Thursday, February 28, 2008

A Bee In My Bonnet

On another blog, I was recently told that, because I was wanting the government to do everything for me that I should perhaps move to Europe. I'm thinking, perhaps, that my politics were slightly misunderstood. Rather than use the the comment section in another blog to justify myself as a liberal commie pinko, instead I would like to post some thoughts here about something that has our country deeply divided right now.

Health care.

I think a bit of a history lesson is in order first. In the 1950's, health care began to be more technical and therefore more expensive. Unions saw pension and health care benefits as a way companies could help take care of workers without actually increasing wages and began negotiating with companies to try and improve the quality of their member's lives. I'll use the automakers as an example.

Union leaders sat down with the big bosses from the Detroit automakers, trying to encourage these large companies to pool both their health insurance and their pensions. The idea was that a larger pool of risk would generate more money. Also, a larger principle in pension funds would create larger interest payments and the pensions would have greater long term security.

The problem was that the unions had such a history of Communism and, yes, Mafia ties, that the businessmen didn't trust them. In addition, anything that required these competing companies to work together was regarded with unveiled contempt. The result? Single companies cut their own deals with the unions. This same practice spread to other companies and insurance suddenly became a really cutthroat business as companies shopped around to pay premiums for a few hundred employees here and there.

In the 80's a lot of manufacturers began to see the writing on the wall--with shrinking labor forces because of improved technology, smaller profit margins, and cheap overseas steel and workers--pensions and health care became unbearable burdens. Many of these companies are paying out pensions to widows whose husbands haven't worked in decades! And while the pensions are a pittance each month, if there are thousands of them . . . well, you get the idea.

The answer to the pension problem, at least for many workers, has been that most companies have gotten rid of their pension programs all together in exchange for 401K's, which they will sometimes match. (Social Security is a different issue entirely.) But nobody has figured out what to do about the health care issue because the rising costs of health care have so far outstripped inflation and manufacturing profits that traditional methods have not worked.

I would, in fact, argue that it isn't just cheap labor that has sent American manufacturing overseas, it is expensive health care. Full-time, American workers, whom companies want to hire, train and keep for 30 years do not come cheaply. Besides wages, a compensation package must accompany most full-time jobs. This is not the case in other countries. Not only do workers not expect such exorbitant salaries, but they do not need pension or health care plans because the government provides these things. The result is that in the 80's and 90's, blue-collar jobs left the US in the numbers of the tens of thousands, but in this century, professional jobs are beginning to leave as well.

So, it seems to me, that history would teach big business (and certainly small business) that they should be the most ardent supporters of some kind of government subsidized or run health care. I mean, a slightly heavier tax burden HAS to be cheaper than going out of business. Right?

Now, I am not so naive as to think that the government needs to put insurance companies out of business. We have an American problem here requiring an American solution. I've heard many good ideas recently, which I will now share here. Please add to the dialogue; I'm always trying to refine my thinking.

1. Create some kind dual system. When an employee is hired, they can opt for a certain salary and private health care they and the company both pay into, or they can opt for a slightly higher salary and government health care. The private health care/insurance is obviously going to allow a person to choose their doctor, probably wait less time to see a doctor and greater access to specialists. Both sets of employees would be a higher social security tax (2-3%) with an employer match. (For those who are paying a premium on top of this, the long-term benefit to a society with a healthier population is very real, though difficult to measure.) For people like my parents--getting older, two incomes, etc. private insurance would be a great options. For my family--young, kids needing immunizations and well-baby visits, low risk pregnancies, one income, etc then government insurance would be ideal.

Those who did not opt into private insurance either on their own or through an employer would automatically (with a legal social security number) be enrolled in government health care; if not everyone, at least the children. To keep some of the wait time down at government clinics, and to help people take some ownership over their own health reasonable co-pays ($30 or so) for everyone would still need to be in place for office visits (this would prevent people from waiting in line for every sniffle) and emergency room, etc.

While the bureaucracy costs of such a program are high, I would argue that the actual health care itself is cheaper. Why? Three reasons doctors in private practice are so expensive is that (a) they spent, in many cases, hundreds of thousands of dollars just to get educated. (b) The overhead in a typical doctor's office just to keep up with insurance claims is exorbitant. (c) Malpractice premiums increase all the time. All three problems would be mitigated under a federal program because government doctors would take a generous, but reasonable, salary in exchange for a payment of student loans, no insurance issues and malpractice protection via the federal government (including caps on punitive damages).

