Health Care: The Road to Real Reform
The Supreme Court will rule tomorrow on the constitutionality of major provisions of the Affordable Care Act, the health care reform package crafted by President Obama and Congressional Democrats. As we await the ruling on this legislation, let me offer a few thoughts on the economics and spiraling costs of health care in the United States, the kind of health care reform we really need, and what we as Christians can do to help meet needs now.
The Economics of Health Care
In my first economics class in college, I was introduced to the concepts of supply, demand, and elasticity. Elastic goods are most sensitive to price changes; if a price goes up, demand goes down because consumers will substitute something else in its place. Inelastic goods are not affected by price changes; consumers will pay whatever price because such goods and services are necessities and have no substitutes.
The professor used health care as an example of something with a near inelastic demand curve. When choosing a physician, surgeon, or course of treatment, most of us ask first about quality and expected outcomes. Cost is low on the list (or not even considered) when someone’s life hangs in the balance. Those who do want or need to compare prices find it difficult, and at times, impossible.
We hear a lot of talk about market-based solutions to health care, but too few of these discussions take into account the particular qualities that make the market for medicine so different from that for most consumer goods.
A Good Return on the Investment?
The United States spends more money on health care per capita than any other country, and the rates of spending are growing faster than anywhere else. In 2008, the U.S. spent $7,538 per person. Norway was second highest, spending $5,003. The U.K. spent $3,129, Germany spent $3,737. In 2010, total health care spending in the U.S. was an astounding $2.6 trillion.
It is not always clear if we get what we pay for. On the one hand, the United States is the undisputed center of medical innovation that paves the way for new drugs and devices. People travel from all over the world to receive medical care in the United States. On the other hand, we don’t rank as high in positive health outcomes. In 2006, for example, the U.S. ranked 39th for infant mortality and 36th for overall life expectancy.
The numbers tell a clear and compelling story. Health care costs are rising much more quickly than wages and inflation. The spiraling costs are unsustainable for government and for the private sector. Health insurance premiums have risen more than 100% in the past decade, increasing costs for employers and employees while also dampening wages. Health care costs are the largest piece of the current federal budget and will consume even more of our limited dollars as costs rise.
Experts disagree on the exact reasons for the high costs, but some of the contributing factors include the high cost of medical technology and prescription drugs, the expense of administering such a complex public-private hybrid system, overtreatment, and the increase in chronic illnesses.
Health Care for Everyone?
I am not particularly impressed with much of what I see in the Affordable Care Act. Although it will be several years before most of the provisions are in effect, the plan appears overly complex and deeply tied to our current system which most observers agree is broken.
Although I have many concerns about how this would work well, my current view is that we need to move toward some form of single-payer health care delivery system that provides basic medical services to all Americans. We need to start at the drawing board, creating a new system that compensates medical professionals fairly and guarantees basic standards of care for everyone.
Our current public health delivery programs, Medicaid and Medicare, are not wise models. The payment schedules are so low and the red tape is so complex that payments don’t always cover the costs. Many doctors, especially specialists, do not accept Medicaid and Medicare patients. Some doctors I know find it is more cost effective to set aside portions of their practice to treat Medicaid patients for free.
We need a bold initiative created in a transparent process by policy and medical experts, not negotiated in back rooms with pharmaceutical and insurance lobbyists. I don’t know exactly what that would look like, but I will suggest some useful principles to guide true reform.
Access to basic medical care is a right, not a privilege. Advanced industrial societies should provide a way to provide basic care to all of their citizens. I realize that the debate over “preventative care” can get murky very fast (as we are witnessing with the controversial HHS mandates announced earlier this year), but we need to work toward creating a system where any man, woman, or child has access to a doctor or dentist when they are ill or in need of periodic check-ups.
Medical personnel are highly-trained professionals who deserve reasonable compensation. Doctors devote many years to schooling and additional training. Our system needs to encourage, not discourage, promising students to pursue medical careers.
Seek alternatives to our current fee-for-service system that encourages unnecessary procedures and over-testing. Many procedures are essential, but many others are not. Medical research helps physicians develop best practices; patients should pay more for tests and procedures beyond that which is medically necessary.
Waiting for Results: Helping Now
Given the current political climate, I have little expectation that we will see comprehensive health care reform anytime soon. What can we be doing in the meantime?
