Tom Power - June 08, 2009
Health Reform
Health Reform Is Not Insurance Reform: Looking at the Whole Picture
Montana Senator Max Baucus, the Democrat in charge of shepherding “Health Care Reform” legislation through the Senate got an earful from constituents when he sent his staff to town meetings across Montana to discuss the reforms he had in mind. Many citizens attending these meetings were outraged to learn that Senator Baucus categorically rejected a “single payer system” and was almost exclusively focused on how to use public policy to assure that all citizens were covered by a private health insurance policy. Baucus was even hesitant about the federal government providing an alternative to private health insurance.
Senator Baucus is primarily focused on the extension of the current private health insurance regime to all citizens. That might well increase access to health care once a person is sick, an admirable goal, but a far cry from a health policy. Such an approach does not focus on keeping us from getting sick nor does it do anything to control the skyrocketing costs associated with treatment once we are sick. If our health continues to deteriorate and heath treatment costs continue to rise, the costs of this expanded health insurance regime will ultimately sink it, leaving us all less healthy and poorer.
Studies of the determinants of our health indicate that access to health care is one of the minor determinants. If we ask what determines the odds that we will die early from disease, only 10 percent of the early deaths are related to short falls in medical care. Forty percent of the of the early deaths are associated with our behavior patterns including our diet, lack of exercise, smoking, abuse of alcohol, etc. Social circumstances, including poverty, genetic predisposition, and environmental exposure explain the other 50 percent of premature mortality from disease.
Clearly, expanding access to health care is a good idea. But that will not make us healthy! There is a big difference between “sick care funding reform” and a national health policy.
The major problem with our current health system is that it is built around a for-profit sick industry. Most of our medical care is provided by private individuals and companies that make their money by treating us once we are sick. Most of that money is funneled to them through for-profit insurance companies who collect it from us ahead of time.
The medical care providers focus on treatment, making money off of every treatment provided, regardless of its effectiveness. Since we are not in a position to evaluate the alternative treatments and are largely shielded initially from the price tag associated with those treatments, there is almost no cost control built into the system. Our insurance companies use many of the dollars we pay to them as premiums to avoid paying as many of our medical treatment cost claims as possible. They also use our money to lobby against any meaningful reform of the whole sick-care industry. Meanwhile medical insurance costs rise right along side the skyrocketing medical care costs.
It seems highly unlikely that we can find a way out of this costly medical care mess and get focused back on health unless we do what every other affluent nation has done: adopt a single payer system that finances both an expanded public health system as well as universal basic medical care.
Many politicians are afraid to talk about that approach because they know that their constituents do not want to hear about the “R” word: the rationing of medical care. But we absolutely have to face up to the fact that we as individuals are almost never in a position to evaluate the alternative treatment regimes that might be used once we are sick or injured. We do not have the technical training to evaluate the medical technologies. Also, we are usually not in either the physical or mental condition to carefully evaluate the available choices and make an objective decision. Most importantly, in situations where we or a loved one is in pain or possibly facing death, the impulse to do anything that might help is overwhelming, no matter what its actual effectiveness, cost, or quality of life considerations may be. We cannot be “rational shoppers” guided by commercial market considerations in that setting.
One thing that a single payer medical care system can provide is an objective evaluation of medications, diagnostic techniques, and medical procedures. That system, not motivated by private commercial interests, can make clear statements about the efficacy and consequences associated with the alternatives and make us pay attention to their evaluations by saying the system will not pay for certain things. Those who can afford to pay for those medical measures on their own can and will proceed. But a clear objective message about efficacy, safety, and cost will have been provided. Only that can help us get health care costs under control.
Just as important, a single payer medical care system can also focus dollars on health rather than exclusively on sickness. A major public effort such as the effort to reduce smoking could focus on the behavioral patterns, environmental exposures, social circumstances, and genetic predispositions that are responsible for 90 percent of early death due to disease. That would be real health reform.
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