difference is important.  Those with large amounts of extra money (the ‘rich’) really don’t need health insurance – if you have $50 million in the bank earning 2% interest every year you don’t need health insurance.  And, in fact, some 240 million to 250 million US citizens were covered by health insurance of some sort or another before the ACA.  The ACA is supposed to add 30 million citizens onto the list.  Why the government didn’t construct a system that addressed all 60 – 70 million (there are 311 million US citizens) is a bit of a mystery to me (not that I want them to, but it is curious).

But at the same time there is no effort to increase either the total quantity or the overall quality of health care.  So, the ‘goal’ of the ACA is in reality ‘more people with health insurance’ while making no efforts elsewhere to improve healthcare.  Ask yourself this question: if the goal were to improve overall health of American citizens and increase life spans, is this how you would have gone about it?

The ACA expands the amount of money the federal government pushes into healthcare each year without otherwise addressing the fundamentals of healthcare.  That translates into expanded federal control. That seems to make it fairly clear that the ACA is about issues of control and mandatory insurance is a vehicle for that control, and that actual healthcare is secondary to the issue of control.  (For those who doubt that government bureaucracies equate ‘money’ and ‘control’ you need to go look no further than education; the federal government has repeatedly asserted that it can dictate terms to private schools if any student at the school accepts federally guaranteed student loans, whether the school knows of the loan or not.)

It is worth noting that every single person in the US already has access to critical or crisis care through Medicaid.  But it is also worth understanding that long before Medicaid / Medicare, or the Department of Health and Human Services, or its predecessor the Department of Health, Education and Welfare, were created, or even gleams in some bureaucrat’s eye, hospitals across this country operated within the confines of a strict moral and ethical code that demanded that they treat everyone who showed up at their doors.  Further, every doctor in the country individually operated under the same code.  The fact is that if people could get themselves to a doctor’s office or a hospital they would receive care.  When money became a problem, ways were found around it.

What was missing from healthcare were: 1) a program to pay for annual physicals as a preventative to further problems; 2) some sort of coverage to address catastrophic illness; and 3) a means to address the shifting demographics that left certain segments of the population physically isolated from medical care – in particular inner city poor as hospitals expanded outside urban centers and doctors and nurses moved away from urban centers.  The ACA sort of covers #1, in some cases may cover #2, and ignores #3. 

The ACA does not address the issue that the young – who are predominantly healthy – feel they don’t need healthcare insurance, except by taxing them (which only serves to underline George Washington’s point that in the end governments are really only about force – forcing people to do things. (It also serves to point out Washington’s point, that governments must, therefore, be kept on very tight leashes)).  Using taxation to force certain behavior is both a favorite tactic of governments throughout history, and hardly the mark of a limited government.

If the issue were to improve healthcare, and there was a real desire to improve the quality of healthcare might it not have been better do have done something like this?

1)             Every dollar spent on healthcare insurance – no matter your income level – is deducted from your gross income, thereby reducing your taxable income, creating an incentive for people to buy healthcare.

2)             Everyone is free to buy any insurance they want, in any county or state – no arbitrary federal, state or local regulations protecting this or that insurance company.

3)             Provide tax breaks for retirement age doctors and nurses, creating incentives for them to remain in practice.

4)             Provide ‘fast-track’ procedures for foreign doctors and nurses to immigrate and receive accreditation, working with the AMA and others as necessary to maintain standards.

5)             Work with the AMA, the universities of the US, US hospitals and American industry to provide opportunities to found new schools and expand old schools of medicine, and to expand the various residency programs.

6)             Work with hospitals, clinics and industry to develop an improved, streamlined process for the FDA to approve new drugs and new treatments.  The FDA approval process is currently one of the slowest and most cumbersome in the world.

7)             Work with universities, hospitals and industry to expedite new technologies and new techniques that improve healthcare.  Expedite in particular the approval of those treatments that exploit technologies that utilize non-medical personnel, as well as ‘remote’ technologies that allow more medical care to those people physically distant from treatment centers.

8)             Provide tax incentives for doctors, nurses, other medical personnel, and companies across the entire medical industry to provide healthcare to the poor; ensure that these incentives are easily tracked and that the paperwork is not onerous.

9)             Develop legislation that provides caps or limits to malpractice liability claims – for individuals and organizations.

This is a start.  There is more, but we should begin here.

We need to realize is that shoveling more money at healthcare while expanding government control is unlikely to work; it hasn’t worked in the past and why it would mysteriously start working now is beyond me.  But especially ludicrous is the unspoken premise that ‘healthcare can be fixed,’ that the government can mandate some sort of solution and then it’s fixed, that the solution the government comes up with today will work just as well in 5, 10, 20 or 50 years.  The fact is that healthcare, as with a great many other problems, is a very complex set of issues that not only defies easy characterization, it defies nearly any characterization at all.  There are large segments of the healthcare industry that, far from being broken, are performing superbly.  Any action by the government in these areas is likely to make matters worse, not better.  More to the point, we need to accept that in anything as vast, as complex – and as personal – as healthcare there can be no ‘right’ answers, no answer that is adequate and appropriate for every person, no answer that once given will never change.  Instead, every answer is constantly evolving, as technology and treatment change, and as we as individuals and as a society change.  The answers to healthcare do not lie in the offices of politicians or bureaucrats at all; the only thing government can do is to, as best as possible, ‘clear the field’ and allow the ingenuity and creativity of people across the nation to continue to refine and develop healthcare.  The real answers can only be found among patients (that’s all of us), doctors and nurses, and inventors and engineers; let’s go there for the solutions.  

Health Care - Again pt. 1

The Affordable Care Act (ACA) has now been effect for more than a month.  We are all aware of the mess that is the computer support piece of the ACA.  Although that is a ‘non-trivial’ issue, centralized, computerized support for healthcare being a key element of ACA, I’m going to ignore it for today.  Irrespective of the computer support for the healthcare, the central issue is whether the healthcare provided under the ACA will be an improvement or not.  So, let’s take a look at the issue of the healthcare that will be provided versus what needs to be done.

First, here are a couple of observations from a survey of healthcare workers – doctors and nurses - who were asked what effect the ACA will have on healthcare nationwide, this from an article in the Washington Examiner on 27 September: 

- More than nine in 10 believe that there could be major negative impacts such as a drop in quality care

- 53% believe that “Quality of health insurance policies will suffer.”

- 51% believe that “Quality of care will go down.”

- 42% believe that “Insurance exchanges will be poorly managed.”

- 19% believe that “Americans will die earlier.”

I would think the last line would give people pause: just a bit less than 1 in 5 doctors and nurses think that the ACA will result in Americans dieing earlier.  Isn’t healthcare about people living longer, healthier lives?  Yet 1 in 5 doctors think this new healthcare system will result in a decrease in life expectancy.   That alone should cause a great deal of concern. 

But, the proponents of increased government oversight and control of healthcare will respond that with the rising costs of healthcare over the past 4 decades something needed to be done for those who were without health insurance and were already dieing ‘early.’  So, let’s set aside for a moment the new concerns about dieing earlier and simply ask two questions: 1) What caused healthcare costs to rise above the rate of inflation over the past 45 years?  And 2) What might be done to control costs?  (Asked otherwise: How does the ACA address these issues?)

 

Healthcare costs have risen as a result of a number of different forces, each is relevant, but all are to blame, so the order below is not significant.

a)     Government funding; simply, when government starts pushing money into medicine (or any sector of the economy), prices rise; the greater the government ‘flow,’ the more the increase in prices.  (Government support of housing loans caused home prices to rise, for example.)

b)    Technology; as technology to diagnose and treat diseases has improved, treatments that weren’t available 5, 10, 15 or 20 years ago are now available, whether we talk about drugs (think of some of the pharmaceuticals developed in the last 20 years), treatment schemes (the advancement in cancer treatment) or hard technology (MRI, etc.)  These new technologies are incredibly capable, but they also expensive.

c)     Liability Law and Malpractice Insurance; various court decisions have had the effect of driving costs up across the board; malpractice insurance rates soared, and every element of the healthcare industry became possibly culpable in nearly any situation.  This has not only increased the amount of oversight – and hence cost – in medical care, it has also led to changes in medical practices, to include greater specialization as well as increases in the breadth of diagnostic testing – both of which drove up medical costs.

d)    Supply; the number of medical schools and nursing schools, and residency programs, in the US has remained essentially unchanged for most of the last 40 years.  This began as an effort – by the AMA and the federal government – to maintain standards.  But it is now unbalanced, and the US now produces less than half the number of doctors and nurses it needs.  Further complicating the issue, one of the effects of medical malpractice has been to drive physicians out of certain fields and into others, resulting in even greater shortages, for example among general practitioners and OB/GYNs.

 

In short, over the last 45 years ‘supply’ has more or less been kept constant, real costs (technology and the operating costs of hospitals and doctors’ offices) have increased, and the government has poured money into the ‘industry.’  Where does that leave us with the second question: What might be done to reduce costs? 

 The first issue is that there is no easy answer to the ‘supply’ problem.  There needs to be a concerted effort to open new medical schools and nursing schools and new residency programs around the country.  Doing so while maintaining standards will not be easy – or quick, but it must be done.  In the meantime, two steps should be taken: provide some sort of incentive to older doctors and nurses so that they put off retirement for several years, and pass a specific immigration bill to facilitate the immigration of doctors and nurses.

Steps must also be taken to cap or otherwise limit malpractice settlements.  The ‘deep pockets’ that the courts have dipped into in the past have been emptied at the expense of the entire nation.  Limits must be set on such settlements.  At the same time, the insurance conundrum is further complicated by limiting all concerned with insurance coverage within their own state – for doctors, nurses, and patients.  Now it appears that within the ACA there will be prohibitions to not only crossing state borders, but in some cases crossing county borders.  In short, one of the key issues with insurance costs that needed to be addressed has been made decidedly worse under the ACA.  That should be ended – it simply stifles competition and drives up prices.

Can anything be done to control the costs associated with new technology?  Probably less then we want.  The approval process (within the FDA) for new drugs and new treatments could be dramatically streamlined and that would be helpful.  But the truth is that many of these new drugs and new tools are expensive.  But with those new and expensive tools come cheaper ways to do business. Thus, operations that used to require a week in the hospital now often mean surgery and release on the same day.  Costs increase because of the technology involved, but the overall cost of treatment might be less.  In short, the real answer would be in letting the ‘marketplace’ develop the answer.  Certainly the technology has improved over the last 75 years in such a manner that medical care that was not available to kings, queens and presidents at the time is now available to everyone, and at reasonable costs.  Technology and the market place are like that – it takes time for technology and education and production and ‘SOPs’ (standard operating procedures) to all catch up and balance out – it cannot happen overnight, and government attempts to make it do so only result in severe imbalances, price spikes and mistakes.

Where does that leave the ACA?  Sadly, the only thing the ACA does is pour more money into the healthcare field.  Shortages are not addressed, nor are any of the other cost drivers – except eligibility for treatment.  In short, more money – which will mean higher prices, and managed access to supply, which is a polite way to say ‘rationing.’

There is another way to say that as well: Pay more, get less.

Tomorrow: some suggestions on what government might do – if it were inclined to actually improve the health of the citizenry.