One place to start is helping free and low-cost medical and dental clinics by volunteering time and/or donating funds. Community-based health clinics offer a range of services to care for those in need. Many Christian medical professionals also contribute by regularly seeing a few patients for free. Hospitals provide billions of dollars in free care each year, much (but not all) of this in compliance with government regulations.
We can also support those elected officials who have the political courage to pursue comprehensive health care reform. Scores of legislators and several presidents have made serious attempts at reform over the past half century, but voters have rarely rewarded such efforts. We need to encourage and reward those willing to take the political risks necessary to find a long term solution to the nation’s health care crisis.
Amy Black has written a very thoughtful, balanced essay. She rightly notes that market forces do not work well in health care field and documents serious problems with our current system. And her three basic principles are right and well-stated. Especially the first one (access to medical care is a right, not a privilege) is rooted in a biblical concept of justice and a concern for the common good.
But I wonder if there is not a tension between her rightly noting the incredibly complex nature of our current system and her call for the radical move to a single-payer system, as well as her not being impressed by the more incremental approach of Obama’s ACA. Given human frailty, our limited knowledge, and the ever-present danger of unintended consequences—not to mention human perversity—there is much to say for an incremental approach to policy making in very complex policy areas such as health care. We then take modest steps, implement them, see what the results are, and based on experience take the next steps. Now that the Supreme Court has ruled the ACA meets constitutional norms, we are in a position to move ahead with the ACA, see how it works and observe its successes and failures, and then take additional action to correct problem areas and build upon successful areas. At some point we may conclude that a single-payer system is needed, but I believe if we ever reach that conclusion we should do so gradually, incrementally, and based on our experience with more modest steps.
Amy Black has written a very thoughtful, balanced essay. She rightly notes that market forces do not work well in health care field and documents serious problems with our current system. And her three basic principles are right and well-stated. Especially the first one (access to medical care is a right, not a privilege) is rooted in a biblical concept of justice and a concern for the common good.
But I wonder if there is not a tension between her rightly noting the incredibly complex nature of our current system and her call for the radical move to a single-payer system, as well as her not being impressed by the more incremental approach of Obama’s ACA. Given human frailty, our limited knowledge, and the ever-present danger of unintended consequences—not to mention human perversity—there is much to say for an incremental approach to policy making in very complex policy areas such as health care. We then take modest steps, implement them, see what the results are, and based on experience take the next steps. Now that the Supreme Court has ruled the ACA meets constitutional norms, we are in a position to move ahead with the ACA, see how it works and observe its successes and failures, and then take additional action to correct problem areas and build upon successful areas. At some point we may conclude that a single-payer system is needed, but I believe if we ever reach that conclusion we should do so gradually, incrementally, and based on our experience with more modest steps.
Amy Black has written a very thoughtful, balanced essay. She rightly notes that market forces do not work well in health care field and documents serious problems with our current system. And her three basic principles are right and well-stated. Especially the first one (access to medical care is a right, not a privilege) is rooted in a biblical concept of justice and a concern for the common good.
But I wonder if there is not a tension between her rightly noting the incredibly complex nature of our current system and her call for the radical move to a single-payer system, as well as her not being impressed by the more incremental approach of Obama’s ACA. Given human frailty, our limited knowledge, and the ever-present danger of unintended consequences—not to mention human perversity—there is much to say for an incremental approach to policy making in very complex policy areas such as health care. We then take modest steps, implement them, see what the results are, and based on experience take the next steps. Now that the Supreme Court has ruled the ACA meets constitutional norms, we are in a position to move ahead with the ACA, see how it works and observe its successes and failures, and then take additional action to correct problem areas and build upon successful areas. At some point we may conclude that a single-payer system is needed, but I believe if we ever reach that conclusion we should do so gradually, incrementally, and based on our experience with more modest steps.
In such short essays, we cannot begin to plumb the depths of these topics. So many aspects of this discussion deserve elaboration. Steve Monsma and Paul Brink’s comments offer me a good opportunity to expand some of my thoughts and encourage others to weigh in as well.
I generally favor incremental approaches to public policy problems for many of the reasons Steve expresses in his comment, and I am not opposed to incremental moves now. My biggest concern is the direction of such moves. I am growing increasingly convinced that we need to move away from our current system of employer-sponsored health insurance and find another model. I also worry that our health care system is so complex that it is becoming increasingly difficult to figure out which aspects work well and which are creating the most problems.
