I can’t tell you how many times people walk up to me and ask me, “Gitabushi, what you you do to improve the mess that is our nation’s health care system?” but it is at least seven or eight times a day. That’s why I carry a taser with me at all times.
But sometimes someone asks me that question online, and if I can’t find their physical address to tase them, even after a few days of intense googling, then I have no choice but to answer the question.
So here goes.
To begin with, the first thing that needs to be changed is the general understanding of health care.
Everyone wants to get more care than they pay for. Everyone. I’ve seen strong conservatives go extremely Socialist when it comes to health care. The Rich can be taxed for health care costs, it seems.
Maybe that’s unfair. Maybe the Conservatives that like health insurance, and like the US Govt underwriting their health insurance in some manner, are really just attracted to the idea of risk pools with people that are relatively healthy, so that they get roughly what they pay for, with the security of a really big medical bill being spread out across all the people in the pool, and that happening rarely enough that they can still get roughly the amount of care they pay for.
The problem with this attitude is, the math simply doesn’t work.
First, the US is excellent at trauma and life preservation, but not so good at actually treating illnesses. So for any given life-threatening situation, there are probably dozens of things that can be tried; most of them are expensive, and depending on the seriousness of the threat to your life, there may be little chance of success. Is it worth it? If it is your life, or the life of your loved one at stake, then of course the answer is “yes”. But if you are in charge of the money behind those choices, sometimes it isn’t.
Look, I get it: it is horrible to have some bean counter decide your life (or your Grandma’s) life isn’t worth a series of risky life-preserving attempts, and writes that life off to ensure the company doesn’t go bankrupt. That’s bad. But it is far, far, far, worse to have a bureaucrat make the decision based on whether you are still a source of tax revenue or whether you vote the way the bureaucrat wants. And that is what Single Payer brings about.
There are more than 300 million people in the US. 90% of us will see a life-threatening situation at least once in our life, where our life could be preserved for years more if money were no object. Multiple times, if you include situations where a life could be extended for a few extra months, or days.
There is simply no way to pay for all that without someone else making choices for you and/or your loved one based on cost. And it will seem heartless to you.
So the first change that needs to be made is:
“If your life isn’t worth your own money, why is it worth mine?”
I think one serendipitous benefit of this is it would be harder for people to just be assholes to everyone. You’d have to work to maintain relationships with family, to extend your circle of friends, etc., so that if you get extremely sick and can’t pay for it, there are more people willing and able to help out and pool resources to save your life. But that might be a stretch.
Moreover, we need to get the Health Insurance Companies out of the business. As has been pointed out several times, what would your car insurance bill look like if you had gas fill-up insurance, oil change insurance, and air freshener insurance?
Routine and predictable care should not be paid for by insurance. I don’t know why anyone wants to, even. If it costs you $100 to see a doctor, you can bet you are getting billed at least $130. Because your visit has to be logged, approved, tracked, etc., and that takes manpower, and manpower costs money, and the company has to make a profit on top of that. Heck, the visit to the doctor only costs $100 because they have to pay the people to make sure the insurance is billed correctly. So get insurance companies out of routine visits, and the price probably drops from $130 to $75.
So the second attitude change needs to be:
“Pay for more care out of pocket, particularly routine and predictable care”
Another problem was alluded to above. The US is great at trauma, not so good at cures. In many cases, the medicine and treatment is mostly designed to keep the symptoms from killing you until your body recovers on its own.
A study of Medicare in Oregon showed that having Medicare didn’t improve health outcomes at all. So that’s a hella amount of tax dollars spent to merely improve people’s sense of security.
People need to understand that choices have consequences. Poor health is the result of poor choices. If you want better health, you don’t need cheaper health care, you need to make better choices.
Once, I was walking with a girl and she started to go through a crosswalk, but a car was coming. I held her back, and she was indignant. She said, “If that car hits me, my Daddy will take care of the driver!” My response was, “Even if your Daddy kills him, that doesn’t change the fact you got hit by a car!” There are some things that can’t be fixed by cheap health care.
So the third attitude change needs to be:
“Health Care Reform can never be a panacea. Live better, or accept poor health outcomes. Don’t expect taxpayers to bail out your poor choices. That’s where your family/friend relationships come in.”
Okay, Gitabushi, this article is getting really long, and you are still talking about attitude adjustment.
Yeah, well, I’m writing this piece, and you’re not. But I needed to explain those necessary attitude to shifts to make the rest make sense. Well, more sense, anyway.
Concrete Reform Proposals
Retail clinics: Most people don’t really need to see a doctor. They certainly don’t need to see an ER doctor, most of the time. People go see a doctor because they don’t have the ability to know whether an injury, illness, or condition is serious or minor. So they see a doctor.
