The Need for Healthcare Workers
As the population increases in size and simultaneously expands its portion of elderly members, the demand for medical staff climbs. Only increased efficiencies and automation can offset the need for more personnel. Healthcare, by its nature however, is nurturing and caring aid that is done by one human being for another. Star Wars aside, we are not likely to see robotic nurses on duty.
The costs to enter the medical profession in terms of both time and money are at odds with the need for more staff. In addition, doctors are specializing instead of generalizing because the pay is far more rewarding. This runs opposite to the need for more primary care physicians. If the government wanted a more active role in healthcare, it might be to subsidize the training of the next generation of medical staff. Any shortage in the supply of staff will lead to less total care or higher costs as people compete for access to scarce resources. In such a scenario, there could be an effort to cap payments to providers. The government can do this arbitrarily (Medicare does) while private insurers negotiate these caps. If the caps become oppressive where the reward is not worth the effort, providers will opt out of being part of the plan if they can. Patients in such a plan will then have less choice and fewer resources to serve them, driving up wait times. The whole dynamic of price control is fraught with potentially unintended consequences.
Arguing over who gets care and who pays for it will be meaningless without enough providers to deliver the service. This fact seems to be overlooked in today’s debate.
The Healthcare Marketplace
The market for healthcare is chaotic. Unlike shopping for many consumer products where prices are easily known and quality can be determined with moderate effort, information on healthcare prices and quality is not easily available to the recipient. In the case of persons covered by health insurance (85% of the population), the "consumer" is not one party, but two. The first party is the patient who typically pays some portion of the bill. The other consumer is the insurance firm who pays the balance. It is the insurer who bargains on behalf of the patient to get the best price from a network of providers. As long as the patient stays in the "network," the price is fixed. The patient "shops" by staying in the network for services where the price is fixed. However, for uninsured patients who could price shop, access to this information would only be available by calling various providers and asking for their fees, assuming they would cooperate. Hospitals run
ads touting their awards and care, but when have you seen an ad promoting discounted prices? In general, individual consumers lack leverage on prices.
Finding information about the quality of physician and hospital services, a concern to every patient regardless of insurance, is only available after intensive research on the internet. Even that data is sketchy. More generally, people have relied on anecdotal stories from friends, or the recommendations of their current healthcare providers. In many cases, the choice of a hospital is not based on its outcome quality, but on whether the patient’s physician has the privilege to practice there. Choosing a better hospital may mean changing to a new doctor – an uneasy trade off. Consumers lack leverage on quality.
Because consumers lack leverage on prices and quality due to poor information, normal market forces cannot apply pressures to achieve efficiencies, cost reductions, and quality improvements. This job falls on the insurers and various accrediting councils and professional boards. As a result, suppliers are more insulated from pressures from the consumer than in a normal market. Until the dynamics of the market can be fully activated, the normal forces of private enterprise will not be sufficient to bring about major change. Until healthcare prices and outcomes are much more transparent and the information easily accessible (like prices in the supermarket and ingredients on a food label), market-driven improvements in healthcare may only be a dream. When patients and insurers can take their business to successful healthcare providers and stay away from error-prone ones, then the pressure will build to improve results. Better results mean fewer errors, and fewer errors mean lower costs.
Add to this mix the confusing constellation of policies with thousands of variations in what is covered, under what conditions, and for how much and the entire marketplace is awash in chaos. The use of insurance as a buffer against the uncertainty of future personal medical costs leads to individuals paying vastly different amounts for essentially the same final services. There is nothing inherently wrong with an array of competitive insurance offerings in a free-market, but it does appear to contribute to additional administrative costs. The New England Journal of Medicine reported that in 1999, the cost of administration was 31% of U.S. healthcare cost Compare that to Canada's nationalized system where it was 16%. This demonstrates the advantage of single payer systems is in reduced administrative costs. A simpler system is less expensive to operate.
Monday, August 31, 2009
Sunday, August 30, 2009
Healthcare Installment #6. Please read prior posts staring 08/25/09.
Healthcare and an Aging Population
Healthcare increases with age. The aging process naturally brings a need for more care as the body begins to wear out. With an aging baby boomer population about to enter the "Medicare years," the government will face a demand of unprecedented proportions in paying for this care (as it will retirement income for Social Security). The nation will be forced into a debate about the use of its national monetary resources to care for the elderly versus maintain the health of its younger productive working citizens. Compassion will collide with necessity. With the largest expenditures for healthcare typically coming shortly before death, cost control will force the nation to consider end-of-life treatment limits. This is the true "death panel" debate. Is the horrifyingly real "elephant in the room."
A sad irony to the success of helping people live longer is that it increases their lifetime need for healthcare. Dying younger means spending less for healthcare. Sad, but true. Success in extending life increases total costs. Unless the elderly have saved for those expenses, the costs are transferred to the younger workforce. This is exactly what Medicare does. As the ratio of retired citizens to working citizens rises, taxes on the workforce climb unless the cost and/or amount of services to the elderly are held in check. The first "generation" of Medicare saw the existing workforce paying for existing retirees. The boomer generation supported the one before it. As the boomers retire, the following generation ("Gen X") cannot support them completely. The result is the use of debt to make up the difference. This passes the payment load back to the generation following the "X‘ers" – "Gen Y." These dynamics are enough to spur the action of groups like the AARP to protect existing retirees and the boomers. It appears that Gens X &Y have yet to wake up to what is about to happen to them. "Us versus them" may turn out to be one generation versus another.
