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An unanswered (or is it unanswerable?) question [health care]
I've been mostly sitting on the sidelines as health insurance and health care have taken over the mediascape and the blogosphere. For me, much of the "debate" has been an exercise in frustration -- there's a lot of railing against the Evil Insurance Companies, the Evil Government Bureaucrats, and the Evil Drug Manufacturers, and even many of the more thoughtful commentators have not, to my mind, really managed to come to grips with what I consider the real underlying problems.
I also note for the record that much of my own context on the discussion arises from observation of my father's professional career. He spent virtually his entire working life in the nonprofit health insurance field, beginning in the 1950s as a claims clerk for a smaller Blue Shield plan. By the time he retired in the 1990s, the company had become a great deal larger, and his final big project as a senior executive and general counsel was coordinating its evolution into a group of affiliated Blue Cross & Blue Shield plans covering most of four western states. As you might expect, I am therefore easily irritated by those who rail indiscriminately against Evil Insurance Companies; by the standards of many such commentators, I am obviously the Spawn of Evil and thus irredeemably tainted.
However, as![[livejournal.com profile]](https://www.dreamwidth.org/img/external/lj-userinfo.gif)
e_moon60 points out in an excellent recent post, the foregoing is not itself a point of civil discourse; it's an emotional response. And as it happens, a different post from kateelliott crystallizes for me what one of the key issues actually is.
It's this: people can tell you without too much difficulty what they've spent on health insurance and/or medical care in a given year, and frame that figure as a dollar amount (call it $xxx for simplicity's sake, recognizing that there are often more digits than that in the real figure). But in order to accurately frame the the economic context, we need a second number. We need to know $yyy, where $yyy is the value of the resources received for that expenditure.
This leads to two distinct levels of complication. One is that determining an exact $yyy figure for any given specific case can be extremely difficult. Different analysts may apply different values to the same test, procedure, or drug depending on who they're working for, who supplied the product or service, and to what degree their evaluation metric controls for inflation, overhead, supply-demand issues, and what they think the product or service should cost.
The second is simpler, but no less problematic. In order for the health care system to "break even", the sum total of everyone's $xxx figures -- what's been paid in from all channels, public & private -- needs to be at least equal in value to the sum total of the $yyy figures -- the actual value of all the resources expended. In practice, however, most of the legislative proposals I'm hearing (and many of the anecdotal reports I see from individuals about what their costs are now) involve situations where $xxx is often-to-always less than $yyy. But that way lies a black hole. In order to both (a) make the system break even, and (b) provide a high level of care for all consumers, you need a sizeable pool of consumers who pay into the system, who don't use it -- and who also don't complain about paying for the resources they don't use. And as far as I can tell, that pool of consumers just doesn't exist.
Nor is this simply a problem in the world of "catastrophic" care -- organ transplants, cancer treatments, long-term premature-infant care, and the like. Consider a single middle-aged male whose insurance costs $250/month with a $250 deductible, for a basic $xxx cost of about $3,250 in a year. Now say that in that year, he gets a routine physical ($250 for the exam, another $250 for assorted tests), a flu shot ($50), and a broken arm (guesstimate $3800 after adding up an ambulance, assorted exams, treatment, and supplies). That's a $yyy cost of $4,350 in resources, such that our hypothetical patient has is $1,100 ahead...and that $1,100 has to come from somewhere. I am also given to wonder about all those $4-copay drug programs; clearly they're a great deal for the consumer, but someone still needs to pay the real resource cost of manufacturing, distributing, and dispensing the drugs -- and even in the world of "big pharma" the pots of money that are subsidizing those programs can't be truly bottomless.
I don't have a good resolution for the foregoing situation (although I think it helps explain why health care bills are going up as fast as they are). My sense, though, is that the underlying problems we're having with health care distribution in the US are not, or not primarily, a function of whatever corruption there may be in the system. Rather, they're a function of a fundamental and increasing imbalance of resources that can't be corrected merely by rearranging the mechanics of the distribution system.
I also note for the record that much of my own context on the discussion arises from observation of my father's professional career. He spent virtually his entire working life in the nonprofit health insurance field, beginning in the 1950s as a claims clerk for a smaller Blue Shield plan. By the time he retired in the 1990s, the company had become a great deal larger, and his final big project as a senior executive and general counsel was coordinating its evolution into a group of affiliated Blue Cross & Blue Shield plans covering most of four western states. As you might expect, I am therefore easily irritated by those who rail indiscriminately against Evil Insurance Companies; by the standards of many such commentators, I am obviously the Spawn of Evil and thus irredeemably tainted.