Instead, we need to have a triage system where people see nurses, who send most people home with pain reliever or something. When there is something complicated, they are sent directly to the Physician’s Assistant. Minor treatments can be prescribed at this stage. If it is more serious, they go to see a Doctor. And if it is really bad, they then are sent to a specialist.
With proper manning and proper triage training, someone with actual trauma could receive life-saving treatment quicker than waiting in line at the ER. The precious (and expensive!) time of the doctors and specialists would be reserved for people who actually need it.
The US govt can and should set up incentives to encourage the development of retail clinics. Tax breaks to corporations are great for that.
Let the Rich be Guinea Pigs: The Rich already are guinea pigs. Like your surgery-corrected vision? Thank a rich person. Like that miracle cure that is now cheap enough for you to pay for? Thank a rich person who paid for it when it was still experimental.
The rich have plenty of money. Let them pay for experimental treatments that are very expensive. Once we figure out what works, economies of scale make it affordable for the rest of us.
Again, the US govt can establish some incentives to encourage this. Perhaps tax breaks on inheritance if you die in an experimental trial?
Other Experiments: Likewise, there are many drugs and procedures that might be lifesavers, but can’t get enough trial subjects to determine their safety. At least part of this is due to FDA rules that prevent exploitation. It is insanely easy to set up incentives to encourage people to participate: just look at how many parents are subjecting their kids to experimental gender reassignment procedures, just so they can get some minor improvement in social status! But along with incentives, we probably need to look again at some of the rules surrounding volunteering to be in a medical trial. At the very least, people with terminal illnesses should be given incentives to participate…by being terminal, and the treatments they undergo to deal with being terminal, the results of experiments won’t be fully applicable to the wider population, but we’ll still get valuable information.
Doctors and hospitals should provide a clear, itemized price for every service and treatment, before you are given that service or treatment. The biggest problem with pricing right now is that it is a list price, not an actual price…insurance companies use the power of groups to negotiate a lower price, cash payments can get a lower price, and the hospitals/doctors need to cover the free care they gave at the ER (required by law). So the list price is a fiction for everyone except the responsible individual who wants to pay for care himself, and you get charged $17 dollars for a glass of juice (whether you drink it or not) and $27 per OTC analgesic. And since that price is fiction, how can you comparison shop? And if you can’t comparison shop, where is the pressure to control costs and find innovations that deliver better service at lower cost?
Stop Giving Incentives to Illegal Aliens:
I don’t think the law that requires hospitals to give care to anyone/everyone at need is a bad law. It prevents someone from bleeding out while hospitals are doing a credit check or trying to figure out if you have insurance. However, like all systems, this one has been exploited nearly to death.
There is nothing we can really do about indigents using Emergency Rooms. They have no money to go after.
But illegal immigrants use Emergency Rooms because, being illegal, they are more difficult to hold responsible for payment.
We don’t need to change the compassion law about treating people without demanding up-front payment. However, we need to provide incentives for going after non-payers. If you want life-saving treatment and can’t pay for it immediately, then you will owe. Yes, it sucks to have spend the next 50 years paying back debt on life-saving treatment, but at least you are alive to make those payments. And then you have stronger incentive to figure out a way to get rich to pay it back earlier, don’t you? And if you don’t want to be in debt for 50 years for something that isn’t life-saving, don’t go to the ER for minor colds. It all goes back to one of the first attitude changes: if your health isn’t worth *your* money, why is it worth *mine*?
I’m open to arguments the “Illegal Aliens in the ER” costs aren’t really that high. Even so, that’s a non-zero cost that drives up expenses for the rest of us. Medical care rules represent a subsidy that benefits illegal alien employers by shifting costs to the rest of us. There are multiple reasons to end incentives for illegal aliens. When multiple issues align to the same solution, it is more likely to be a correct policy.
We need to do a better job of figuring out what is actual failure to be responsible in treatment decisions/actions, and what is an honest mistake. Bad things happen. Drugs have side effects that aren’t fully clear in drug trials. People who undergo treatment sometimes die or have less-than-perfect outcomes, and sometimes that is due to circumstances not related to the treatment. Maybe this should also be under the “attitude change” section, but the point is: just because something bad happens doesn’t mean someone with money is at fault.
Juries are too easily moved by descriptions of misery and suffering, to the point they assign awards because they want to help the plaintiff, rather than their condition actually being the fault of the doctor or company. All the massive awards increase the costs of medical treatment to everyone else.
Okay, there are other things I’ve thought of before, but this is getting long enough. If we enact even some of these changes, health care will have outcomes more in line with costs, and people will be able to make better decisions about their health and health care that will avoid costs being a disproportionately large expense in life.
If I think of anything else, I’ll add it in the comments.