I wasn’t intending to be a radical (but perhaps I was!) when I suggested a new direction for health care policy: “Although I have many concerns about how this would work well, my current view is that we need to move toward some form of single-payer health care delivery system that provides basic medical services to all Americans. We need to start at the drawing board, creating a new system that compensates medical professionals fairly and guarantees basic standards of care for everyone.”
I’m not advocating an overnight switch, but I do think we should work less to shore up the private insurance industry and do more chart a path toward basic care for all. As I noted in my initial post, I am not sure the best way to move forward, but most commentators agree that the current system is unsustainable. It is especially complex and problematic for the poorest and most vulnerable, those most in need of care.
It is hard to know the effects of the Affordable Care Act until it is fully implemented, but it is a very complex law tied to our current system. Many of its goals (such as moving toward universal coverage, protecting patients from losing insurance when they get too sick) are laudable, but other aspects seem problematic. For example, the legislation calls for an expansion of Medicaid and pays for part of the costs through Medicare cuts. If many providers cannot afford or even refuse to take Medicaid and Medicare patients now, what will happen after these changes are implemented?
As all of our posts so far have noted, health care reform is complicated. Those who have access to great care fear losing it. Most of those who don’t have insurance are at great financial risk and have few voices representing them in Washington. Professions and industries with deeply entrenched interests monitor every move and spread their money and influence far and wide. The issue is polarizing and has vexed many previous presidents and congresses from both parties for decades.
We need visionary lawmakers who will put the common good ahead of special interests and seek a new approach to health care delivery and payment. Perhaps some APC readers have greater expertise in this area and can offer a constructive path forward.
In such short essays, we cannot begin to plumb the depths of these topics. So many aspects of this discussion deserve elaboration. Steve Monsma and Paul Brink’s comments offer me a good opportunity to expand some of my thoughts and encourage others to weigh in as well.
I generally favor incremental approaches to public policy problems for many of the reasons Steve expresses in his comment, and I am not opposed to incremental moves now. My biggest concern is the direction of such moves. I am growing increasingly convinced that we need to move away from our current system of employer-sponsored health insurance and find another model. I also worry that our health care system is so complex that it is becoming increasingly difficult to figure out which aspects work well and which are creating the most problems.
I wasn’t intending to be a radical (but perhaps I was!) when I suggested a new direction for health care policy: “Although I have many concerns about how this would work well, my current view is that we need to move toward some form of single-payer health care delivery system that provides basic medical services to all Americans. We need to start at the drawing board, creating a new system that compensates medical professionals fairly and guarantees basic standards of care for everyone.”
I’m not advocating an overnight switch, but I do think we should work less to shore up the private insurance industry and do more chart a path toward basic care for all. As I noted in my initial post, I am not sure the best way to move forward, but most commentators agree that the current system is unsustainable. It is especially complex and problematic for the poorest and most vulnerable, those most in need of care.
It is hard to know the effects of the Affordable Care Act until it is fully implemented, but it is a very complex law tied to our current system. Many of its goals (such as moving toward universal coverage, protecting patients from losing insurance when they get too sick) are laudable, but other aspects seem problematic. For example, the legislation calls for an expansion of Medicaid and pays for part of the costs through Medicare cuts. If many providers cannot afford or even refuse to take Medicaid and Medicare patients now, what will happen after these changes are implemented?
As all of our posts so far have noted, health care reform is complicated. Those who have access to great care fear losing it. Most of those who don’t have insurance are at great financial risk and have few voices representing them in Washington. Professions and industries with deeply entrenched interests monitor every move and spread their money and influence far and wide. The issue is polarizing and has vexed many previous presidents and congresses from both parties for decades.
We need visionary lawmakers who will put the common good ahead of special interests and seek a new approach to health care delivery and payment. Perhaps some APC readers have greater expertise in this area and can offer a constructive path forward.
In such short essays, we cannot begin to plumb the depths of these topics. So many aspects of this discussion deserve elaboration. Steve Monsma and Paul Brink’s comments offer me a good opportunity to expand some of my thoughts and encourage others to weigh in as well.
I generally favor incremental approaches to public policy problems for many of the reasons Steve expresses in his comment, and I am not opposed to incremental moves now. My biggest concern is the direction of such moves. I am growing increasingly convinced that we need to move away from our current system of employer-sponsored health insurance and find another model. I also worry that our health care system is so complex that it is becoming increasingly difficult to figure out which aspects work well and which are creating the most problems.