Healthcare Costs Climb with Advances in Medicine
Healthcare costs continue climbing because of advances in medicine and treatment. Compared to 50 years ago, diagnostic services, treatment procedures, and prescription drug availability add significantly to the practice of medicine and also to its cost. In the same way a modern car has more standard features at a higher price, so does modern medical care. It is no surprise that we spend more for healthcare. We also get more.
While medical advances are a wonderful benefit, the existence of advanced diagnostic and treatment options does not mean they are truly available. In a free-market economy, these things are rationed based upon the ability of the consumer to pay for them. Some things are available, but not affordable. For example, a trip to outer space on a Russian spacecraft is really available, but only to a limited few with the money to pay for it.
Rationing Healthcare
Healthcare today is allocated largely on a patient’s ability to pay – either directly or through his insurer. Pay the price, get the treatment. When price is not used to allocate/ration services, then rationing is done by another method. In the case of "free" healthcare, that may be the time spent waiting for care. A patient at a free clinic will necessarily wait longer for free care than will a paying patient at a for-profit practice. People waited for days at the Los Angeles Coliseum in August 2009 to get free care from the Remote Area Medical group who was there instead of a third world country. Waiting is a common complaint in nationalized care countries. In Canada, the average wait time for a non-urgent procedure is 17 weeks (4+ months). The Canadian government committed $4.5 billion dollars in 2004 for a six-year program aimed solely ate improving wait times. In less "civilized" countries, corruption and bribery become companions to the bureaucratic rationing process.
The easiest way to avoid the question of rationing healthcare is to pay for unlimited care with borrowed money. Because there is no immediate taxation, it appears temporarily to be "free" healthcare. This is political slight of hand and an economic illusion. It is behind the idea of improving coverage while increasing the government deficit. It is a healthcare house of cards that will ultimately collapse in the form of higher taxes and less care when the system reaches its breaking point and returns to a true economic equilibrium.
Is Prevention the Cure?
The use of prevention to drive down healthcare costs is desirable on its face. The means of prevention is, however, crucial to it cost-effectiveness. Personal preventive measures such as good diet and exercise are low-cost means for prevention. So are steps such as vaccinations. What is less cost effective are large scale screenings for possible problems across the entire population. While the benefit to the individual in finding a potential illness is quite high, the total cost of examining many healthy people to find the one sick person can be cost-prohibitive. The cost to find the one sick person is not the $200 for his test, it is the cost for the 100 other healthy people who were also tested ($20,000). If treatment costs only $10,000, then some diseases may be cheaper to cure than to screen for – when viewed from a societal perspective.
This was highlighted in a report from the Congressional Budget Office in August 2009 that cited a study showing only about 20% of traditional preventive care services saved more than they cost to provide to the broader population. It also noted, somewhat less convincingly, that about 60% of preventive services provided clinical benefits that were felt to be cost-effective. While the individual may enjoy the peace of mind screening provides, the role of preventive healthcare as a cost containment strategy on a large scale basis remains uncertain.
Healthcare increases with age. The aging process naturally brings a need for more care as the body begins to wear out. With an aging baby boomer population about to enter the "Medicare years," the government will face a demand of unprecedented proportions in paying for this care (as it will retirement income for Social Security). The nation will be forced into a debate about the use of its national monetary resources to care for the elderly versus maintain the health of its younger productive working citizens. Compassion will collide with necessity. With the largest expenditures for healthcare typically coming shortly before death, cost control will force the nation to consider end-of-life treatment limits. This is the true "death panel" debate. Is the horrifyingly real "elephant in the room."
A sad irony to the success of helping people live longer is that it increases their lifetime need for healthcare. Dying younger means spending less for healthcare. Sad, but true. Success in extending life increases total costs. Unless the elderly have saved for those expenses, the costs are transferred to the younger workforce. This is exactly what Medicare does. As the ratio of retired citizens to working citizens rises, taxes on the workforce climb unless the cost and/or amount of services to the elderly are held in check. The first "generation" of Medicare saw the existing workforce paying for existing retirees. The boomer generation supported the one before it. As the boomers retire, the following generation ("Gen X") cannot support them completely. The result is the use of debt to make up the difference. This passes the payment load back to the generation following the "X‘ers" – "Gen Y." These dynamics are enough to spur the action of groups like the AARP to protect existing retirees and the boomers. It appears that Gens X &Y have yet to wake up to what is about to happen to them. "Us versus them" may turn out to be one generation versus another.
Healthcare Costs Climb with Advances in Medicine
Healthcare costs continue climbing because of advances in medicine and treatment. Compared to 50 years ago, diagnostic services, treatment procedures, and prescription drug availability add significantly to the practice of medicine and also to its cost. In the same way a modern car has more standard features at a higher price, so does modern medical care. It is no surprise that we spend more for healthcare. We also get more.
While medical advances are a wonderful benefit, the existence of advanced diagnostic and treatment options does not mean they are truly available. In a free-market economy, these things are rationed based upon the ability of the consumer to pay for them. Some things are available, but not affordable. For example, a trip to outer space on a Russian spacecraft is really available, but only to a limited few with the money to pay for it.
