Monday, 22 June 2009
Healthcare in the United States has been a major issue for years. Simply put, the system is way behind that of many other developed nations, a claim that I will discuss further in this article. Considering the economic might of this nation and the advanced training and technology available, one would simply expect it to be unrivaled but this is not the case.
As a trainee doctor I have found this medical debate most fascinating, and of direct relevance to my future, so I felt I should write my own take on it.
The simple fact of the matter is that the United States healthcare is a long way behind its counterparts in other developed nations. .
For starters, life expectancy in America is ranked far lower than it should be currently, well behind other developed nations. Clearly there are a wide range of factors that influence life expectancy, so this is not too significant on its own, but when you also take into account the absurdly high infant mortality rate and a much higher incidence rate of clerical errors, it starts to paint a far more worrying picture.
Add to this the problem of ever increasing costs both for the companies, government and of course the end patient. The government spends much much more than other developed nations on healthcare. This you can almost expect for such a big country, but our patients also spend three times as much, on average, as patients from other developed nations, for which there is no justification.
Despite all this expenditure, one in five of all Americans are without health insurance, our system is still bogged down with inefficiency and administrative errors, and costs continue to spiral out of control, at this rate we will be spending 20% of our GNP on healthcare by 2018. Essentially these are our three problems, poor coverage, an overly complex and inefficient system, and prices that are dictated by private companies, paying doctors per procedure rather than a fixed salary.
It is hardly a matter of national pride that USA is the only developed, industrialized nation in the world without a universal healthcare system. The problem with a completely privatized system like this is that when doctors are paid per treatment by the insurance companies, it is in the best interests of these healthcare industries NOT to treat you, bizarrely, and this results in the insurance companies having absurdly selective policies about who to cover, resulting in poor coverage. Since they set the prices, this also leads to unchecked inflation of expenses. Meanwhile efficiency is compromised by all the extra paperwork and bureaucracy involved in a system like this, not to mention a serious underfunding of preventative care and routine care with companies that are far more business minded than medical.
Clearly much work needs to be done, so what do each of the parties propose?
Barack Obama wants universal coverage. To do this he plans to implement a government funded health insurance which has far more coverage than the existing system and will be far less discriminating with regards to who gets treatment and who doesn't. This also has the bonus effect of creating more competition in the industry, which inevitably will force private companies to adjust their own policies to some extent.
Obama also wants to revamp the administrative side of things. With a government run health insurance company there is far less changing of hands when it comes to paperwork, and therefore runs far more smoothly and with few mistakes. This is supported by his push to computerize patient notes, an obvious and logical step for patient management. He also plans for major investment into preventative medicine, another key initiative in healthcare around the world today.
Clearly the problem with this is that it's very expensive up front, with the emphasis being placed on rapid change that will hopefully lead to a much cheaper and more effective industry within Obama's tenure. I also don't see this as the ideal fix for the system as well. Government funded or not, a healthcare system that is still so dependent on health insurance is never going to be truly universal. This seems less of a revolution and more like a very expensive evolution.
As expected, some Republicans have issues with it as well. They feel that introducing a cheaper alternative to health insurance will result in people opting for lower quality healthcare just because it's cheaper, and undermining the more expensive private companies.
Well while I freely admit that the healthcare package isn't perfect, in fact I don't like it very much at all, the Republicans have picked two of the most banal points I can think of, trying to scare away support by linking the package with negative economic consequences. Frankly there is no reason to suspect any of this would be true.
First of all, private and public healthcare providers exist side by side in pretty much every developed country in the world aside from America, so for them to declare that they fundamentally can't is just bizarre. Further more I think the assumption that everyone will opt to save money with worse healthcare is ridiculous. In any healthcare system in the world, in any day and age, people will always go for the best healthcare they can afford. I'm sorry but this is just fact, I can't imagine many beyond the poorest people going for worse health care just to save some money, this is exactly why public and private healthcare co-exists in most countries. In addition, employers who offer the more expensive health care to their employees, obviously, would gain a massive competitive advantage over those who don't, this is pretty much the fundamental basis of our economy.
The Republicans have drafted their own proposition. This bill support's Obama's calls for an increase in preventative care measures and a reform of the administrative side of things, but has one or two key differences. Rather than spending more money on government funded health insurance, they want to increase coverage by offering tax incentives for people to buy private health insurance. This they believe would accomplish the same expansion in coverage with far less cost and without undermining the private insurance companies.
While there are good ideas in this bill, the fact is that as I have already mentioned, public healthcare will not destroy the private sector as Republicans are envisaging, and frankly tax cuts cost the government money too, indirectly, so for all we know the costs won't be vastly different. Indeed the Republican assertion that their reform is cheaper holds little weight when they haven't even made estimates of the cost yet. On top of this, it's hard to imagine how making health insurance a little cheaper is going to create the same sort of coverage as Obama's plan, simply because cost of insurance is not the only limiting factor with the problem of coverage, as I have already detailed.
However the biggest problem is simply that this entire thing just sounds like a temporary fix. Tax cuts may add a little additional coverage, but it won't do anything to control the inflation of healthcare prices and frankly there is nothing at all in their proposition which addresses this crucial issue. Call me old fashioned, but papering over the cracks to save a few bucks for the next 6 months, after which we'll be paying even more than we would otherwise have paid just doesn't seem like a smart move.
So ultimately, in this battle for the healthcare industry, we have two propositions here from opposing armies, one full of goodness and light, and one full of darkness and evil... or so they'd have you think.
I don't particularly like either of them. The system in America is fundamentally broken, and rather than try to change the fundamentals, Obama is trying to fix them. Is it better than what we have now? Yes definitely, it is at least a few steps closer towards what our healthcare system should look like, but it is not the change that is needed to bring the American healthcare system up to snuff.
The Republican alternative, on the other hand, is simply untenable, and I say that with every ounce of insight into the medical profession that I possess. Simply, it doesn't fix anything, it just papers over the cracks and delays the effect of our broken system for a little while longer so we can worry about it later.
Now, I can see why they would want to do this. With all the money we have spent recently on stimulus, can we really afford another massive expenditure? It certainly sounds like a scary amount of money. However I think it is hard to simply ignore a problem of this magnitude, no matter how expensive the solution, and I think the logic that we'll be able to afford it better next year is flawed, underestimating the amount our broken system costs us, as detailed above, and underestimating the degree to which that amount increases every year.
The conclusion must be, then, that the Democratic option is the lesser of two evils. At the very least it's a few steps in the right direction, and despite the cost may actually be better value in the long run.
However despite this there is still a surprising amount of resistance from the medical community to Obama's plan. As a medic I take no pleasure in explaining the very simple answer for why this is the case. Simply put, doctors in America will earn more money under our current system, with insurance companies charging exorbitant amounts and then paying doctors per procedure, as compared to a system where they have a set salary. Doctors may be doctors, but they still like money, and any medic (like me) who cares more about patient care than making money will never support the Republican plan over Obama's, and it is therefore no wonder that this is the direction that all official medical organizations in America are taking, even if a few individual doctors are having a hard time coming to terms with it.
Fortunately there is no rush to move this bill through, with Obama setting a deadline in September for it to be on his desk ready to sign. I think the best solution for this measure is for there to be a lot of discussion in congress over the next few months, and a final bill that takes Obama's plan and waters it down to make it a little less frightening for fiscally conservative politicians to swallow.