However, as
e_moon60 points out in an excellent recent post, the foregoing is not itself a point of civil discourse; it's an emotional response. And as it happens, a different post from kateelliott crystallizes for me what one of the key issues actually is.It's this: people can tell you without too much difficulty what they've spent on health insurance and/or medical care in a given year, and frame that figure as a dollar amount (call it $xxx for simplicity's sake, recognizing that there are often more digits than that in the real figure). But in order to accurately frame the the economic context, we need a second number. We need to know $yyy, where $yyy is the value of the resources received for that expenditure.
This leads to two distinct levels of complication. One is that determining an exact $yyy figure for any given specific case can be extremely difficult. Different analysts may apply different values to the same test, procedure, or drug depending on who they're working for, who supplied the product or service, and to what degree their evaluation metric controls for inflation, overhead, supply-demand issues, and what they think the product or service should cost.
The second is simpler, but no less problematic. In order for the health care system to "break even", the sum total of everyone's $xxx figures -- what's been paid in from all channels, public & private -- needs to be at least equal in value to the sum total of the $yyy figures -- the actual value of all the resources expended. In practice, however, most of the legislative proposals I'm hearing (and many of the anecdotal reports I see from individuals about what their costs are now) involve situations where $xxx is often-to-always less than $yyy. But that way lies a black hole. In order to both (a) make the system break even, and (b) provide a high level of care for all consumers, you need a sizeable pool of consumers who pay into the system, who don't use it -- and who also don't complain about paying for the resources they don't use. And as far as I can tell, that pool of consumers just doesn't exist.
Nor is this simply a problem in the world of "catastrophic" care -- organ transplants, cancer treatments, long-term premature-infant care, and the like. Consider a single middle-aged male whose insurance costs $250/month with a $250 deductible, for a basic $xxx cost of about $3,250 in a year. Now say that in that year, he gets a routine physical ($250 for the exam, another $250 for assorted tests), a flu shot ($50), and a broken arm (guesstimate $3800 after adding up an ambulance, assorted exams, treatment, and supplies). That's a $yyy cost of $4,350 in resources, such that our hypothetical patient has is $1,100 ahead...and that $1,100 has to come from somewhere. I am also given to wonder about all those $4-copay drug programs; clearly they're a great deal for the consumer, but someone still needs to pay the real resource cost of manufacturing, distributing, and dispensing the drugs -- and even in the world of "big pharma" the pots of money that are subsidizing those programs can't be truly bottomless.
I don't have a good resolution for the foregoing situation (although I think it helps explain why health care bills are going up as fast as they are). My sense, though, is that the underlying problems we're having with health care distribution in the US are not, or not primarily, a function of whatever corruption there may be in the system. Rather, they're a function of a fundamental and increasing imbalance of resources that can't be corrected merely by rearranging the mechanics of the distribution system.
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A couple of things, though:
I think the problem in the US is exacerbated because we have the largest and most diverse population in the world -- and because we're also founded on principles that strongly defend the rights of individuals (and individual states), so that it becomes exponentially more difficult for us to impose social-engineering solutions as a matter of public policy. Note that this condition isn't unique to the health-care discussion; it's also a major factor in the realm of public K-12 education, which we in the US administer and govern even more explicitly at the local and state levels.
Also, the resource imbalance isn't a problem that can be solved purely by throwing money at it. I have a cousin who graduated from medical school some three years back on a Navy scholarship -- but between the Navy and the entities overseeing medical residency programs, he hasn't yet begun his medical residency, and so has been mostly sidelined from being able to actually practice medicine for the past several years. Nor is this is a matter unique to him; from what his family reports, the Powers That Be that govern such things have been months late this year in handing out residencies to just about everyone in the application pool my cousin's been in. More frustrating yet, my cousin is trying very hard to go into small-town family practice, which many people will tell you is exactly where we desperately need more physicians -- and "the system" seems to be doing its level best to delay his ability to get there.
As I said, immensely frustrating....
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While the argument continues, people are DYING and a great many of us (myself included) are going without any health care at all.
And somehow it's wrong to get emotional about it?
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That's one point where I'd -- not diverge from Elizabeth's comments on healthy discourse, exactly, but amplify on them. Introducing emotion into rhetorical advocacy isn't inherently wrong; as our best rhetoricians (Lincoln, Kennedy, MLK Jr.) illustrate, honest passion is a powerful and valuable element of the persuasive speaker's arsenal. But the kind of rhetoric and discourse that's appropriate for broad-based advocacy (that is, stating principles) is not the same as that needed for the hard work of framing and implementing legislation (that is, agreeing on policy).