The cons to such a system would be the need for strict oversight to ensure that separate is equal, and that the poor would still have decent access to health care that was both fair and equitable. On the plus side, educated, medicated people know that lifelong health begins at conception, so any universal plan would have to address babies and children very specifically. Some form of subsidized health care would get more poor, pregnant women into the doctor sooner. I also see parenting classes with public health educators and nurses as being essential to the success of a plan like this.

2. Another idea involves use of the term "moral hazard." A couple of years ago, Malcolm Gladwell wrote an exceptional article in The New Yorker (part of his piece was based on a report actually put together by the Bush Administration). Although his article doesn't offer a lot of solutions, it does help to define the problem. For those of us whom have cheap insurance, we over consume it: we have a lot more than we actually need. For those with expensive insurance, there is never enough. He suggests some ideas for playing with the price structure.

3. 20/20 (I can't find the exact transcript from the piece, but the highlighted article is helpful) with John Stossel (who I normally can't stand) did a really interesting series of interviews in the aftermath of Michael Moore's movie, "Sicko." Stossel is a fairly conservative commentator and he pursued the idea that Americans need an American solution not a French or Canadian one as suggested by Moore. He talked to the owner of Whole Foods, who believes very strongly that the answer lies not in socialist principles, but in capitalist ones.

He maintains that Health Insurance ought to be more like auto insurance with a high deductible. The consumer takes care of all the little expenses, and maintenance expenses. But something like cancer, now that is totally covered, after your high deductible. The company also adds to a health savings plan for each employee that can be rolled over from year to year. Money in the health savings plan can cover everything from eyeglasses to acupuncture to TMJ surgery (things not typically covered under traditional health care.)

While there have been problems, the long term effect of people shopping around for health care and taking more responsibility for their actions would be a lowering of medical costs. Why? Well, right now, if you call your doctor and ask them the cost of a checkup and a round of shots for your three year-old, he or she probably has no idea. But under a Whole Foods-type model, generally applied, doctors would want to be competitive. If people are paying for themselves to go to the doctor then they want the best deal around.

4. This option does involve more of sinking the insurance companies, but it is not for reasons of socializing the system. Many doctors are finding that they can slash their costs drastically by refusing all forms of insurance all together. For the Stossel piece, a doctor in Appalachia was interviewed. He was a family practice doctor working on everything from shots to stitches to broken bones to general check ups. His frustration over insurance some years back led him to get out of the business all together and instead, put together a cash-only price list. Most of his "customers" have no health insurance, but can afford his low prices.

It turns out that paying out of pocket, at least for small expenses, is much cheaper than paying a 20 or 30% copay, a monthly premium and STILL meeting a deductible (what my "good" insurance plan looks like). And while getting a price list from your doctor, like a menu in a restaurant, might seem a little bit strange, what other service to you get from anybody that you have NO IDEA going into it how much it will cost? No where. Only medical care.

If your family is like mine, and you've changed professional jobs a few times in the last decade or so, it seems like your health care shake gets a little bit worse each time. The irony is that each time our premium or copay goes up or our benefits go down, each plan is touted as the "best" around. And while you might balk at the fact that I've cited three different articles here from a "liberal" magazine, the writers themselves have thought out and researched the problem and are trying to give the reader the most logical assessments of the facts at hand. Conservative pundits and magazines are going to scream and pull out their hair about "socialism" and costs. But I have to maintain that the long-term costs to the widening class-gap of health care are far worse to swallow than finding a way to equalize the system.

Barack Obama is going to be elected president of this country. I think the writing on the wall is plain. The choice now is to be part of the national discussion on health care or to rage against it and forever have our voices out of the compromise. It must be remembered that the Constitution, so upheld and revered by members of both parties, was an endless source of frustration to all of its drafters, as none of them got exactly what they wanted. But it is that very issue of compromise and civility over their differences that makes the Constitution, and our country, great.


Kimberly Bluestocking said...

Interesting - I'll have to give these options some thought. All the conflicting opinions make my head spin, but I don't want to just stick it in the sand and let other people do the thinking.

