How Not to Run a Nationalized Health System
Charges are being leveled at the NHS in the UK for failing to properly care for men with prostate cancer. The issues are money, access to the proper multi-disciplinary health team, and who should pay for treatments.
I raise this issue because it is the kind of thing that will happen if we hearken to the siren song of many USA bioethicists, and formally ration health care. Rationing, in my view, is a polite word for medical discrimination against those who need health care most. Moreover, in a rationed system, disease groups would be fighting each other for pieces of the limited pie. Diseases with strong political advocacy groups behind them would do well, e.g., HIV, breast cancer, etc. Those without the political muscle would probably fare more poorly.
We do have to find ways to bring a much broader swath of people into the health care system in the USA. This is a matter of growing urgency. To avoid rationing, I think it will best be done with a mixed system of private insurance with public backup for catastrophic diseases, and a pool for the hard to insure. We need to permit nationwide underwriting to permit greater spreading of the risk.
What we definitely do not need is a system like the NHS in the UK. What a disaster.
posted by Wesley J. Smith @ 7:26 PM
11 Comments
11 Comments:
I disagree with any private/public system.
The simple truth is our private health insurance system is a total disaster; many people are being forced out altogether, and companies are increasingly trying to squeeze people out of coverage, so it becomes "rationing" anyway.
No, health care is a RIGHT, not a privilege, and, like police, fire, and schools, should be a government function. Sorry if people disagree, but that's the truth.
We are about the only industrialized country in the world without a national health care system, and it is a scandal. Having a single-payer system, like your former associate Ralph Nader advocates, IS the answer. This does NOT have to result in "rationing."
The current mess of a private insurance system already does it, and we need to get rid of private health insurance. It exists just to leech off of people and businesses.
Susan, you are wrong. A public system _inevitably_ results in rationing, and this is because of its intrinsic nature. It's because the money involved is thought of as a single pool of "our money"--communal money--and then those in charge decide for everyone in the system what is a "rational" way to use it. This inevitably involves telling some people that their claims aren't as "rational" as others' and shifting money around for the whole large group according to the values of the higher-ups in charge. In fact, that's what those advocating the whole thing usually _want_, and they will talk at length about the "inefficiencies" of the present system. One of the things they mean by that is _precisely_ that it doesn't conform to their priorities, meaning the way they would ration the money if they were in charge. For example, there is usually much moaning and groaning about how "much we spend" on people toward the end of their lives and how much "better" that money would be spent on childhood vaccines, pap screening, and other preventative medicine. (As if this would obviate the need for taking care of people at the end of their lives!) This, however disguised, is advocacy of rationing.
Moreover, in the UK the "universal" system has resulted in incredible amounts of power for doctors. Leslie Burke has been told that he can be dehydrated to death by doctors at the end of his life despite his repeated statements that he doesn't want to be. The doctors get to decide. Charlotte Wyatt's parents have been given virtually no say in her health care. And David Glass was nearly actively euthanized years ago by diamorphine drip. Indeed, his relatives spent time in _jail_ for struggling with doctors after the relatives removed the drip that was quickly killing this disabled boy. Yet they were the ones lectured by the judge for interfering with the all-wise doctors.
We are fools if we don't see what nationalized health care would mean. In some of these ways we've already moved the same direction in the U.S., but not as far nor as fast. The solution is not more of the same!
I'm not sure how to apply universal health care would work in America, given our peculiar economic concerns.
I do think we have a moral imperative to provide a basic health care universally to our citizens. Not just the fed govt, but to society in general - the states, private groups - should also play a role. But I don't think we can remove profitability (i.e., capitalism) from medicine, otherwise we'll drastically curtail medical technology and pharmaceuticals.
Perhaps rationing is the only effective way of doing so, given that politics inevitably mixes in.
I'm trying to learn more on how Vermont did it and if it's working or not. Any ideas on where I can find info on it?
Health care as a RIGHT. To what extent? I think Royeale has stated it better: we have a "moral imperative" to to provide access, but to say it is a right like free speech is way overstated and nowhere to be found in the constitution.
If you want maximum coverage for the most people, I think it will have to be a mixed system. And, I think there will have to be decent sized deductibles and co pays to prevent over utilization. A purely private system won't work any more, nor a purely public system.
I just read a very interesting piece by the Mackinac Institute (a small free-market think-tank in Michigan) about what they call Romney-care, the Mitt Romney proposal in Massachusetts, which is a mixed system. It sounds like it has some good points and some bad. The worst problems are a) that it will indeed encourage over-utilization and b) that a panel will get to decide which plans otherwise uninsured people can buy with pre-(state)tax dollars. The Mackinac prediction is that this panel will not allow them to buy high-deductible catastrophic insurance in this way, because in the Romney plan a whole bunch of items of required coverage are already listed which wouldn't be covered by such relatively cheap plans.
I follow brachytherapy news because I have a client in the business and I very frequently get news alerts about prostrate patients in the UK having to resort to lawsuits to get brachytherapy treatment.