Not that we're going to be able to legislate as if we were Vulcans; even in that setting, it's important to acknowledge that some people's positions are derived in whole or in part from strongly held beliefs rooted in emotion. But as Elizabeth observes, in the context of making policy for a community as a whole, healthy discourse requires a healthy respect for logic as well.
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Last year we spent $5,800 on health care, not including the cost of our share of the insurance. I figure that we received approximately $45,000 worth of services. I had four surguries and my husband had one. I take 20 different drugs on a daily basis, and another 4 as needed. He takes four drugs. We're the people who'll bankrupt the system.
I'm skeptical of any government agency giving me the same level of health care. Otoh, for a while I was on Medicaid (though not really because AZ rejects the federal plan and has their own ACHESS (pronounced "access"). During that period I had five surgeries and a lot of drugs. I paid not a dime out of pocket. But the money to pay those bills came from the taxpayers of AZ, and from the MDs and hospitals themselves, for they agree to treat ACHESS patients for a reduced cost.
All of which is to say, somebody's got to pay for it. My GP has said if they try to go with a standard payment for each patient treated, he'll go out of business (& he still has $250,000 left on his student loans).
Yes, there's got to be a way to do it, but it's not as easy as some people think it is.
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As several folks above have pointed out, there are actually a fairly large number of exactly those sorts of groups that function right now. Unions, who have everyone contribute, Teacher's collectives who do the same - any group, whether it's run by a gov't agency or by a private insurer (for or not-for profit) depends on exactly that model - a lot of us pay in for when we need it with a certain percentage not needing it at all and another not needing it till later - when more young, healthy types are enrolled.
I'm not sure how that complicates your issue - it's the way this kind of a shared risk system works in general.
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On one side, the employers are understandably reluctant to substantially increase their per capita payments into the trust; on the other, the union is understandably reluctant to ask its members to accept payroll deductions for a share of the cost of premiums (mostly this has not been required before now). Nor has it helped that the brand new union leadership was badly sideswiped, shortly after taking office, when what had looked like a good contract negotiated by the prior leadership in another part of the state suddenly turned out to be a lot more expensive for members than had been expected, also due to rapidly rising health care costs.
You and
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But more to the point - the huge # of uninsured is one of the biggest issues that drives the HC reform movement - getting them into the insured pool helps reduce the strain on systems from folks just "dropping in" and getting their care from ER's.
Discussion about which regulations make sense, how to provide HC for everyone - these are the kinds of topics that need to be discussed.
At some point in our history we decided that education for all was sufficiently important to make it a standard part of what government pays for - that it also benefited Big Business probably helped get it started (an educated populace is more capable of working in complex environments) - this should be no different. While 79% of the population currently supports a public option, the Senate is still tied in knots over whether that's a good thing - the argument has been muddied by *some* private insurance companies who are working very hard to shut down reform - because they're afraid it will cut into their profits, because they prefer the status quo, and for a host of reasons I can't name (UnitedHealth Group being the most active as far as I can tell).
First agreeing that HC for all is worth doing - as we once did with education - is vital. If we don't agree that it's a moral imperative - or at least that it's a Good Thing, all arguments over *how* to provide will constantly be harried by the under-whispers of "do we really need to do this?"
I suspect this is one of the reasons that this is such an emotional argument.
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I don't know exactly why the materials and manpower involved in providing healthcare are more affordable everywhere else than here. But those costs can't be as inevitable as everyone makes them out to be, or else we wouldn't be the only country struggling with this issue to this degree.
I mean, even out of pocket costs (which no one really pays, unless they're visiting tourists--and some places even not then) are lower beyond our borders--it's not only that insurance costs less (whether the government or citizens shoulder the costs), but so does what's being insured costs less.
And whatever the reason for this, it's becoming more and more clear to me that that reason is not because we get better care than everyone else. We don't. Even those of us who can actually swing care right now don't, let alone everyone else.
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What I saw when I worked there is that the Float was all important, and that they took the premiums and invested them, to earn lots and lots of interest. They didnt like having to cash in anything to pay out.
Because of improved healthcare and medical advances, people are living longer with conditions that would have killed them. Thus increasing healthcare costs.
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Healthcare Issues are Complex\
In systems theory, this is known as an unintended consequence. Health care is a systems problem and is more complex than anyone working on it understands, than nearly everyone reading about it understands, and that everyone will form their opinion based on the emotional arguments put forth.
There are systemic issues with the current health care system that contribute greatly to the problem, that are outside the current insurance debate, and that, if dealt with, would contribute far more to a "solution" to the health care problem than fixing the insurance system.
Re: Healthcare Issues are Complex\
Also, welcome to LiveJournal! (I, you see, have deduced your Secret Identity....)
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