Also, it's a shame that so many people judge an idea based on its conservative or liberal source rather than its actual merits. And then we wonder why Arabs and Israelis can't just let the past go and get along . . .

Sherry said...

Hear! Hear!

I find it a little bit crazy that so many Americans cry "Socialism" as a reason not to have national health care when so much of American society is, in fact, socialized.

I don't know what the solution is, but I know there has got to be something we can do.

Doreen said...

I kind of like the insurance I'm currently on. Preventive care does not require deductibles or co-pays, it's completely free to get a yearly physical. Very valuable, in my opinion, as it can help detect problems before they grow out of hand (especially the case with cancer or heart disease), but then you do have a co-pay for office visits (undoubtedly to discourage people from going for every little sniffle). Of course, my policy also has a $5000 maternity deductible, soooo.... I don't know, it's been very interesting to follow the whole health care debate. I don't know what the answer is, or even where I personally stand, for that matter. All I know is that the system as it currently stands is NOT working. I just read an article in this month's Mothering magazine about the maternal mortality rate in the US, and it was truly a shocking read. What it boiled down to was that many maternal deaths could be prevented if follow-ups were done at home after moms are discharged from the hospital. I always thought it was extreme that in other countries, women stayed in the hospital for 5-7 days even after a normal, uncomplicated vaginal birth. Now I can see the reasoning behind that practice. Not that I'm saying we should keep all moms in the hospital that long, but it would certainly be of benefit to have nurses do home visits a couple of times after mom is discharged. I know that's common practice for home births, midwifes typically come back for home visits a few times during the first two weeks post partum. Anyway, going off on a tangent. I guess what I'm trying to say is that they current system is not only overly expensive, but in a way also dangerous. Insurance is just part of it.

Doreen said...

Sheesh, I should proof read before I post, excuse the typos. And in my final sentence, I meant to say that insurance companies are just part of the problem... :p

FoxyJ said...

Well written post. Health care in this country is such a mess; we really need to figure out some sort of solution. I think a lot of people don't realize that many of our current problems with debt and overextension come from health care costs. For many people health expenses are a major financial problem, especially because (as you pointed out) it's extremely difficult to even find out how much a doctor's visit or other procedure will cost. We're careful budgeters and figured out that one year our health care expenses were almost 35 percent of our spending for the year. That's with a fairly average young family. That's a lot of money we could have put towards paying for school or saving for a home.

Jessica said...

i always find your posts such food for thought and very well-written and researched. this will definitely give me some things to think about.

Kimberly said...

Being self employed for over 5 years now, healthcare is a huge issue for our family. My husband even said, "Whichever candidate for President who has the best health care plan will have my vote!" The healthcare issue SHOULD transcend party lines and opinions. While I was in England for the summer of 1998, I badly twisted an ankle and went to a nearby hospital to have it checked out and x-rayed. Granted it was 10:00 at night, but I didn't have to wait in line, the care was nothing to complain about, and I walked out shocked that I didn't have to pay a dime. I'm not saying that socialized medicine is the right thing, because I think there are way too many people in America that think they deserve a free ride for everything. But it doesn't make sense to pay $650 a month premiums to insurance companies and get very little coverage in exchange. It would make more sense to have save money in Health Savings Accounts with catastrophic insurance for stuff like cancer, etc. People still need to be responsible for their own healthcare -- and that includes the cost of it. The rising cost of healthcare is due in some part to fear of litigation, and that's where government can step in to helpwith laws and caps, etc. We are opening up a Bioidentical Hormone Clinic in May and are opting to bypass the whole insurance company headache, offering services at cash-only costs. Healthcare is a mess, and there's not going to be an easy solution.

Science Teacher Mommy said...

Hey, Slim, I didn't know you ever lived in England! I love blogging. In just minutes you can reveal more about yourself than in years of knowing a person. I will email you and ask you more about your new company. Are you guys paying out of pocket for your pregnancy too?