I wasn’t intending to be a radical (but perhaps I was!) when I suggested a new direction for health care policy: “Although I have many concerns about how this would work well, my current view is that we need to move toward some form of single-payer health care delivery system that provides basic medical services to all Americans. We need to start at the drawing board, creating a new system that compensates medical professionals fairly and guarantees basic standards of care for everyone.”
I’m not advocating an overnight switch, but I do think we should work less to shore up the private insurance industry and do more chart a path toward basic care for all. As I noted in my initial post, I am not sure the best way to move forward, but most commentators agree that the current system is unsustainable. It is especially complex and problematic for the poorest and most vulnerable, those most in need of care.
It is hard to know the effects of the Affordable Care Act until it is fully implemented, but it is a very complex law tied to our current system. Many of its goals (such as moving toward universal coverage, protecting patients from losing insurance when they get too sick) are laudable, but other aspects seem problematic. For example, the legislation calls for an expansion of Medicaid and pays for part of the costs through Medicare cuts. If many providers cannot afford or even refuse to take Medicaid and Medicare patients now, what will happen after these changes are implemented?
As all of our posts so far have noted, health care reform is complicated. Those who have access to great care fear losing it. Most of those who don’t have insurance are at great financial risk and have few voices representing them in Washington. Professions and industries with deeply entrenched interests monitor every move and spread their money and influence far and wide. The issue is polarizing and has vexed many previous presidents and congresses from both parties for decades.
We need visionary lawmakers who will put the common good ahead of special interests and seek a new approach to health care delivery and payment. Perhaps some APC readers have greater expertise in this area and can offer a constructive path forward.
The following comment submitted by Thomas Major (artistagent@gmail.com) is posted by Harold Heie on Tom's behalf.
________________________________
In a “closed narrative,” the terms of the conversation are set and there is no room for the introduction of new ideas. This has happened in the Health Care debate.
In particular, what has been “closed out” of the public conversation on Health Care has been one of the “causes” of runaway health care costs: the spiraling expenses associated with standardization of health care procedures and treatment, which has the added negative effect of diminishing the importance of the relationship between doctor and patient.
I gained first-hand knowledge of this problem when I overheard the following sales pitch made by representatives of a health insurance company in the office of a country doctor: "Doctor, you were trained to be a doctor. There is no need for you or your wife to do the book keeping too. And we have made it very easy for you by training medical coders to process all of your billing. We recommend 6 coders but you can get by with 4. The salary for each coder is about $45,000 dollars a year. They will keep detailed records, file them in these walls of files, and they will make all of your appointments.”
I also have first-hand experience of what happens when such a system of standardized procedures is set up. Before standardization, my office visit cost $25, which seemed to satisfy the doctor. But after the new staff came in and the doctor said that I should be charged $25 because I was a disabled vet and had no insurance but always paid my bill before I left, the staff grumbled amongst themselves asking, loud enough for both the doctor and me to hear: “What is wrong with him [the doctor], doesn't he know that there is no $25.00 charge? There is no code for that.” But when the doctor just wrote NC (no charge ) across my chart, a staff member went ballistic, asking, “How are we supposed to file that?” I smiled and said, “Try filing it under my name.” Needless to say, the woman didn’t know my name.
Before these new staff members showed up, I didn’t have to wait three weeks for an appointment, the doctor would take me as a “walk in” any time. And on a few Saturdays he called me back after I called his answering service, and told me to meet him at his office in 15 minutes. He would come in wearing a flannel shirt, listen to me and give me a more thorough examination than those I have been given by Emergency Room doctors.
So, here is my “outside of the box” suggestion: Set up doctor’s offices that work “like the good old days.” Eliminate the complicated forms and standardized procedures that are very expensive, are not understood by most patients, and have a destructive effect on the doctor/patient relationship. The old fashioned office will work smoothly, at a profit, and no one will need to wait three weeks to be seen for a sore throat that is happening today. We don’t even need to set up a committee or wait for an act of Congress to try this. Maybe we should be even bolder and set up something like “Doctors without Borders” within our own country.
What do you think?
The following comment submitted by Thomas Major (artistagent@gmail.com) is posted by Harold Heie on Tom's behalf.
________________________________
In a “closed narrative,” the terms of the conversation are set and there is no room for the introduction of new ideas. This has happened in the Health Care debate.
In particular, what has been “closed out” of the public conversation on Health Care has been one of the “causes” of runaway health care costs: the spiraling expenses associated with standardization of health care procedures and treatment, which has the added negative effect of diminishing the importance of the relationship between doctor and patient.