In the US, this is not an issue, a NY Times article last month examined how US health insurers will cover the latest cancer treatments regardless of cost:
"The rise in cancer-drug prices is a microcosm of broader trends pushing up health care costs nationally. Despite decades of efforts by governments and insurers to restrain costs, patients continue to want the newest — and most expensive — drugs and medical devices. And doctors and the health care industry have little reason to keep costs in check, because insurers rarely deny coverage for new treatments on the basis of price."
The full article can be viewed here: http://www.nytimes.com/2006/10/01/business/yourmoney/01drug.html?ex=1162702800&en=ddb2e0f5009ce576&ei=5070
I agree that the best system is a mix of private and public - private for those who can pay, public for those who cannot afford it. I think that many of the Americans who advocate for government only healthcare would be in for quite a shock if they had to give up their private coverage for a socialist style system.
I agree with both of Gregory's points.
I think people have to get past the idea that they shouldn't have to pay anything for their care, or that they can't have what their insurance won't pay for. I read an article some time back about a woman who had metastatic breast cancer. She hadn't been getting her mammograms because her health insurance wouldn't pay for them. I paused a moment and thought about how sad it is when a person in middle age can't shake loose a hundred dollars or so, once a year, for something so important. But the article went on to say that when she found a lump, she waited until she and her husband got back from their week-long trip to the Bahamas before she went to the doctor. I still think about that article because that attitude baffles me completely, and I know it isn't rare at all.
I know a lot of people agree with Susan, but I think our healthcare crisis is partly due to people just not wanting to step up and take responsibility for themselves. I know people with chronic illnesses that they need help paying for; I'm not talking about that. That's where Gregory's second point comes in. I'm talking about Joe Blow American, who has a full-time job and expects to put his own roof over his head and food on his table, taking ownership of his health care needs too. If health care becomes a goverment function, that's one more step down the road of taking the responsibility that every able adult ought to have, away from us.
I don't claim to understand all of the economic issues here, but let me point out one interesting parallel: Why is body work on your car so expensive? Answer: Because most of it is paid for by collision insurance. We never buy collision on our cars, and one time when the front panel was dinged, it was some enormous amount of money to have it replaced--far more than an individual would normally be willing to pay.
When a third-party payer becomes the most frequent payer in an area of the economy, this seems inevitably to drive up prices. This is clearly part of what's going on in health care. It seems to me that if we're going to go to any sort of "mixed system" _beyond_ what we already have (and we already have a mixed system between public and private expenditure--ask your local emergency room), then we _must_ encourage high deductibles so that people are paying for more things out of their own pockets. This will drive down cost and also drive down overusage.
But note: This is in conflict with the emphasis in our current medical training on screening and prevention. People are constantly pressured (for example) to bring perfectly healthy children to the pediatrician every year for a check-up for no particular reason. This is _encouraging_ over-use of the system, and it would likely not be pushed so hard by pediatricians if people were paying for their own ordinary visits, because fewer people would take the advice. They'd bring their kids to the doctor when they were sick.
So bizarre has the emphasis on "screenings" of apparently healthy people become that it now sometimes trumps follow-up on clinical symptoms that individual people actually have.
Lydia, so are you saying that preventive health care is not worth the cost? Is it matter of scale (we should have less preventive screenings) or get rid of it altogether?
I think it should probably (at least for some diseases) not be pushed as hard as it is. I think it is pushed as a sort of cure-all and has become an ideology--and an expensive and not always rational one.
I could give lots of examples. Perhaps you would disagree with them all. But there seems to be an odd idea that we could just prevent everything if we just screened enough people for enough things--as if then we could become nearly immortal.
And as I say, things have obviously gone too far when
a) clinical symptoms of X are virtually ignored while the symptom-free patient is pressured to have a "screening" for disease Y
b) healthy people are constantly worried by doctors about the mere possibility that they _might_ have something wrong with them
and
c) things (like mental health, for example) that do not really fall under the "cancer model" are treated as being like cancer such that people who are having no problems are made to feel (or their parents or guardians made to feel) that they should be "screened" in case there is a "hidden" problem. (This is beginning now with a push for universal "mental health screening" for children in schools.)
And I think that people would be more likely to stop and think the risk-benefit issues through--including, for example, the risks and costs (emotional as well as monetary) associated with false positives for such screenings--*for themselves* more if the tests were not paid for by insurance.
I guess I might as well say outright that I do think yearly pediatric visits for children in no special risk category should not be encouraged. A doctor could easily say to a mom, "You know, it's fine if you don't bring her in every year. She's a healthy girl, and we do see her from time to time when she is actually sick. But of course, feel free to come in if there's something you want to ask or consult us about."
I'm not talking about immunizations here, but those are mostly done by age two with just one or two more at age five. I'm talking about bringing in your healthy eight-,nine-, and ten-year-old on the dot after his birthday. No point to it. And in fact, family practice doctors are far less likely to push this or even suggest it than pediatricians, who tend to be more aggressive and to think of themselves more in the "social worker" mode than in the "doctor" mode. It's largely a matter of style and ideology, not a medical issue.
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