I know a person who just got married and is attending BYU-I. The university requires you to buy their insurance if you don't have private insurance. The premium is not too high, but the coverage is lousy. This person takes a very expensive medication for a very mild form of epilepsy. Her meds have allowed her to live almost entirely seizure free for the past five years and are effective enough that she is even able to have a driver's license. Anyway, her BYU health plan won't even cover a portion of her medication, but having the health plan precludes her getting on Medicare. So, does she drop out, get on Medicare and get the meds she needs to be seizure-free, or does she go to school and take a gamble on quitting the meds? At least temporarily I think her parents are going to step in, but we are talking about $400 a month.

I'm sure that each of us can come up with something anecdotal, but the real research has also been done and it is really shocking the massive policy failure, on nearly every level and from both parties, that has taken place over the last 50 years.

But it is coming, and other changes too. The latest environmental bill before congress? Co-sponsored by Obama, Clinton, Leiberman and McCain. Yes, some of this may be campaigning, but it also signals a new era of progressive thinking and policy shift in this country. The next president will have a clear mandate for a new direction, and I think any one of them might be up to the task.

Yankee Girl said...

Hurrah for progressive thinking and thanks for the post. I know we have a huge problem to fix but I am completely clueless on how we should go about fixing it. This helps me a ton.

Desmama said...

Good thoughts, STM. I don't have much to add, but I do have much to consider after reading this. ;)

EmAndTrev said...

Ditto Desmama's comment. My first thought after reading your opening paragraph was "say what?" Isn't that what makes America great? Having an opinion? And an educated one at that? More power to ya, STM!!

Shaylee'n'Eric said...

Hi STM, its your brother I thought this would be a good blog to chime in on, and since I first introduced you to the dual insurance system and you don't give me credit(wink wink) I wanted to say a few things. Good historical insight, the first company that really saw a problem with their health spending was goodyear tire in OH, they realized they spent more on employee health insurance than they did on raw rubber for their product ergo = HMO! RE: 1) a dual system is possible. But for physicians that practice in the gov't funded program, you must make it competitive. It is the same reason why so many physicians are entering the private sector and leaving academia, the money. And your argument that private is good for our parents, and public for you may be backwards. The closest thing we have to social medicine in america is medicare and though it has its many flaws is still a good system. Our parents are 6 years from tapping in. Next, a public system would regulate many expensive services for the good of the group. This may sound perfect, but if your child is the rare kid that needs a bone marrow transplant, or experimental chemotherapy, and the state decides not to cover it, the system suddenly failed for the few. The three reasons for high health care cost you mentioned were a)loans b)overhead c)malpractice. You were sorta right. The three reasons a doctors bill is so much is #1 rent (for the office) #2 health care and wages for employees #3 malpractice. Student loans hav only become a huge problem in the last 10 years as insurance has cut reimbursments. The government has stated that a student loan payment shouldn't be more than ~9% of your gross income when you start paying, that would mean I would need to make nearly a million dollars a year as a first year attending. Yes, we need help. 3) even if the gov't becomes the single third party payer in America, it will be contracted out to current companies much like BlueCross BlueShield oppurates. For instance the "blues" here in DC are run by a company called CareFirst. They have ~3.6 million subscribers. Last year they gross 6 BILLION (with a B) in NET revenue and 2 BILLION of that is PROFIT. (add your own explitives here). 4) insurance not shrinking, only growing. In 10 years at our current rate there will be only 4 insurance companies the blues, United, Aetna and Signa.
Lastly, socialized medicine only works if you have the proper providers to supply it. In England (which if we went to social medicine it would be modeled after them not canada) the physician work force is 80% primary care providers and 20% specialist. The numbers are nearly reversed in america. It is predicted that by 2015 (just 7 years away) that only 5% of US senior medical grads will enter a primary care residency. When considering the solutions ask your self some questions: "Does the CEO of my company's children deserve the same health care as my child? Do I deserve the same health care that the CEO receives? Should we each have to pay the same percentage of our wage for it? DO the housekeeper in the building derve the same? If you answered yes to all of those questions you may be ready to provide health care to all 350 million american's including the 46 million uninsured. Just remember that your tax dollars just funded every emergengy room visit for every drug overdose, for every gang shooting, and every drunk driver that hit your family with their car. The last issue is overuse. Last time I checked when something is free we all use it (like blogger, or free pizza at lunch) are we ready to wait? Lastly 16% of the GDP is spent on health care. That means that health care cost for a family of 4 is more than a minumum wage earner makes in a year. Just a fun stat.

