Dr. Tom Roberts - September 02, 2005
Rethinking the Health Care System
People without health insurance are different from those with health insurance. Half of them owe money to hospitals. A third are being pursued by collection agencies. Children without health insurance receive less care for serious injuries, ear infections, asthma, and you name it. Adults without health insurance get less care for cancer, heart disease and pneumonia. People without health insurance are 25 % more likely to die, than those with insurance. It is not a trivial problem. There are 45 million of us in the US now without health insurance. One fifth of Montanans have no health insurance. We hear these numbers and get a glimmer of the problem, yet we seem hopeless and helpless in terms of really finding a solution.
In fact one of the great paradoxes of our time is that we continue to be committed to supporting such an outrageous system of health care. We spend over twice as much money per person on health care as the average developed country in the world. Despite this, our health care statistics are abysmal. Not just the number of us who have no real access to adequate health care. We have fewer doctors and see them less than other countries. We have fewer hospital beds and spend less time there than other countries. Childhood immunizations rates and infant mortality statistics are near the bottom for industrialized countries. High end and expensive studies and procedures are near the top, but 30 to 40% of these are probably unnecessary. We aren’t preparing for our future needs with a good developed primary care base. Even finding a basic doc is getting harder and harder and its going to get a lot worse. The system is clearly a mess. By all appearances and statistics, it’s getting worse. What the H is going on?
In past commentaries, I’ve tried to describe some of the economic issues that drive up our costs while decreasing our services. Competition, in our town, such as having two helicopter services, or two OB units, or two heart or rehab programs, certainly increases overall health care costs while decreasing quality. Specialty hospitals increase overall health care costs and the frequency and intensity of health care services, while siphoning money away from basic services like alcohol and addiction treatment, diabetes care and the psychiatric needs of our populations. This is of course all done in the spirit of free enterprise which our health care system is based on. If there is a way to make a buck, somebody is going to do it. Unfortunately making a dollar is not the same as providing good, comprehensive, cost effective health care. And we as a town, state, and nation suffer from this delusion.
One of the main arguments supporting the status quo shifts the blame from the system and the providers to the consumers. It goes like this. People consume health care. The reason we spend so much is that we consume too much. The way to control costs then is to make the individual responsible for how much they spend. Insurance is bad because people don't have worry about the cost and therefore use medical care when they don't really need it. Universal
health insurance, as seen through this lens, would lead to a significant increase in health care expenditures, and so is to be avoided. In fact, having a significant portion of the population responsible for their own health care costs is no cause for alarm since is serves to decrease health care utilization. Each person should be responsible for their own health care costs. They can decide to get or not get care, and so make individual choices about reducing care that may be unnecessary.
It’s not a bad idea intellectually, but it’s wrong in how it works out in reality. People who have to limit their care, because of cost concerns, limit all of their care. Not getting a headache, or a mole, or a lump, or a cough, checked out until it’s serious doesn’t save anybody money. The problem is that we don’t always know what is serious and what isn’t. Sometimes we just need to go and find out. Very few of us go to the doctor or the hospital for entertainment. To put the burden of the decision about when to seek care much less decisions about what kind of care on to the consumer is just too much to ask. Do I need a CAT scan for this headache, or just an aspirin? Who’s supposed to know that? It’s the doctor, not the “consumer”.
In some ways what this issue gets down to is whether we think that individuals are responsible for dealing with the costs of their own health problems, or if it is an issue for society. Is health care something that a society should be providing to all of it’s members, or is it something that those who can afford it should be providing for themselves? Despite it’s flaws, we have decided that we should provide the elderly with comprehensive health insurance with Medicare. The argument of the current administration is that we probably shouldn’t be doing that and we certainly don’t want to start thinking about it for the rest of the population. In fact according to them what we need to do is just the opposite. And that’s where we’re headed now.
You might wonder if the problems with our health care system have anything to do with this kind of thinking. If that occurs to you, guess what… You are absolutely right.
For a more in depth discussion of this issue, see Malcolm Gladwell’s article “The Moral-Hazard Myth” August 29th issue of The New Yorker magazine.
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