My favorite subject. I work in health care, so I deal with this every day.
The real issue isn't universal health care. What we lack is a rational system of universal health insurance. And there are 3 problems that must be addressed:
1) Our biggest structural flaw is the linkage between health insurance and employment. 60% of Americans are covered through employer-provided group health plans. That's fine as long as one is employed, but the policy belongs to the employer, not to the employee. People lose coverage if they're laid off, or change jobs, or go on strike. In the first 3 months of 2009, when the full-force of the recession hit, over a million people lost their health coverage. That's crazy. Your health insurance should belong to you. Just like your homeowner's and car insurance. Not to mention this is an enormous burden for American business, and puts us at a competitive disadvantage with foreign companies operating in places with national health plans. We talk about tax cuts and job growth, but that's a flyspeck. The single best thing we can do to stimulate business growth and job creation is to remove the need for American employers to be insurance providers.
And when Bush proposed taxing it as income, the poo really hit the fan. From the right as a tax increase and from the left because they complained it would have the exact effect you are advocating here. We need to make insurance personal. Right now it is the only cost that is both deductible to the employer and not taxed to the employee so it is both parties interest to make employer insurance a great perk. Remove that and you'll see people begin to choose their own policies. It doesn't have to be the feds forcing people into a government program, but too many on the left think that's the only way to accomplish it.
2) Adverse underwriting by carriers. This ties in with #1. Employer based group plans must insure all employees. Enrollees can't be denied coverage due to health status (though waiting periods may apply.) And premiums are based on the entire group risk, and can't be raised for any one individual. But for someone who loses his group coverage, he may face terrible problems getting insurance, especially if he, or a family member has pre-existing illness. After his 18 months of COBRA, his premium can be completely unaffordable. State laws differ, but in general, carriers are allowed to be much more restrictive in covering individuals, than in covering an employee group. Only about 9% of Americans have coverage in the individual market. Again, it's kinda crazy that companies can refuse to sell their product to those consumers who need it the most. This must change.
Another reason to remove group policies. If you buy your own policy when you get dropped from your parents and keep it, you won't have to worry about being covered. Simple rules about disabilities allowing you to stay on your parents and making it so you can't be re-rated if you started healthy and paid your premiums on time would solve a lot of people;s problems at the expense of a very few who won't think to the future. And I'm pretty sick and tired of caring for people who simply will not make a good decision no matter how much hand holding you do.
3) Cost. Several factors are at work here. The largest is technology. Unlike most other industries, advancing health care technology raises cost, rather than lowering it. Example: 75 years ago, if you had kidney failure, you'd be put on a low sodium, low protein diet. Not much else could be done. Very simple and cheap, but you'd probably die of uremia in 6 months. Now you can get a transplant ($50K or so) or go on dialysis ($60-70K a year.) You can have years more of productive life, but at a huge cost. The other big cost factor is our expectations. Americans want technologically advanced care, and we tend to be high utilizers. We also look to insurance to cover most all of our health needs, rather than reserving it for catastrophic health expenses. We like low deductibles, which further remove us from the actual cost of care. Finally, we have great resistance to price controls on health care, which are used in some countries to lower costs. And we're even more resistant to "utilization managment," a euphemism for rationing by medical need, which is used to some degree in other places. Shifting the costs of care for the uninsured onto those with insurance is also a factor. As is medical liability costs. But I think these are lesser factors than technolgy and expectations.
Adding more government control will just further insulate us from the cost, though. I don't know what you do, but check out the emergency room utilization sometime. Medicaid patients are notorious for overuse, demanding extra tests, and showing up for colds and other non emergencies. Worse than the uninsured. Because they have $2 co pays per day and simply do not care what anything costs.
The overutilization thing is an interesting conversation, though. We use 90% of the worlds ritalin, we do twice as many knee replacements per capita as any other country, etc, etc. The question is, Is that good or bad? I can send a patient to 5 different imaging for an mri the same day, a non emergency image in germany takes a week or more. Here if you have a bad knee, you get it replaced. In Europe they tell you to lose weight and maybe they'll replace it when you are no longer ambulatory. There's no doubt we're paying a lot of money when "lose weight" would be cheaper and better for the patient.
Medical liability is a huge problem. If you look at the costs of malpractice it's a tiny fraction of overall health care costs, but defensive medicine is a problem and it's hard to quantify. If I send you for an mri because I want that defense in case you sue me I commit insurance fraud if I bill for it. And they won't pay for it if it's defensive. So I come up with a reason, something I'm looking for, and then it's covered but the cost attributed to defensive medicine goes away. Which is why any doctor will tell you it's an enormous problem but the statistics don't bear that out.
There is also a philosophic problem. Some people do not see universal health insurance as a necessity of modern life, or even as socially desireable. It's opposed even when it can be shown that universal coverage can be achieved in the private sector, without a huge tax-funded government bureaucracy. But health coverage is as much a necessity as police and fire protection. Lack of universal health insurance hurts the quality of life for everyone. There is a non-governmental solution. But that's for later. This post is long enough.
I disagree that it's as necessary as police and fire. Take 2 twins, one lives next to the best hospital in the country and has 100% insurance coverage but eats fast food for lunch every day, never exercises, and sits in his cubicle stressed out about getting all his paper work done, then take his bother who lives in the burbs, bikes every day, and cooks his own food. With a $5000 deductible. You tell me who's healthier and is going to live longer.
Health insurance isn't even in the top 10 of items that contribute to a long life. Sex, stress, exercise, where you live, how much education you have is even more important.
Plus, if health insurance were used like car and home, never for maintenance but only for catastrophic care, costs for routine visits and things like physical therapy would drop dramatically. PT has gone from 75 to 350 and hour in less than a decade because of increased insurance coverage. What was 6 visits at 50% is now 30 at 90% so go figure that the PTs jacked the rates through the roof.
I think the philosophic problem is one of liberty versus making everyone equal. Even if you could prove to me that universal health care or universal insurance coverage would solve all of out health care problems: doctors would be happier, people would live longer, and the sun would shine every day, I'd still be against it because I don't want anyone controlling my life. We have bans on trans fats and happy meals under the auspices of saving money on health care. We ban smoking and control advertising for the same reason. "Lose weight" is great advice but when it comes from the federal government who controls whether you "take this pain pill" or get the surgery to help it becomes tyranny. When the government is the payer, the doctors won't be able to opt out and the patient is under their control. "You want a new hip? Do you have your sign in sheets proving you went to the gym 3x/week for the last 5 years? No? Well, we'll just have to see about that hip. We'll be in touch."
The facts are: Europe's programs are getting worse every year. We lead the world in innovation. We have the best cancer survival rates. Live birth rates are skewed in most of the world because they don't count sub 500 gram babies as a live birth. The best doctors from all over the world want to practice here because they don't get paid well anywhere else.
The facts also include our prices are out of control. That's because the free market influences have been removed. People here expect the best for free if they have insurance. The solution isn't more control, it's more freedom.
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