Science Teacher Mommy said...

Wow, E, thanks for the comment. And I did intend to give you credit when I wrote my bit and just forgot. Really.

I think your excellent and lengthy remarks point out a few things:

1--When the logistics of "universal" (I hate that term by the way, are we insuring people on Jupiter? Miss Universe? Does she have two heads and blue hair?) health care are ironed out, the intracies of the law will not be accessible to average Americans. The key will be to build on the system in place: medicare, keeping what works while rejecting what does not. And making it USEABLE, if not totally understood by every average Joe or Jane on the street.

2--A consortium needs to be put together to draft the law that includes doctors, economists, moderate politicians from both parties, white house staff and lawyers. The law needs to be taken to Congress with a preliminary stamp of approval from the center left and right of both parties and from the White House. This would allow a quick passage through Congress with the dissenters coming from the extremes, not the center.

3--The minutiae of the law will be complicated, but if politicians allow themselves to be too caught up in it, then passage of anything will be difficult. (See Governor Romney who signed a bill into law with an abortion co-pay. It is important to remember that he did nothing illegal and more people were better off with health care than without just so he could make a stand on something that he couldn't change.) This legislation has been needed since the early 90's. The Democratic Congress approached it all wrong, with the wrong person in charge of making it work. As smart as Hillary Clinton is, America was not ready for a first lady who did any more than help feed the homeless and read to kids at the local libary.

4--I think providing health care for everyone might reverse the trend in specialists vs. primary care if issues of litigation and lower overhead were addressed. Your point about your student loans is instructive. You'll never make a million dollars running strep cultures and listening to wheezy chests. The other reason the trend can be reversed is that emphasis needs to be pushed on preventative medicine. (I'm not putting you out of business here; I'm sure that our current, intemperate habits will give us heart problems for years to come.) Long term health issues can be mitigated if every child in America is fully covered for the first 10 to 18 years of life.

As to the overuse issue: I'm not sure that health care can be in the same class as free pizza or blogger. Though your point is interesting, to what extent do we want people monitoring their own health? I mean, we need to make good choices and have common sense when it comes to going to the doctor (co-pays would help), but as a professional. . . I guess I'm thinking like a teacher here and my frustration over every parent who thinks they can pull their kids and do a better job at home. For example, Plantboy is using scratched glasses, has a tendonitis issue in his foot, Poopy Pirate needs a 3 year check up and Captain Tootypants is thre months behind on his shot and I'm due for a yearly exam. And all five of us need to see the dentist. These are mostly preventative health care issues (not like free pizza) and mostly even within our deductible, but depending on the extent of Plantboy's foot issue, taking care of all this in the next two months will probably cost us $700. That is why I'm delivering papers every morning at 3am, even though we have coverage as good as you are going to find everywhere right now.

I think that ANYTHING that can be done is better than nothing and the law can be refined over years. Society as a whole is immensely benefitted when it is healthier.

Shaylee'n'Eric said...