Rationing Healthcare
Healthcare today is allocated largely on a patient’s ability to pay – either directly or through his insurer. Pay the price, get the treatment. When price is not used to allocate/ration services, then rationing is done by another method. In the case of "free" healthcare, that may be the time spent waiting for care. A patient at a free clinic will necessarily wait longer for free care than will a paying patient at a for-profit practice. People waited for days at the Los Angeles Coliseum in August 2009 to get free care from the Remote Area Medical group who was there instead of a third world country. Waiting is a common complaint in nationalized care countries. In Canada, the average wait time for a non-urgent procedure is 17 weeks (4+ months). The Canadian government committed $4.5 billion dollars in 2004 for a six-year program aimed solely ate improving wait times. In less "civilized" countries, corruption and bribery become companions to the bureaucratic rationing process.
The easiest way to avoid the question of rationing healthcare is to pay for unlimited care with borrowed money. Because there is no immediate taxation, it appears temporarily to be "free" healthcare. This is political slight of hand and an economic illusion. It is behind the idea of improving coverage while increasing the government deficit. It is a healthcare house of cards that will ultimately collapse in the form of higher taxes and less care when the system reaches its breaking point and returns to a true economic equilibrium.
Is Prevention the Cure?
The use of prevention to drive down healthcare costs is desirable on its face. The means of prevention is, however, crucial to it cost-effectiveness. Personal preventive measures such as good diet and exercise are low-cost means for prevention. So are steps such as vaccinations. What is less cost effective are large scale screenings for possible problems across the entire population. While the benefit to the individual in finding a potential illness is quite high, the total cost of examining many healthy people to find the one sick person can be cost-prohibitive. The cost to find the one sick person is not the $200 for his test, it is the cost for the 100 other healthy people who were also tested ($20,000). If treatment costs only $10,000, then some diseases may be cheaper to cure than to screen for – when viewed from a societal perspective.
This was highlighted in a report from the Congressional Budget Office in August 2009 that cited a study showing only about 20% of traditional preventive care services saved more than they cost to provide to the broader population. It also noted, somewhat less convincingly, that about 60% of preventive services provided clinical benefits that were felt to be cost-effective. While the individual may enjoy the peace of mind screening provides, the role of preventive healthcare as a cost containment strategy on a large scale basis remains uncertain.
Saturday, August 29, 2009
Healthcare Installment #5. Please read posts starting from 08/25/09.
The Need for Health Insurance
Given the unpredictable nature of health and its associated costs, we protect our personal finances by buying health insurance. It is simply too risky to bear all the potential costs ourselves. As a result, discussions of healthcare include not only the cost of service, but also the cost of insurance to pay for that service.
Insurance spreads the risk over a pool of people. In exchange for paying a fixed premium amount, we get the assurance that we will not be forced to pay exceptionally high amounts – the amounts being set by the policy we purchase. The more risk we are willing to take on ourselves in the form of higher deductibles, the lower the premium. Private firms send us a bill. If we have employer-sponsored insurance, then our portion of the premium is paid through payroll deduction. The amount paid by the company is usually invisible to us. The government collects premiums for Medicare in the form of the Medicare payroll tax (1.65% on the employee and also the employer). Check your year end pay stub to see how much you contributed to Medicare last year.
When we participate in insurance, we are partners with all the other people in the plan. The insurance company brings us together and administers the provisions of the policy. As a result, we now have more parties with a stake in our health and healthcare expenses because they are helping pay for them. This creates one of the most intractable aspects of managing healthcare. How do we preserve decision making at the doctor-patient level when those decisions affect other insured parties and the shareholders who own the insurance company itself? The short answer is that we sacrifice some personal freedom in other to get the protection offered by the group. Unless we are willing to pay unlimited premiums to provide unlimited care, there is no other approach. Finding the proper way to balance decision making is one of the major issues to be resolved in the healthcare debate. It is the sensitive spot that flared into prominence with Sarah’s Palin’s remarks about "death panels." That ill-conceived and inaccurate comment did however, touch on this underlying issue. Unfortunately, it inflamed passions rather than led to useful discussion.
It is helpful to look briefly at other forms of insurance to see issues hidden in healthcare insurance. Homeowner’s insurance protects against many perils, but not against floods. If you live on a flood plain, you need special flood insurance because you are in a special risk group. This gives individuals some incentive not to live on flood plains. The higher the cost for flood insurance, the greater the incentive (the same could be true for hurricanes and wildfires). Persons wishing to live high-risk lives pay more for the privilege. In a similar fashion, people with higher risks for illness are charged higher premiums by health insurance firms. This is not meanness. It is practical economics. In the same way a bad driving record increases car insurance, a poor medical history can increase healthcare insurance premiums.
To expect private insurers to lower premiums to high risk persons is to fail to understand the nature of insurance. High risk people will always cost more to insure and when the cost of insurance is unaffordable to them, only charitable or government assistance can close the gap. When government closes the gap, it forces the taxpayer instead of the insurer to fund the coverage. Mandating that private insurers cover high risk people either raises the premiums for all the policyholders or bankrupts the insurer when claims exceed premiums. We cannot legislate away basic economics.
Why Do We Provide Healthcare?