I gained first-hand knowledge of this problem when I overheard the following sales pitch made by representatives of a health insurance company in the office of a country doctor: "Doctor, you were trained to be a doctor. There is no need for you or your wife to do the book keeping too. And we have made it very easy for you by training medical coders to process all of your billing. We recommend 6 coders but you can get by with 4. The salary for each coder is about $45,000 dollars a year. They will keep detailed records, file them in these walls of files, and they will make all of your appointments.”
I also have first-hand experience of what happens when such a system of standardized procedures is set up. Before standardization, my office visit cost $25, which seemed to satisfy the doctor. But after the new staff came in and the doctor said that I should be charged $25 because I was a disabled vet and had no insurance but always paid my bill before I left, the staff grumbled amongst themselves asking, loud enough for both the doctor and me to hear: “What is wrong with him [the doctor], doesn't he know that there is no $25.00 charge? There is no code for that.” But when the doctor just wrote NC (no charge ) across my chart, a staff member went ballistic, asking, “How are we supposed to file that?” I smiled and said, “Try filing it under my name.” Needless to say, the woman didn’t know my name.
Before these new staff members showed up, I didn’t have to wait three weeks for an appointment, the doctor would take me as a “walk in” any time. And on a few Saturdays he called me back after I called his answering service, and told me to meet him at his office in 15 minutes. He would come in wearing a flannel shirt, listen to me and give me a more thorough examination than those I have been given by Emergency Room doctors.
So, here is my “outside of the box” suggestion: Set up doctor’s offices that work “like the good old days.” Eliminate the complicated forms and standardized procedures that are very expensive, are not understood by most patients, and have a destructive effect on the doctor/patient relationship. The old fashioned office will work smoothly, at a profit, and no one will need to wait three weeks to be seen for a sore throat that is happening today. We don’t even need to set up a committee or wait for an act of Congress to try this. Maybe we should be even bolder and set up something like “Doctors without Borders” within our own country.
What do you think?
The following comment submitted by Thomas Major (artistagent@gmail.com) is posted by Harold Heie on Tom's behalf.
________________________________
In a “closed narrative,” the terms of the conversation are set and there is no room for the introduction of new ideas. This has happened in the Health Care debate.
In particular, what has been “closed out” of the public conversation on Health Care has been one of the “causes” of runaway health care costs: the spiraling expenses associated with standardization of health care procedures and treatment, which has the added negative effect of diminishing the importance of the relationship between doctor and patient.
I gained first-hand knowledge of this problem when I overheard the following sales pitch made by representatives of a health insurance company in the office of a country doctor: "Doctor, you were trained to be a doctor. There is no need for you or your wife to do the book keeping too. And we have made it very easy for you by training medical coders to process all of your billing. We recommend 6 coders but you can get by with 4. The salary for each coder is about $45,000 dollars a year. They will keep detailed records, file them in these walls of files, and they will make all of your appointments.”
I also have first-hand experience of what happens when such a system of standardized procedures is set up. Before standardization, my office visit cost $25, which seemed to satisfy the doctor. But after the new staff came in and the doctor said that I should be charged $25 because I was a disabled vet and had no insurance but always paid my bill before I left, the staff grumbled amongst themselves asking, loud enough for both the doctor and me to hear: “What is wrong with him [the doctor], doesn't he know that there is no $25.00 charge? There is no code for that.” But when the doctor just wrote NC (no charge ) across my chart, a staff member went ballistic, asking, “How are we supposed to file that?” I smiled and said, “Try filing it under my name.” Needless to say, the woman didn’t know my name.
Before these new staff members showed up, I didn’t have to wait three weeks for an appointment, the doctor would take me as a “walk in” any time. And on a few Saturdays he called me back after I called his answering service, and told me to meet him at his office in 15 minutes. He would come in wearing a flannel shirt, listen to me and give me a more thorough examination than those I have been given by Emergency Room doctors.
So, here is my “outside of the box” suggestion: Set up doctor’s offices that work “like the good old days.” Eliminate the complicated forms and standardized procedures that are very expensive, are not understood by most patients, and have a destructive effect on the doctor/patient relationship. The old fashioned office will work smoothly, at a profit, and no one will need to wait three weeks to be seen for a sore throat that is happening today. We don’t even need to set up a committee or wait for an act of Congress to try this. Maybe we should be even bolder and set up something like “Doctors without Borders” within our own country.
What do you think?