Your family plight is unfortunatly not uncommon. In general, what a sad commentary on the most powerful and rich nation on the planet, who's hard working educated citizens are deciding between the gas bill or vaccinations. I agree with the consortium thoughts. The reason HIllary's program failed I don't think it was cause of hillary. It failed I believe for 3 reasons. #1) She introduced it in the early 90's only 3-4 years after health care made more money than it ever has in history. HMO's were booming and it wouldn't be until the late 90's/early 2000's that we realized they were a huge embarresing failure (with the exception of some Kaiser centers in california). #2) take a guess at how many practicing clinical physician she had on her task force? Yup ZERO. #3)The pharmacutical company started booming in the early 90's. If you want an awesome quick read, read "overdosed america" by Dr. Abrams or Abraham something like that, it is awesome (i mentioned that twice now).
I am glad you brought up preventative medicine. Most of us don't have a great understanding of what that means. First, yearly physicals for men between the ages 6yo-35yo are not cost effective with the exception of vaccine boosters. Now I am not encouraging people to not see the doctor (gosh knows I don't need that), I am just saying if you have no symptoms, it doesn't help. I would argue, if you are over weight at all, that is a symptom (technically a sign) and you should see your doctor at least every year. For women same thing only it is from 6yo-21yo. Caveat, a women needs their first gynocologic exam at 21 yo or 3 years after their first sexual contact whichever comes first. Both sexes should probably have someone taking their blood pressure twice a year starting at 21 (not necessarily the doc)Both sexes should see their doc's at 35 for their first cholesterol screen. Women should start to consider mammo's at 35 depending of family history. At age 40 women should start getting yearly mammo's unless they have a 1st degree relative with Breast CA before menopause (especially before 35) then they need to start talking to their gyno at that first appointment. Though I believe that women should do monthly self breast exams, it has never been proven to improve morbidity or mortality in any study ever. Most studies actually show an increase in morbidity in groups who did SBE. Completely healthy normal weight men should start that yearly appointment, probably at age 45, since that is the point that men get a cardiovascular risk factor against them for age. Colonoscopy a must at 50 unless a first degree relative has been diagnosed with colon cancer before age 60, then your colonoscopy is 10 years before they got diagnosed (ie, if daddy got it at 54, you get tubed at 44). There is a bunch other but I won't bore you with them. You are absolutly right about long term health issues if you were covered 18years of life (a model they use in italy) but this is an idea I have been tossing around lately, and just let it marinate, how about universial coverage (ity-bity living space, Aladdin reference) for every member of the family if you have a child under the age of 18 (including foster kids)? Time your least strapped for cash? when the last kid leaves home, and your only 5-15 years from medicare. Just an idea

Science Teacher Mommy said...

I really like your last idea because that would be when healthy habits could be extablished. Also, children have few options about insurance if their parents are not insured. And it is definitely not the fault of a seven year old kid if his parents are not insured.

Did you get my message about Herbie Hancock?

Kimberly said...

Hey STM. Yes we are paying out of pocket for our pregnancy -- maternity insurance would have cost us almost $10,000 for the year we would be required to carry it. Might as well pay cash and not mess with insurance. With our experiences, I am really leaning toward the idea of where we were before the 1950's and eliminating the money-monger insurance industry altogether. That's the beauty of a democracy -- good old fair competition between doctors would bring prices back down to a palletable size. Still, I understand that medicine has come a long way since the 1950's and with increased technology, comes more expensive treatment methods, so perhaps catastrophic insurance coverage still makes sense. But wow. Somebody's got to pull in the reins on these insurance companies. And by the way, the the three reasons your brother gives for the rising cost of healthcare are correct to some extent, but another factor is how much the doctor wants to put in his pocket at the end of the day. Email me about the BHRT clinic we're starting.

Shaylee'n'Eric said...

Kim, this is STM, brother again, the three reason's I gave aren't actually my reasons, they are the reason's published in the medical literature. I have to disagree with your comment about how much a doctor has to put in his pocket. For a doctor to take home $100,000 to his family, he must bill 1 million dollars (approximately). This is not easy to do. A general surgeon would have to take out nearly 1,000 appendicies or do nearly 1,300 hernia repairs in one year to bring in $100,000. Pediatrician sometimes see 40 kids a day, and many of them can't make $100,000 a year. If your doctor spends 4 years in college, 4 years in medical school, and somewhere between 3 and 9 years in residency making minumum wage, how much should your doctor be paid? Take into consideration that he/she went into extreme debt to do this. The average US senior medical student graduates with $135,000 dollars in debt and some of us (hmm, hmm) will have nearly three times that amount. And while we are working 80 hours a week the interest is accumulating on those loans. What are you willing to pay as a society for physicians? said...

Having lived in England I agree that National health care has it's problems but I still think we need a form of it here. Over there private health insurance is available and is often given as a corporate perk; but National Health Care is available for people who don't get it and can't afford it. It makes me want to vomit that we spend so much money on all kinds of useless things (useless in my opinion) while people in this country can't get good health care. My sister is having health problems right now and just spent her ENTIRE pay check on one visit to the specialist - and she is going again tomorrow and that will cost her another $1200. She makes to much to qualify for government health care but not enough to be able to afford insurance. Even if she had insurance you can bet they'd drop like she's hot as soon as they found out something was wrong with her.... this is a hot button topic for me.

btw - I know it's wrong but recently for me being called a commi has become like being called a b****, it is almost a compliment depending on the person who says it.