Thursday, September 24, 2009

More on Healthcare

Sorry for the blitz of postings-- I have a lot of thoughts to catch up on.

The posting I did on healthcare leaped off a post at feministe about healthcare, and the conversation ensued in the comments. I don't want to lose the points from that conversation, so here goes:

The author said that what I proposed-- a tiered system that can grant basic access to all and good care to people with good jobs-- was what they have in France, Germany, Switzerland and Japan. I replied:

But these other countries don’t exactly have it figured out, for a variety of reasons. In Germany, doctors’ salaries have the purchasing power of about 20% of what they have in the U.S. On top of that, everyone’s salary is taxed at an additional 10-15%. EVERYONE. You can’t opt out, but you can buy supplemental coverage at high cost if you want… which means that, to get anything above the level of healthcare offered to the general public, you need to pay about two months’ salary every year on healthcare. And then, of course, the doctors aren’t as good (see: salary differential). Finally, in Germany, the tax rate for healthcare is set, and the ’sickness funds’ have to be self-supporting; if you join a sickness fund and there’s a nuclear meltdown on the other side of the country and the town next to the plant was populated by people in your sickness fund, there’s no money left for your knee replacement.

In France, there’s this: More than 92% of French residents have complementary private insurance. This insurance pays for additional fees in order to access higher quality providers. Private health insurances makes up 12.7% of French health care spending. These complementary private insurance funds are very loosely regulated (less than in the U.S.) and the only stringent requirement is guaranteed renewability. Private insurance benefits are not equally distributed so there is, in essence, a two-tier system… Which is what I was proposing. But can you sell a universal healthcare package that’s, you know, crap? If we make it cheap enough, you’ll be able to just keep everyone on life support, I guess, sort of. We’re bigger than France and have twice as large a portion of the population (France’s 6% to our 12-17%) living below the poverty line and therefore not paying in.

Also, in France, billing and recordkeeping are organized by the government. We don’t have this because of, among other things, privacy concerns; in the 90s, non-centralized and highly-private record keeping became a big deal in the U.S. because people didn’t want their employers to know they had AIDS. Also, people applying for all sorts of insurance policies– not only health, but also life– want these records to be kept secret. So, things are different in France because the costs are spread out among more people and there are systemic differences that make healthcare cheaper. These might be some of what the President is referring to when he talks about limiting inefficiencies in the current system, but he needs to make that clearer. Also, French doctors earn about 40,000 Euros/year, which, even if you turn that into dollars at roughly $80,000, is a lot less than what U.S. doctors make. This is partly okay because French medical school is free, while U.S. medical school is not, so French doctors don’t have 100,000 Euros of debt to pay off. All the same, you lose the support of the U.S. medical community the second you start talking about changing compensation or practices.

Switzerland has, essentially, no poor people. Only 3% of the country relies on government assistance. when everyone works and pays in, it’s easy to have good healthcare, because there’s plenty of money around to provide the right incentives. It’s great to be a doctor in Switzerland. If you can motivate more brilliant people in the U.S. to become doctors by increasing compensation, you can have broader medical coverage. Also, in Switzerland, healthcare is all private; the companies are just prevented by law from making a profit on basic coverage, but still have to compete against each other to get basic coverage customers, so they can convince some of their basic coverage customers to buy the profit-permitted add-on coverages, for things like, uh, dentistry. you can picture how this would play out in the U.S.; the profitable coverages, and the basic coverages, would all put their focus on getting the people who have health insurance now anyway (i.e. people who can buy the add-ons), while people in communities without coverage now would be getting, you know, half-hearted motions in the direction of coverage. this is partly because of how dramatically economically segregated we are in this country.

And then, in Japan, the hospitals are all going bankrupt.

So there’s the reasons why European plans wouldn’t work here the way they do over there. Part of it is BS cultural posturing (why NOT have centralized recordkeeping and take that item off hospitals’ budgets? Privacy seems to be in the same category as those accusations of haughty individualism the Europeans like to throw at us), part of it is economic (i.e. we all know the U.S. is lousy with economic disparity, so there would be a higher percentage of the population not paying in, and a lower percentage paying in), and part of it has to do with the medical profession as it exists in the United States (insurance companies pay for doctors’ education, sort of. Also, we respect our doctors more.).

But what if you expand the ranks of medical schools by 20%, and then create a two-tiered system where the bottom 50% get put into the public insurance system, and the top 50% go into the private insurance system, which would address the issue of doctor quality for people getting private insurance, would expand the resources of the system to accomodate more participants (over time; this would take a decade to really hit), and would keep compensation and quality of care options for medical professionals available to enough of them to make it a real possibility.

The original author asked where I got the information that doctors are worse in Germany, since she'd been under the impressions that outcomes are just as good and infant mortality is better, there. I replied:

While you’re right that outcomes in those countries have good statistics, that’s partly because statistics in this country include people who are getting crummy care because they’re not covered by insurance. So if you limited your statistics in the U.s. to people who have decent insurance, you’d probably get a very different comparison.

And, even setting that aside, doctor quality isn’t the only factor influencing outcomes or infant mortality– those are driven by access to care, resources available in the course of care, genetic diversity in the population (we’re much, much more diverse than any of the countries discussed. And if you want to see how genetics drives those statistics, consider the case of Utah, with about the highest life expectancy in the U.S.– it’s not just because Mormons abstain from alcohol. It’s environmental and genetic. Utah is 95% white.), etc. Doctor quality isn’t really an issue until you get to tricky stuff– like how, in that story you linked to about the woman with leukemia, her doctor told her she should, no-way, no-how, go to a local or regional hospital, but had to go to a research hospital. So, a) she had a very good doctor at that moment, and b) he knew the other doctors in his area weren’t good enough.

So the factor that often indicates “quality” when you’re dealing with fields that depend on research and development is frequency of citation. The U.S. leads that in spades, even if you account for population size. You can see total citations for all scientific papers here:

And see what the most-cited papers in medicine have been, lately, here:

I did my homework on those papers that are indicated as being international, and almost all of them are dominated by U.S. authors.

I should add that, of course, there are phenomenal research centers internationally, but in terms of creating a system that encourages multiple fountains from which may spring the continued improvements in life expectancy and quality of life that we see among the insured in the U.S., the U.S. does a much, much better job of encouraging smart, enterprising people to become doctors and deal with our toughest cases. That’s not to say that there aren’t countries that have excelled at specific fields– like opthamology in Cuba– but for systemic medical excellence, you can’t beat the U.S.

Fun background note from a professor of mine in law school who had been a doctor before he became a lawyer: the U.S. *does* take the lead when it comes to looking at care for the well-cared-for. The U.S. is #1 for life expectancy… at age 85. so if you’ve been well-taken-care-of such that you made it to age 85, you obviously have the resources to keep going, beyond what other countries can offer. *that’s* what people don’t want to give up.

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