An Unenviable Health Care System

 

Ezekiel Emanuel has written an analysis of health care in the world with the provocative title of “Which Country has the Best Health Care.” * I read TR Reid’s “The Healing of America”**several years ago (excellent) that looked at the differences between health care in approximately twenty industrialized nations including the United States.  The U.S. does not fare well. We consistently rank spend more money to achieve worse outcomes than other countries. “The U.S. spends more on health care as a share of the economy — nearly twice as much as the average OECD country — yet has the lowest life expectancy and highest suicide rates among the 11 nations. ***

I did not know that the first universal health care proposal came from Harry Truman in 1945.  As an artillery officer in WW I, Truman had been appalled at the poor health of his troops.  In fact, more than five million draftees in WW II had been rejected as unfit for duty.  He blamed it on the disparity in incomes. “People with low or moderate incomes do not get the same medical attention as those with high incomes.”  He was also concerned by the paucity of medical facilities in rural areas.  Almost half the counties in the United States did not have a hospital. His plan called for universal health care that would be funded by a federal payroll tax and include full medical and dental coverage to all wage earners and their dependents. People got to choose their own doctors.  The private insurance system would continue with a requirement that policy holders would contribute to the federal system. 

His plan was denounced by the Republicans as socialistic supported by the AMA (described by Milton Friedman as “the strongest trade union in the United States) and the pharmaceutical industry.  True to form the label became more important than the content. They accused Truman of turning Americans into “dainty, effeminized, pampered, sissies... [it was] an Un-America n system blueprinted in the Kremlin headquarters of the Communist Internationale.”  We heard similar rhetoric –I hate to elevate the words to that level – during the debate on the ACA in 2009.  

There was little support for the plan. To compensate workers for wages lost to wartime price controls, Congress had exempted health care benefits from taxation.  The unions loved that companies could dole out benefits in the form of ever-increasing health benefits that were not taxed. It currently costs the government $250 billion annually in lost revenue.  

The NHS won out in England over the opposition of the British medical establishment only because Labour had won the elections, the opposite of what happened in the United States. While the NHS is extremely popular and no one wants it replaced, it is seriously underfunded leading to staff shortages and longer wait times for elective surgeries. Everyone wants a fully funded – read fully operational NHS. 

In the U.S. four tiers evolved:  a fully socialized VA system, federal Medicare for the elderly and disabled, partially state funded Medicaid for the poor, and employer-based health coverage.  I would add a fifth, privately paid health care for the very wealthy.  I once had an interesting discussion with a Republican congressman in Maine who claimed that there shouldn’t be any health insurance and that all you needed to do was negotiate costs with your health care provider. I don’t know how that’s works in the ambulance, but there it is, another option. To quote Ezekiel: “The United States has every type of health financing ever invented, this is preposterous.” I would add that it certainly helps explain the huge paperwork overhead that costs an additional 20%.  He writes that our costs dwarf those of other countries with better outcomes.  We pay $10,700 per capita which is 17.9 percentage of GDP. Childbirth in western Europe averages about $4,000.  In the U.S. it’s $30,000 split into multiple bills from anesthesiologist, radiologists, hospital, etc. Many of these physicians you might never even see.  Americans spend half(!) of the $1 trillion world-wide pharmaceutical bill while having only 5% of the population.  Either the prices are too high, or we are far sicker, both mentally and physically than everyone else. That’s an exceptionalism we should avoid. In the meantime, 10 million remain uninsured, placing an enormous strain on emergency rooms and hospital budgets. It also places the United States at a severe competitive disadvantage as companies are forced to shoulder the health care costs their competitors don’t.  In addition, some $500 billion (yes with a “b”) is spent on billion and insurance-related costs” according to Ezekiel. A U.S. physician spends four times as much on billing as his Canadien equivalent. 

COVID-19 will strain the system even further. Intensive care units are filling, people without insurance are reluctant to even visit a doctor if they have symptoms, drug costs are spiraling upward and costs for procedures are wildly different depending on your carrier and circumstance.  Elective surgeries, a primary revenue source have dried up.  

          The 2017 Commonwealth Fund that ranks health care and costs around the world. They rank the United States second to last, after China.  The UK, Australia and the Netherlands rank first. He likes the Netherland system the best: You get to choose your private insurer; you get to choose your primary care doctor. And their primary care doctors are really gatekeepers to a higher level of care.  They’re also innovative.... But there are lots of alternatives I’d be more than happy with." 

 

*Emanuel, E. J. (2020). Which country has the world's best health care? PublicAffairs. 

** Reid, T. R. (2010). The healing of America: A global quest for better, cheaper, and fairer health care. Penguin.My review at https://www.goodreads.com/review/show/459583953?book_show_action=false&from_review_page=1

*** U.S. health care from a global perspective, 2019. (n.d.). Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019