In July, Fox News reported that some Americans are not renewing their health insurance. Purportedly, about one million have made that election, after learning that the taxpayers would not contribute to their insurance premiums. The article concludes that data supports that "the high-price plans on the individual market are unaffordable and forcing unsubsidized middle-class consumers to drop coverage,” according to research from the Centers for Medicare and Medicaid Services.
The article draws attention back to the promises made when Obamacare was proposed in 2009, such as: “If you like your health care plan, you’ll be able to keep your health care plan – period,” Similar promises were made about keeping your doctor, according to Politifact.
The reality is that medical care costs money. There are some who contend that the American system of medical care delivery is broken. In the LA Times, Dr. Robert Pearl (health care provider and industry CEO) takes issue with the manner in which health care is delivered. Dr. Pearl notes that America spends "50% more than any other nation on the globe and our results are in the lower half." Think about that for a minute, We spend $1.50 for every dollar in the next highest country, and we do not achieve results in the top 50%. Apparently, there is support for the contention that shoveling money at a problem may not necessarily solve it.
He points fingers at (1) doctors clinging to antiquated methodology and technology, (2) the foundational "fee for services" model that pays for procedures or tests, rather than for results, (3) a siloed record-keeping process that frustrates access to information for both patients and care provider, (4) a reluctance to engage in preventative medicine (he says we "value intervention over prevention), and (5) a reluctance to leverage technology to facilitate better, more frequent care. These are detailed in his book Mistreated. It is a recommended read for anyone who will engage the American health system (this means you).
There are a number of complaints about the delivery of medical care in this country. Pharmaceuticals are expensive in America. In fact "Americans spend more on prescription drugs than anyone else in the world," according to Bloomberg. The cynic in my head is chanting "We're number one" repeatedly as I compose this. Some, like the American Association of Retired Persons, have contended that importing drugs from Canada is an easy solution to that issue. However, there are some who question the AARP's motives, after details emerged regarding the financial impacts of its support for the failed Obamacare experiment, as reported by Forbes.
Anyone who has visited the doctor's office for a cursory examination may have complaints. A conference attendee recently related to me a sports injury. He made an appointment and visited his family physician as scheduled. Despite arriving 15 minutes early at their urging, he then spent over an hour in the waiting room. Once with the physician, he had his abdomen prodded, his ears examined, and was repeatedly asked to "say ahhhhh." And then, the doctor eventually examined the injured foot, opined that he "thought" it was sprained, ordered an x-ray, and referred him to follow-up with an orthopedic surgeon. The gentleman complained of a wasted morning, and wondered aloud why he had not just gone to an orthopedic to begin with (he was convinced his throat and ears were unrelated to his foot complaints). He perceived that this physician had delivered no value to him.
There are always two sides to every debate. The New York Times recently published a rebuttal to what it calls "myths" regarding the cost of American medical care. It contends that the "quality of health care looks pretty good." The study that it cited concludes that hospitalization is less frequent in America, that there is no indicia of an extraordinary number of doctor visits, and that cost containment is a challenge in more than just America.
The Times refutes any perception that there are not enough primary care physicians in America, and contends that Americans do not "use too much medical care" in a general sense. However, it cites evidence that America ranks "near the top in its use of certain medical services, including expensive imaging tests and specific surgical procedures, like knee replacements and C-sections." Thus, the Times seems to suggest that solutions lie not in the costs of care, but in our selections of the types of care.
Imagine that you are eating at a cafeteria. Those have become less common perhaps. But in the "old days," we walked through a serving line and viewed various dishes. We selected what we wanted and in the end, we paid a price per dish selected. There is some argument that the ultimate charge (what we are spending on eating) is too high in the national aggregate. But, the Times is suggesting instead that the issue is merely that some selections that are expensive are being consumed too frequently, thus driving up that aggregate.
There are those in society that advocate for universal medical care. The Washington Post recently lamented the repeal of the Obamacare "individual mandate" (a provision in the law that said Americans had to purchase something, whether they wanted to or not). The Post contends that medical care is a "human right," and that every person should have access to care regardless of their ability to pay for it. By definition, when something is provided to those who feel they cannot pay for it, that means someone else will have to pay for it. The simple economics of socialism are lost on too many.
The Post lamented "No longer will the government ensure that the nation is insured," as a result of the mandate repeal. That statement ignorantly ignores that even when Obamacare mandated everyone to have insurance, the media reported that 27 million remained without such coverage, according to Bloomberg. That may not be curious to some, but if Obamacare was mandatory, as it said it was, how is it that anyone was without coverage? Perhaps there are various definitions for "mandatory?" My understanding of "mandatory" is that it means "required." If something is mandatory then everyone would have it. However, the Quixotic imposition of mandatory did not affect full participation.
It is also worth noting that Obamacare did result in a larger population of "covered" Americans. However, there are some who believe that a significant amount of that increase was through the concurrent expansion of government benefit eligibility. The Heritage Foundation calculated in 2014 that 71% of early Obamacare coverage expansion "was attributable to the Obamacare expansion of Medicaid to able-bodied, working-age adults." It seems debatable whether Obamacare resulted in significantly more individuals purchasing health insurance.
Back to the Fox News article that started this discussion. Some states (13) report that the cost of certain health insurance "plans are already at least 40 percent higher this year than last year." One state has reportedly seen "premiums leap 65 percent." According to the Kaiser Foundation, premiums increased significantly in 2017 (in some locals the increase was double-digit). Since 2013, health insurance premiums have roughly doubled according to eHealth. Arguably, Obamacare neither reduced the cost of health coverage nor achieved its mandate of coverage. The lamentation "no longer will the government ensure that the nation is insured" seems a bit disingenuous in these regards.
There is conjecture that without government coercion, fewer will purchase health insurance. That may be due to the increase in premium cost in recent years, which some perceive was driven by Obamacare itself and others say was inevitable even without that experiment. That may be because Americans have been rooted in individualism and freedom for centuries, and perhaps they do not favor being told what products they must purchase? I can only imagine the hue and cry if the strawberry producers convinced Congress to mandate that all Americans buy $321 worth (cost of average health plan) of strawberries each month ("but I don't like strawberries," - "no one said you have to eat or enjoy them, just buy them.") Some cynics would complain about buying something they neither want nor believe they need, and others might argue that forcing people to make purchases is antithetical to American freedom.
In the end, the debates about health insurance may be worthwhile. However, the discussion points raised by Dr. Pearl and the Times may also have merit. Could we leverage technology so that a follow-up appointment with our physician might be a Skype experience rather than a morning spent sitting in a waiting room full of sick people? Might we figure out a way to allow patients and other providers with ready and inexpensive access to records, as the Cleveland Clinic and Medicare have done? Might pricing transparency (June 2015), record portability, and technology leveraging, as advocated recently by Medicare, provide a path to better-enabled consumers in the marketplace? What if those consuming services were the ones actually paying the cost, would we each become better consumers?
There are undoubtedly a great many components included in the American medical care "big picture." There are problems and complications identified by Dr. Pearl and others. There is data suggesting that America may be struggling with issues not dissimilar from the rest of the world. There is a seemingly endless parade of contended issues, alleged failures, and purportedly "bad actors." It is complex without a doubt. However, it seems likely that there are solutions more imaginative than shoveling money. Perhaps if the bigger issues were addressed, care refocused on patients, and innovation encouraged, the costs could be reduced?
That is not to criticize shoveling money as "a" solution. It seems fair for the country not to interfere with those who wish to attempt to solve their own problems with their own money. However, it seems that shoveling taxpayer money at a problem should come with some assurance that simultaneous efforts are engaged to streamline waste, to leverage consumer participation, and facilitate good healthcare outcomes.
Of note, some perceive government intervention and management a poor solution to any problem. An attendee at a recent gathering challenged me to name a single government agency that has (1) remained focused on the goal for which it was created, (2) made significant progress on its mission, and (3) did not grow exponentially in size and budget. I was not able to, are you? This attendee contended that the Department of Energy (DOE) was formed in the 1970s to address our dependence on foreign oil. That has allegedly morphed over time. Upon return to the office, I read that some contend the main accomplishment of DOE has been its own growth in personnel and budget - "the result of 15 years of searching for something to do." Will healthcare benefit from more government intervention, regulation, and management?
It also seems fair in this national healthcare debate that we hear no more lies and deception like "you can keep your doctor." We should avoid fanciful promises to suspend the laws of economics. Scarcity is real, the effects of demand are real, and only in Utopia can everyone have as much of anything as they want. To increase access to relevant and affordable care, it is time that we focus on how to deliver better quality health care, with patient engagement, without endless tests, consultations, and procedures that do not contribute to the diagnosis and treatment of the problem. And, while we are at it, we have to focus on preventative care. We will have to get America off the couch and somehow regain activity, exercise, and all of its benefits.
Can we improve American healthcare? Absolutely. Is the solution in forcing people to do things they find distasteful? Is the solution only to be pursued in "finding" money to shovel at the existing and inefficient cost paradigm? It seems probable that there are a great many issues that could benefit from attention, could increase efficiency, and could decrease costs. Perhaps it is time to focus our efforts on the process and its shortcomings, rather than merely trying to find enough of other people's money to continue to fund those various shortcomings?