Healthcare is required to maintain good health, restore poor health, and to treat chronic and end-of-life conditions. We seek healthcare as individuals because without it we either have a diminished quality of life, or no life at all. We provide healthcare as a nation so that we have a population capable of competing in the global marketplace. That’s the economic side. We also provide healthcare out of a concern for our fellow man. We are compassionate. The cost of healthcare, whether for competitive or compassionate reasons, must be balanced with the cost of other national activities: education, transportation, defense, sanitation, etc. Just as a family must prioritize spending for food, shelter, clothing, and healthcare, so must a nation prioritize its expenditures.
The difficulty with healthcare is the total cost to extend full coverage to every citizen for every treatment for every ailment. If that is not economically feasible, then "Where do we draw the line?" and "Who draws that line?" become major questions. These are behind some of the vitriolic attacks against government intervention in health care. People do not want a third party intervening in the health care decisions between a patient and a physician. However, when the patient is part of any insurance plan, government or private, the insurer and all other policy holders have an economic stake in that decision. Those who pay, decide. Therein lies the rub of money against morality.
Given the unpredictable nature of health and its associated costs, we protect our personal finances by buying health insurance. It is simply too risky to bear all the potential costs ourselves. As a result, discussions of healthcare include not only the cost of service, but also the cost of insurance to pay for that service.
Insurance spreads the risk over a pool of people. In exchange for paying a fixed premium amount, we get the assurance that we will not be forced to pay exceptionally high amounts – the amounts being set by the policy we purchase. The more risk we are willing to take on ourselves in the form of higher deductibles, the lower the premium. Private firms send us a bill. If we have employer-sponsored insurance, then our portion of the premium is paid through payroll deduction. The amount paid by the company is usually invisible to us. The government collects premiums for Medicare in the form of the Medicare payroll tax (1.65% on the employee and also the employer). Check your year end pay stub to see how much you contributed to Medicare last year.
When we participate in insurance, we are partners with all the other people in the plan. The insurance company brings us together and administers the provisions of the policy. As a result, we now have more parties with a stake in our health and healthcare expenses because they are helping pay for them. This creates one of the most intractable aspects of managing healthcare. How do we preserve decision making at the doctor-patient level when those decisions affect other insured parties and the shareholders who own the insurance company itself? The short answer is that we sacrifice some personal freedom in other to get the protection offered by the group. Unless we are willing to pay unlimited premiums to provide unlimited care, there is no other approach. Finding the proper way to balance decision making is one of the major issues to be resolved in the healthcare debate. It is the sensitive spot that flared into prominence with Sarah’s Palin’s remarks about "death panels." That ill-conceived and inaccurate comment did however, touch on this underlying issue. Unfortunately, it inflamed passions rather than led to useful discussion.
It is helpful to look briefly at other forms of insurance to see issues hidden in healthcare insurance. Homeowner’s insurance protects against many perils, but not against floods. If you live on a flood plain, you need special flood insurance because you are in a special risk group. This gives individuals some incentive not to live on flood plains. The higher the cost for flood insurance, the greater the incentive (the same could be true for hurricanes and wildfires). Persons wishing to live high-risk lives pay more for the privilege. In a similar fashion, people with higher risks for illness are charged higher premiums by health insurance firms. This is not meanness. It is practical economics. In the same way a bad driving record increases car insurance, a poor medical history can increase healthcare insurance premiums.
To expect private insurers to lower premiums to high risk persons is to fail to understand the nature of insurance. High risk people will always cost more to insure and when the cost of insurance is unaffordable to them, only charitable or government assistance can close the gap. When government closes the gap, it forces the taxpayer instead of the insurer to fund the coverage. Mandating that private insurers cover high risk people either raises the premiums for all the policyholders or bankrupts the insurer when claims exceed premiums. We cannot legislate away basic economics.
Why Do We Provide Healthcare?
Healthcare is required to maintain good health, restore poor health, and to treat chronic and end-of-life conditions. We seek healthcare as individuals because without it we either have a diminished quality of life, or no life at all. We provide healthcare as a nation so that we have a population capable of competing in the global marketplace. That’s the economic side. We also provide healthcare out of a concern for our fellow man. We are compassionate. The cost of healthcare, whether for competitive or compassionate reasons, must be balanced with the cost of other national activities: education, transportation, defense, sanitation, etc. Just as a family must prioritize spending for food, shelter, clothing, and healthcare, so must a nation prioritize its expenditures.
The difficulty with healthcare is the total cost to extend full coverage to every citizen for every treatment for every ailment. If that is not economically feasible, then "Where do we draw the line?" and "Who draws that line?" become major questions. These are behind some of the vitriolic attacks against government intervention in health care. People do not want a third party intervening in the health care decisions between a patient and a physician. However, when the patient is part of any insurance plan, government or private, the insurer and all other policy holders have an economic stake in that decision. Those who pay, decide. Therein lies the rub of money against morality.
Friday, August 28, 2009
Healthcare Installment #4. Please start with post of 08/25/09.
What Makes Us Sick?
To understand healthcare requires understanding the sources of illness that lead to the need for healthcare. If you have been sick, the cause of your illness could affect your perception of how to handle healhcare. Never being seriously ill would also affect your perception. Some general reasons for illness include:
Birth defects
Genetic diseases with early, mid, or late onsets
Spontaneous illness (you just get sick, e.g., cancer)
Aging
Accidents (car, sports)
Contagious illness (tuberculosis, flu)
Unhealthy habits (eating, exercise, smoking)
When we examine the list, it is apparent that some causes of illness are beyond our personal control while others are under our influence if not total control. Avoiding dangerous activities (driving drunk), getting vaccinations, and eating properly are all things we can do to positively influence our health and the costs of our health care. On the other hand, being born prematurely is not a personal decision. Nonetheless, a premature infant is likely to have higher than normal health issues throughout life. Likewise, the body deteriorates with age. Things break down. We can moderate but not reverse this process.
Some of the things that interfere with good health are caused by poor lifestyle choices. Sixty percent of all American are overweight. Of that 60%, half of those qualify as obese. About 10% of all Medicare funds are paid due to obesity-related problems. With limited exceptions for diseases, this situation is one of a person’s own making. It leads to increased health problems (e.g., diabetes) and increased healthcare costs. Smoking is a similar issue, although nicotine deserves special treatment as an addictive substance. Despite continued warnings for decades that "smoking bad for your health" and its links to heart disease and cancer, people still smoke. Even the threat of death is not enough to convince 43 million Americans to stop. The good news? The percentage of smokers is half of what it was 50 years ago. This is evidence that we can become a nation of properly proportioned, nonsmokers. It is costing us too much not to be.
The cheapest way to reduce healthcare costs is to eliminate the need for the care itself through healthier living. There are no secrets here, simply better diet and exercise and decreased nicotine and illegal drug usage. This is not something the government can do for us. We must do it for ourselves. We want the freedom to choose what we eat and do. That is fine, but along with it comes the responsibility to make wise choices. Any "right" to healthcare brings with it the responsibility for personal health management. This is not to suggest that every aspect of our personal health is directly controllable since genetics, accidents, and contagious diseases all are beyond our control. Even with an emphasis on personal health responsibility, monitoring individual efforts in that regard would be highly impractical. This gives rise to the call for taxing alcohol, tobacco, and now "junk food." There is nothing wrong with creating disincentives for bad behavior, but rewards for good behavior have a stronger influence. Once again, the tax code is being highjacked to promote social policy. The use of a "Twinkie® Tax" as a systemic attempt to promote self-control will generate another interesting debate.
Compassionate Care
Really sick people don’t work and without free care, they have no care. Then there are the poor who, due to limited abilities, accidents, disease, poor choices, or other reasons have barely enough income to buy food and housing. Food and shelter come before healthcare. If the income is very limited, healthcare is missing. "The poor will always be with us" and the question becomes "How much healthcare is a nation willing and able to give to them?"
Given that health issues are both controllable and uncontrollable, it hardly seems fair to deny care to someone who is unable to provide for himself when the cause is outside his control. That is compassion. On the other hand, should people who manage their health be paying for people who do not? Probably not.
Unfortunately, there seems to be little good way to separate the deserving from the undeserving. The fit pay for the unfit. Perhaps if each person had an allowance of "healthcare credits" then those who stayed fit would build a surplus they could use for other purposes and those who went over their allowances would have to cough up the payment difference themselves (assuming they could.) Fit people might be able to sell their "healthcare credits" to those needing them and thereby profit from a healthy lifestyle. This is an idea not unlike trading pollution control credits in industry.
Persons advocating universal coverage may do so out of compassion, because they lack any affordable coverage themselves, because of personal beliefs in healthcare equality, or for other reasons. Persons resisting universal coverage probably do so because of a reluctance to pay more to provide it or because of a belief that each person should earn what he or she receives. To some extent, a lack of healthcare is an incentive to improve lifestyle and develop skills that lead to employment with better benefits. On the other hand, disease is no respector of effort and "deserving" people suffer through no fault of their own. Compassion and economics intersect badly in healthcare.
To understand healthcare requires understanding the sources of illness that lead to the need for healthcare. If you have been sick, the cause of your illness could affect your perception of how to handle healhcare. Never being seriously ill would also affect your perception. Some general reasons for illness include:
Birth defects
Genetic diseases with early, mid, or late onsets
Spontaneous illness (you just get sick, e.g., cancer)
Aging
Accidents (car, sports)
Contagious illness (tuberculosis, flu)
Unhealthy habits (eating, exercise, smoking)
When we examine the list, it is apparent that some causes of illness are beyond our personal control while others are under our influence if not total control. Avoiding dangerous activities (driving drunk), getting vaccinations, and eating properly are all things we can do to positively influence our health and the costs of our health care. On the other hand, being born prematurely is not a personal decision. Nonetheless, a premature infant is likely to have higher than normal health issues throughout life. Likewise, the body deteriorates with age. Things break down. We can moderate but not reverse this process.
Some of the things that interfere with good health are caused by poor lifestyle choices. Sixty percent of all American are overweight. Of that 60%, half of those qualify as obese. About 10% of all Medicare funds are paid due to obesity-related problems. With limited exceptions for diseases, this situation is one of a person’s own making. It leads to increased health problems (e.g., diabetes) and increased healthcare costs. Smoking is a similar issue, although nicotine deserves special treatment as an addictive substance. Despite continued warnings for decades that "smoking bad for your health" and its links to heart disease and cancer, people still smoke. Even the threat of death is not enough to convince 43 million Americans to stop. The good news? The percentage of smokers is half of what it was 50 years ago. This is evidence that we can become a nation of properly proportioned, nonsmokers. It is costing us too much not to be.
The cheapest way to reduce healthcare costs is to eliminate the need for the care itself through healthier living. There are no secrets here, simply better diet and exercise and decreased nicotine and illegal drug usage. This is not something the government can do for us. We must do it for ourselves. We want the freedom to choose what we eat and do. That is fine, but along with it comes the responsibility to make wise choices. Any "right" to healthcare brings with it the responsibility for personal health management. This is not to suggest that every aspect of our personal health is directly controllable since genetics, accidents, and contagious diseases all are beyond our control. Even with an emphasis on personal health responsibility, monitoring individual efforts in that regard would be highly impractical. This gives rise to the call for taxing alcohol, tobacco, and now "junk food." There is nothing wrong with creating disincentives for bad behavior, but rewards for good behavior have a stronger influence. Once again, the tax code is being highjacked to promote social policy. The use of a "Twinkie® Tax" as a systemic attempt to promote self-control will generate another interesting debate.
Compassionate Care
Really sick people don’t work and without free care, they have no care. Then there are the poor who, due to limited abilities, accidents, disease, poor choices, or other reasons have barely enough income to buy food and housing. Food and shelter come before healthcare. If the income is very limited, healthcare is missing. "The poor will always be with us" and the question becomes "How much healthcare is a nation willing and able to give to them?"
Given that health issues are both controllable and uncontrollable, it hardly seems fair to deny care to someone who is unable to provide for himself when the cause is outside his control. That is compassion. On the other hand, should people who manage their health be paying for people who do not? Probably not.
Unfortunately, there seems to be little good way to separate the deserving from the undeserving. The fit pay for the unfit. Perhaps if each person had an allowance of "healthcare credits" then those who stayed fit would build a surplus they could use for other purposes and those who went over their allowances would have to cough up the payment difference themselves (assuming they could.) Fit people might be able to sell their "healthcare credits" to those needing them and thereby profit from a healthy lifestyle. This is an idea not unlike trading pollution control credits in industry.
Persons advocating universal coverage may do so out of compassion, because they lack any affordable coverage themselves, because of personal beliefs in healthcare equality, or for other reasons. Persons resisting universal coverage probably do so because of a reluctance to pay more to provide it or because of a belief that each person should earn what he or she receives. To some extent, a lack of healthcare is an incentive to improve lifestyle and develop skills that lead to employment with better benefits. On the other hand, disease is no respector of effort and "deserving" people suffer through no fault of their own. Compassion and economics intersect badly in healthcare.
Thursday, August 27, 2009
Healthcare Installment #3. Please begin with post of 08/25/09
Is Healthcare a Right?
Further complicating the issue is the question of whether healthcare is a "right." The Declaration of Independence lists the rights to "life, liberty, and the pursuit of happiness." It is doubtful that healthcare was debated in 1776, so it leaves us with a contemporary question unique to our times.
Rights, however, are always balanced with responsibilities. Our rights to liberty and voting are balanced with our responsibility to be law-abiding citizens. Shirk the responsibility, lose the rights. Those who advocate a "right" to healthcare will also need to enumerate the responsibilities required to enjoy it and not abuse it.
Symptoms are Camouflaging Causes
The healthcare debate is badly off course because it has dealt with symptoms and has failed to address the causes. The current debate is about how to get healthcare insurance coverage (and thus care) for everyone with some question about how to pay for it. This addresses the appearance of the problem, not its causes.
Further complicating the issue is the question of whether healthcare is a "right." The Declaration of Independence lists the rights to "life, liberty, and the pursuit of happiness." It is doubtful that healthcare was debated in 1776, so it leaves us with a contemporary question unique to our times.
Rights, however, are always balanced with responsibilities. Our rights to liberty and voting are balanced with our responsibility to be law-abiding citizens. Shirk the responsibility, lose the rights. Those who advocate a "right" to healthcare will also need to enumerate the responsibilities required to enjoy it and not abuse it.
Symptoms are Camouflaging Causes
The healthcare debate is badly off course because it has dealt with symptoms and has failed to address the causes. The current debate is about how to get healthcare insurance coverage (and thus care) for everyone with some question about how to pay for it. This addresses the appearance of the problem, not its causes.
Because there are many causes behind the healthcare dilemma the country faces, it makes finding solutions especially problematic. Here are some of the contributing causes:
1. There is no healthcare "system."
2. The focus is misplaced on health care instead of healthy living.
3. The possible costs for healthcare technology and services for everyone exceed a realistic share of personal income from those able to pay.
4. The marketplace is distorted so the usual consumer-driven dynamics do not work to promote improvement and cost reduction.
5. Who pays for healthcare and how they pay is convoluted and hidden.
6. In the absence of significant personal wealth, the unpredictability of health makes risk-sharing through medical insurance a necessity.
7. An aging population naturally increases healthcare needs and costs.
8. Entry to the healthcare profession is expensive and the field is understaffed.
No Healthcare "System"
There is no healthcare "system" in the United States. A system is, by definition, "a regularly interacting or interdependent group of items forming a unified whole." There is nothing unified or whole about the U.S. medical system. It consists of a multitude of diverse providers in every locale, a multitude of insurers including the government, and a vast array of policies and procedures through which they do business – much of which is not standardized across groups. It does not rise to the level of a unified system and it is therefore incredibly difficult to increase its productivity and cost effectiveness.
Improvements to individual elements like hospitals are necessary, but not sufficient to improve the "system" as a whole. Any attempt to improve healthcare must begin with improved standardization, communication, and coordination through shared policies, procedures, practices, and information networks across the nation.
Healthcare may require a paradoxical solution – mass customization. That is, "producing goods and services to meet individual customer's needs with near mass production efficiency." In healthcare, it is standardizing operations while adapting them to the unique needs of each patient. Health services are distinctly different from industrial systems in that the incoming raw material (the patients) is subject to wide variations. (No intent here to dehumanize patients, just trying to draw a comparison.) Most processes require a consistent input to run correctly. Variations in human beings require health service providers to adapt their processes across a wide range of inputs. This complicates standardizing processes to achieve efficiencies. Healthcare providers can borrow from industry, but probably not replicate it.
As an example of changing the entire system, imagine for a moment, a USB thumb drive medical "card" that contains all pertinent patient information required when registering at a doctor’s office or hospital. It eliminates all paperwork for registration across all providers. That standard card contains the customized data for each patient. Patients, or staff when authorized, could update certain data on the drive. The drive would trigger an automatic notification to the provider regarding insurance coverage whenever the drive was used for patient registration. That would eliminate the questions about whether insurance coverage was current. The magnetic strip on a credit card works in a fashion like this. This is not intended as a flawless example, just a way to see a systemic change.
Wednesday, August 26, 2009
Healthcare Installment #2. Please read prior post.
Generosity Underlies "Free" Care
In times of surplus, the American people are especially generous. In times of financial adversity, it is difficult to be as generous. Thus, presenting costly healthcare reform in today’s economic climate could not come at a worse moment. It hugs the heels of huge deficits by both the Bush and Obama administrations. The first to fund wars, the second to fund a stimulus program filled with benefits (nice or necessary?) for which we must pay later. It is no surprise that reform requiring more government spending (borrowing) is virtually dead on arrival today as far as fiscal conservatives are concerned. The government has been selling the country’s collective financial soul to the devil of debt for too many years and some tax payers can see the bill coming due.
The Responsibility Dichotomy Creates Friction
We are being confronted by an emerging dichotomy in the population. There are those citizens who exert self discipline and live responsibly as evidenced by healthy lifestyles and solid personal finances. Then, there are the citizens who eat poorly and exercise little and those who are unable or unwilling to manage their personal finances properly. The epidemic of obesity and the housing market collapse due to bad borrowing are two examples. The responsible citizens are growing tired of a government that seems bent on protecting irresponsible persons from enjoying the consequences of their poor decisions. They realize their prudence and hard work are being used to pay for the ignorance and sloth of the irresponsible group. This is not sitting well with members of the electorate who are asking "Where is my bailout?" When individuals, or nations, fail to exercise self-control, it opens the gate to external forces in the form of disease, marketplace corrections, or actions by other nations to fill the gap. As examples, we have diabetes, the housing market collapse, and interest by other countries in moving off of the dollar as the world currency. If we don’t get our acts together, some other force will do it for us. Too many citizens appear to be coasting on what made America great. They need to start pedaling.
Philosophical Differences Drive a Divide
There are also those citizens who are engaged and enraged by the prospect of more government, simply because they do not believe in big government. They see life as a personal challenge to be met by individual effort where success is rewarded and failure is an unpleasant fact of life that contributes to self-motivation. On the other side are those who believe government has a responsibility to the less fortunate, who through no fault of their own, are dealt a bad hand by life. When it comes to healthcare, this could be persons born with medical problems, those incapacitated by accident or disease. Since they are unable to help themselves, as human beings they are deserving of compassionate help from their fellow man. When private charity is insufficient to help this group, then government should step in. Medicare (for the elderly and disabled) and Medicaid (for the impoverished) are programs representing that philosophy. It may be impossible to reconcile the beliefs of these two groups and the final triumph may belong to the group that musters the largest political muscle in the form of votes and contributions. If the Democrats push a bill through Congress by totally bypassing Republicans, it will be this dynamic at work. In a win-lose scenario like this, the losers will not forget and resistance will continue in other ways.
In times of surplus, the American people are especially generous. In times of financial adversity, it is difficult to be as generous. Thus, presenting costly healthcare reform in today’s economic climate could not come at a worse moment. It hugs the heels of huge deficits by both the Bush and Obama administrations. The first to fund wars, the second to fund a stimulus program filled with benefits (nice or necessary?) for which we must pay later. It is no surprise that reform requiring more government spending (borrowing) is virtually dead on arrival today as far as fiscal conservatives are concerned. The government has been selling the country’s collective financial soul to the devil of debt for too many years and some tax payers can see the bill coming due.
The Responsibility Dichotomy Creates Friction
We are being confronted by an emerging dichotomy in the population. There are those citizens who exert self discipline and live responsibly as evidenced by healthy lifestyles and solid personal finances. Then, there are the citizens who eat poorly and exercise little and those who are unable or unwilling to manage their personal finances properly. The epidemic of obesity and the housing market collapse due to bad borrowing are two examples. The responsible citizens are growing tired of a government that seems bent on protecting irresponsible persons from enjoying the consequences of their poor decisions. They realize their prudence and hard work are being used to pay for the ignorance and sloth of the irresponsible group. This is not sitting well with members of the electorate who are asking "Where is my bailout?" When individuals, or nations, fail to exercise self-control, it opens the gate to external forces in the form of disease, marketplace corrections, or actions by other nations to fill the gap. As examples, we have diabetes, the housing market collapse, and interest by other countries in moving off of the dollar as the world currency. If we don’t get our acts together, some other force will do it for us. Too many citizens appear to be coasting on what made America great. They need to start pedaling.
Philosophical Differences Drive a Divide
There are also those citizens who are engaged and enraged by the prospect of more government, simply because they do not believe in big government. They see life as a personal challenge to be met by individual effort where success is rewarded and failure is an unpleasant fact of life that contributes to self-motivation. On the other side are those who believe government has a responsibility to the less fortunate, who through no fault of their own, are dealt a bad hand by life. When it comes to healthcare, this could be persons born with medical problems, those incapacitated by accident or disease. Since they are unable to help themselves, as human beings they are deserving of compassionate help from their fellow man. When private charity is insufficient to help this group, then government should step in. Medicare (for the elderly and disabled) and Medicaid (for the impoverished) are programs representing that philosophy. It may be impossible to reconcile the beliefs of these two groups and the final triumph may belong to the group that musters the largest political muscle in the form of votes and contributions. If the Democrats push a bill through Congress by totally bypassing Republicans, it will be this dynamic at work. In a win-lose scenario like this, the losers will not forget and resistance will continue in other ways.
Tuesday, August 25, 2009
Analyzing Healthcare - Installment #1
This is the first in a series of posts looking at healthcare and healthcare reform in the USA. This material is not a proposed solution to the healthcare situation. It is an effort to clarify some of the factors and dynamics driving the situation in order to enrich the dialogue about improving the current state of affairs. Hopefully, it gets at some of the "why" behind the many divergent points of view. It does have opinions imbedded in it as well as plain facts and observations. Whether you agree or not, if this expands your thinking, it has served its purpose. Some of the points are self-evident but are included to provide a fuller framework for the discussion.
Frames of Reference
Failure to see others points of view leads to dead end dialogue. In the debate on healthcare, it is easy to see the situation and seek a solution from a purely personal frame of reference. That reference is influenced by our own personal health experiences and expenses.
If a person has enjoyed good health and lived responsibly, it is probable he believes individuals are responsible for their own health care and should not be propped up by taxpayer programs. An individual who has suffered poor health brought on by forces beyond his control may see the benefits of having care provided through government programs because there is no other affordable alternative available.
Seeing the situation from various perspectives can open up territory for exploring mutually acceptable solutions. From shared values can come common goals. From common goals can come common strategies and tactics. To find common ground means sharing the same frames of reference. Each topic that follows is an attempt to help increase our personal frame of reference. The central points that emerge repeatedly deal with: economics (cost), who gets free healthcare (compassion), how much do they get (content), who makes medical decisions (control), and who pays for it all (contribution). These five "Cs" can define a frame of reference.
Health is Priceless
Health is unique among all aspects of life since it affects life itself. Without good health, little else matters. Thus, the price we will pay for it is high and the market reflects this. In addition, it becomes difficult to view it from a strictly rational point of view when confronted with very personal circumstances.
The two objectives of affordable and universal healthcare are grand and difficult for anyone to deny. The crux of the problem is whether or not such goals are truly attainable. The devil is in the details and the current debate mixes grand visions with pragmatic problems without highlighting the difference. It appears that the people with the vision cannot complete the details to achieve it. The people who know the details see no way to achieve the vision. Debate teeter totters back and forth on this impasse. Because healthcare is not free, it becomes an economic decision as well as a medical and moral one.
More posts to follow each day.
Frames of Reference
Failure to see others points of view leads to dead end dialogue. In the debate on healthcare, it is easy to see the situation and seek a solution from a purely personal frame of reference. That reference is influenced by our own personal health experiences and expenses.
If a person has enjoyed good health and lived responsibly, it is probable he believes individuals are responsible for their own health care and should not be propped up by taxpayer programs. An individual who has suffered poor health brought on by forces beyond his control may see the benefits of having care provided through government programs because there is no other affordable alternative available.
Seeing the situation from various perspectives can open up territory for exploring mutually acceptable solutions. From shared values can come common goals. From common goals can come common strategies and tactics. To find common ground means sharing the same frames of reference. Each topic that follows is an attempt to help increase our personal frame of reference. The central points that emerge repeatedly deal with: economics (cost), who gets free healthcare (compassion), how much do they get (content), who makes medical decisions (control), and who pays for it all (contribution). These five "Cs" can define a frame of reference.
Health is Priceless
Health is unique among all aspects of life since it affects life itself. Without good health, little else matters. Thus, the price we will pay for it is high and the market reflects this. In addition, it becomes difficult to view it from a strictly rational point of view when confronted with very personal circumstances.
The two objectives of affordable and universal healthcare are grand and difficult for anyone to deny. The crux of the problem is whether or not such goals are truly attainable. The devil is in the details and the current debate mixes grand visions with pragmatic problems without highlighting the difference. It appears that the people with the vision cannot complete the details to achieve it. The people who know the details see no way to achieve the vision. Debate teeter totters back and forth on this impasse. Because healthcare is not free, it becomes an economic decision as well as a medical and moral one.
More posts to follow each day.
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