Thursday, January 17, 2008

The Politics of Health

One of the major issues in this year’s presidential election is about health care for Americans. Apparently all of the candidates are politically wise enough to agree that people who are sick should get medical attention. A few of those candidates are even wise enough to believe that preventing illness might be a better investment of health care resources than just treating the sick. But apparently that is about where agreement ends. HOW health care should be delivered seems to be a road traveled differently by each party and candidate.

It has been recommended that health care delivery should be evaluated against criteria of quality, access and coverage. Regarding quality, the US on the whole provides care backed with innovation and medical knowledge that is enviable throughout the world. But at the specific level, with individual doctors / hospitals / laboratories / support functions, it is clear that quality varies widely among geographic locations and among all sizes and types of facilities. We as individuals have minimal awareness of the quality and competency of medical services that we receive unless we go to a nationally recognized facility in the specialty of our illness. Part of that is because medical care is a closed industry. Failure rates, complaint histories, price, and comparative performance information is not available to the consumer/patient. Quality is a factor you only know about AFTER the work is done, which is often way too late. This inability to be “an informed consumer” of individual providers is the major flaw in those (particularly Republicans) who advocate “health care delivery by the free enterprise market.”

Which raises the access question: if quality is a variable and in fact often reflects a price tag, who is able to obtain medical care, much less has access to quality medical care? The estimate is that 48 million out of 300 million Americans have no health care. That should outrage each of us. Many of these are people who typically do not go for treatment except as a last resort. Even among those with coverage, day-to-day decisions are made about what care they can afford above the insurance reimbursement, or what life supports (food, shelter, heat, clothing) they must sacrifice to pay for medical expenses. So is quality care truly available to the public?

Regarding coverage, this is the quicksand beneath our feet. Whether or not you agree with his presentation tactics or his specific conclusions, Michael Moore’s “Sicko” movie correctly identified the very real and critical issue of insured Americans not adequately covered. Many of us walk around with our health insurance card in our pocket, believing we are protected from medical calamity. Until we find out otherwise, most often after we have received care. We face deductibles / copayments to be made, limitations on choices of doctors and/or treatments, disagreements of claims over “pre-existing conditions,” or ultimately the stamp of “Not Covered” on our claim form. Worse still are the people trapped in a bad job they cannot give up because they cannot transfer to a new job their employer-based insurance on which they depend.

It’s broken. And it is broken badly. And in this country of outlandish executive pay vis-à-vis worker pay, it is obscene that access to adequate medical care causes any debate at all. The Republicans raise the very old and tired bogeyman of “socialized medicine” when someone talks about government servicing all who need health services. They simply ignore the fact that government has been doing reasonably well (certainly no worse than the private sector) already servicing 8 million children, plus millions more senior citizens, millions of military veterans, and, oh yes, thousands of Congressmen and government officials. State and federal governments have long underwritten health care for a substantial portion of America, so let’s just give up on that scare phrase invented by the American Medical Association in the 1950s. Conversely, the Democrats see an expanded government role in health care, but they are so scared off by the Hillary Clinton reform disaster of the 1990s that they will only stick 1 or 2 toes in the water, keeping the rest of the leg high and dry. Could we please have some truly fresh “change” thinking here?

The two fatal flaws in our current concept of health care delivery are:
-Employer-Based Insurance: not everyone is an employee, so Bush’s tax credits are a nonsensical approach. Health care costs inflate business costs and reduce economic competition with the rest of the world. Employees now change jobs frequently but health coverage does not transcend the workplace.
-Health Insurance: buying insurance to cover your medical costs from someone for whom your needs are their costs and reduced profit is inherently a conflict of interest. You cannot reconcile these two differing objectives in a profit-based competitive marketplace. Especially if you offer insurance on a line-item, illness-by-illness basis. The resulting horror stories from this approach are legion. I insure my car against damage; I do not opt to insure my headlight versus door versus transmission versus motor. If medical insurance is going to be the approach, the industry should do its risk analysis and projections against aggregate total costs of the insured pool and parcel that out, like any other insurance. This is basic insurance 101.

We need to stop talking about how to make health insurance available to everyone. Because health insurance does not work and is not the answer. We need to start over and talk about how to make health SERVICES available to everyone. We need to get doctors and patients back together, while eliminating the incredible waste, inefficiencies and duplication that exist in today’s delivery systems. And you know what? This can be achieved if we focus on those two true objectives.

No comments: