Category Archives: Universal Healthcare

A Transaction Based on Trust

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The consumer of health care is unlike any other consumer, and the product he purchases is unlike any other product. This is something that those who embrace “consumer-driven medicine” choose to ignore.

Advocates like Harvard Business Professor Regina Herzlinger insist that if we just
put the consumer in the driver’s seat, giving him both  transparent pricing and a little “skin in the game,” the consumer  could put a lid on health care prices while demanding the best quality care.  Herzlinger is particularly hopeful that the baby-boomers, a group she describes as “the most manipulative, the most narcissistic and the most effective generation this country has ever seen,” can do the job. (Why one would want such a group setting priorities for our health care is beyond my understanding; I’ll return to this point in a later post.)

Last week I spoke at the Massachusetts’ Medical Society’s Leadership Forum on the rising cost of care.  In two earlier posts (here and here) I’ve described what other speakers had to say about how and why Massachusetts is running into trouble trying to fund its experiment in universal care.

In my speech, I explained why I don’t think that “consumer-driven medicine” is the answer. I don’t believe the “consumer” can rein in healthcare spending.  As an alternative, I proposed a “patient-centered” model of health care which depends on patient and doctor, working together.

Begin with the flaws in the consumer-driven model. First, it assumes that the patient has the same power that a buyer has in the commercial marketplace. But in truth, the patient does not have nearly as much leverage as other consumers.

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Universal Coverage –Why Massachusetts is the Last Place to Begin the Experiment

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At the Massachusetts Medical Society’s 8th Annual Leadership Forum last Wednesday, Dr. Steven Schroeder, former head of the Robert Wood Johnson Foundation
and Distinguished Professor of Health and Health Care at the University
of California, San Francisco, told a provocative story about a poll
that asked patients in the U.S. `Canada,  Australia, New Zealand and
the U.K the following question:

“If your personal doctor told you that you had an incurable and fatal
disease, would you accept that diagnosis or seek a second opinion?

  • In the U.S.           91 percent of patients said they would seek a second opinion.
  • In Canada            80 percent                    “        “       “       “     “     “           “ 
  • In Australia          71 percent                  “        “   
  • In New Zealand     51 percent
  • In the U.K.           28 percent 

“You have to love the British,” Schroeder commented. “You can just hear
an Englishman saying ‘Well, Luv, it’s been a good life, hasn’t it? Now
let’s make a pot of tea and discuss the funeral arrangements.”

At the other end of the spectrum, we find the Americans who, Schroeder
noted, “are the only people in the world who expect to live ‘in
perpetuity’.”

Today, I would like to suggest that our expectations as patients help
to explain why we spend roughly twice as much per person on health care
as most developed countries—even when, overall, it’s not clear that our
healthcare is better. In fact, in some areas outcomes are worse.

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Massachusetts Health Reform: The Canary in the Gold Mine?

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Advocates for health care reform have been keeping an eye on Massachusetts, hopeful that its new health reform law will serve as a pilot program for the nation.

I’m much less hopeful than I was two days ago.

Yesterday I attended the Massachusetts Medical Society’s Eighth Annual Leadership Forum where I was one of four speakers. This year, the Society (which owns The New England Journal of Medicine)  focused on the cost of health care –with a special emphasis on funding universal coverage in Massachusetts. The new was not good. While the citizens of   Massachusetts believe that everyone has a right to health care (when polled 92% say “yes”), no one wants to pay for universal coverage.   When asked “if the only way to make sure that everyone can get the health care services they need is to have a substantial increase in taxes [should we do it] 55% said “no.”

One speaker at the forum recalled a man who explained why taxpayers shouldn’t have to pick up the bill: “The government should pay for it.” (He didn’t disclose who he thinks “the government” is. )

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The Real Danger of Socialized Medicine by Niko Karvounis

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Last week The Washington Post ran a good opinion piece by Ezekiel J. Emanuel, Director of the Clinical Bioethics Department at NIH (and brother of Congressman Rahm Emanuel) on the insidiousness of labeling any and all positions on health care apart from free market fundamentalism as being “socialized” medicine, doomed to failure.

Emanuel notes that “ ‘socialized medicine’ is when the doctors are state employees; when the hospitals, drugstores, home health agencies and other facilities are owned and controlled by the government…” As Emanuel rightly points out, none of the universal coverage proposals being debated in the U.S. today “can be characterized as socialized medicine. None calls for government ownership or control over U.S. hospitals, drugstores or home health agencies, or for making doctors employees of the federal or state governments.”

This is right on the money—maybe even more so than Emanuel intends. Opponents of “socialized” medicine are wrong three times over: not only do most reformers not want socialized medicine, but even European health care systems (often used as examples of socialized medicine) do not meet the criteria outlined above. Further, publicly-run health care carries with it some significant benefits that are evident right here in the U.S.

To dispel the myth of monolithic government-run European health care, look no further than Germany, where most of the population (88%) receives health care through “sickness funds"–non-profit, third-party pools of money devoted to health services. Sickness funds are built on the principle of “subsidized self-governance”: they receive public funding, but the funds must be financially self-sufficient (i.e. be able to govern themselves) and also allow a high degree of freedom on the part of patients and doctors (the former can choose their doctors and hospitals, and the latter have much flexibility in treatments).

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Race and Health Care: Dimensions of Inequity by Niko Karvounis

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Yesterday I talked a little about segregation of patients by race in NYC hospitals, and noted how this is likely a problem repeated across the nation. Wonder no more: a 2006 study in the Journal of the American Medical Association (JAMA) analyzed about 719,000 Californians who had received a wide range of complex surgeries. The authors found that blacks, Latinos, and Asians were far less likely to get these operations done at high-volume hospitals, which tend to have better outcomes for complex surgeries. (After all, practice makes perfect).

If you’re white, you’re more likely to receive care at high-volume, better-performing hospitals. This is bad in and of itself; but unfortunately, discrimination continues beyond the level of medical institutions and into the level of individual doctors. A 2004 study in the New England Journal of Medicine looked at the primary care experience of Medicare patients, specifically looking at 150, 391 visits by black and white Medicare beneficiaries for “medical evaluation and management who were seen by 4355 primary care physicians.” Here is what they found:

“Most black patients were confined to a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs.19.3 percent).

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Comment on Class and Health

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(To see the original post on Class and health, click here.  To add your comment, scroll down and click on “Contact” on the left-hand side of the page.)

Maggie,

A couple of thoughts on this.

First, Americans who work in physically demanding and/or dangerous jobs such as coal mining, steel manufacturing, auto manufacturing, etc. do not live as long, on average, as the population overall despite comparatively good wages and benefits.  I don’t think countries like Iceland and Switzerland have nearly as many people relative to their populations working in these jobs as the U.S. does.  Japanese people in the U.S. also live longer than most people.  I suspect that it’s due to a combination of diet and genetics. However, as they are here longer and adopt a more westernized lifestyle and diet, they probably don’t live as long as Japanese people in Japan with comparable socioeconomic status do.

Second, regarding social inequality, I think our system, does, to a large extent, reflect our more entrepreneurial culture.  While reasonable people can differ about how much taxes should be raised on higher income people to both reduce inequality and raise money for worthwhile public priorities, I think it is important to remember that there could also be economic costs. In Western Europe and Canada, the total tax burden on middle and upper income people generally exceeds 50% of gross income.  It’s expensive to sustain a welfare state with a generous social safety net.  I think, at the end of the day, those countries, which embraced socialism decades ago, are trading less inequality and more economic security for less economic growth and less opportunity, especially for its younger people. 

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HILLARY CLINTON’S NEW PLAN

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   I have written two posts analyzing Hillary Clinton’s healthcare plan. You will find them on www.tpmcafe.com (where I am a contributor). You can comment there.

   

    

If We Mandate Insurance, Should 20-Somethings Pay Less?

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Should insurers be able to offer less expensive policies to the young and healthy? Or should they be required to offer the same benefits to everyone at the same price?

In states where insurance is mandated, should twenty-somethings get a break? In a post on Health Care Policy and Marketplace Blog Robert Laszewski addresses these questions. He begins by focusing on a report  just released by the health insurance trade association (AHIP). The study looks at state health insurance reforms of the 1990s that tried to eliminate discrimination by insisting that insurers must sell “individual” policies to people who are not covered by an employer or another group without discriminating on the basis of health, age or gender. According to the AHIP, these reforms have had some “unintended consequences.”

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