We’re not having the right discussion

Depending on who you listen to, you have definite ideas as to what is wrong with health care in this country. Depending on who you listen to, you have definite ideas about who is to blame. Depending on who you listen to, you have definite ideas as to what should be done.

I’m tired of arguing with most people because most of these definite ideas — per everything I know — are myopic at best, could charitably be classified as misguided, and, if I’m brutally honest, I think are willfully dishonest and driven by partisanship.

Understand, I claim no special knowledge or insight. But I do claim we’re not having the right discussion.

In the words of one of our leaders, who knew health insurance was so complicated? Everybody. Everybody knows, but they still all want an easy answer, a silver bullet.

Before I tell you what I think, I’m going to give you some links. That’s right; you got a reading assignment.

Here’s the thing . . . if you are not going to click on any of these links, stop reading right now. Don’t make any comments at the bottom. Don’t engage in any discussion about what we should do. And especially don’t cast any votes on anything related to health insurance. I say all that because — in my humble and brutal opinion — it’s better for everyone if people who are not informed just remove themselves from the conversation.

Clear? Great.

Here is the first link.
U. S. Health Care from a Global Perspective

This report covers the US and 12 countries and compares health-related data information gathered through 2013 before the ACA went into effect. There are charts covering procedures, costs, health indices, and so on.

The second link.
International Federation of Health Plans

This is a less comprehensive set of data from 2015 but still comparing between countries.

The third link.
Health Care: How the U. S. Compares With Other Countries

This is a PBS report from 2012 also comparing costs and services of different countries. One could argue it’s old data, but that ignores the fact we’ve had no significant changes that could be called improvements in the data.

The fourth link.
U.S. versus European healthcare costs: the data

A deeper look at the data and some commonly explored reasons behind the discrepancies in cost and services. This is worth reading carefully as they explore some of the assumptions that people make about numbers that are thrown around.

OK, then . . . if you read all that, you at least have some information you can marshall in forming your opinion about health care and the issues we face when it comes to cost and coverage.

Want to hear my conclusions?

Well, before we go on, I want to touch on something else.

The ACA

While the ACA was being discussed, I was very much against it. Way back then, while many people were voicing emotional arguments about insuring the uninsured, I argued that the ACA was not a good way to do it. I had many heated arguments, and some friendships ended because of those discussions.

Disclosure: they were ended by me for one reason; the willingness of people to economically hurt one group of people to help another. That goes against my notion of helping everyone.

One can hear many voices positively hating the ACA, and invariably those voices are labeled in less than flattering terms. Sure, some are detractors primarily because of political reasons, but let me show you some numbers.

Picking states with different plans and coverages, I present this chart showing the 2017 yearly premium with and without subsidies for a couple making $55,000 a year if they choose a Silver plan. The cutoff for subsidies is $64,080. If your income is $1 above the cutoff, you get $0.00 subsidy. (Note: these are states we had considered at one time or another when looking to move)

Do you see anything interesting about that chart? Two things to note.

If your family of two is making $55,000 a year and you get a $10,000 raise (or you work overtime, or make a bit of money on the market) at best, you break even. In most cases, you’re actually losing money because you’ll pay a higher premium than the additional money you earned. (Note: Hawaii has a higher cutoff because costs here are higher.)

Here’s the second observation . . . if one of you two is not employed by a company that provides insurance, and you make $65,000 a year, more than a third of your income goes toward health insurance. Likely more because you also have a large deductible.

While you might be glad someone who makes less money gets a break, it might also kind of piss you off that they are making less money than you but are financially better off.

You give a passing thought to perhaps having a kid so that the cutoff is raised to $80,640 and you qualify for a subsidy. But, how much is a kid going to cost you? Can you afford a kid? What if you don’t want a kid?

Now, I urge people to get their own examples. Pick any state you like, choose a plan, choose a family size, choose a salary level, and compare costs with and without subsidies or even different levels of subsidies.

As written, the ACA typically helps lower-income individuals, inconveniences higher income individuals, but can negatively affect people in the middle of the Middle Class. Something like half the country is in that range.

That’s one of the reasons the ACA can and does find vociferous opponents. There are other reasons, but those are outside the scope of this article. Just know that there are other problems with the law as written.

My Opinion

First of all, the ACA, flawed as it is, is what we got. I was against it, but now that we have it, I don’t want to see it repealed. Not because I like it or think it can work as is, but because another upheaval helps no one. I want to see it “fixed” and that gets us into the rest of my opinion.

It should be clear there is no one solution or reason that we find ourselves in the situation we’re in. Well, there is a general reason. Politicians respond more to the needs of political interest groups than the needs of their own citizens, and that is one of the problems we have to address.

However, specifically for healthcare, I see a lot of issues come into play. One is a population that is largely ignorant when it comes to health. It’s also susceptible — because of that ignorance — to all sorts of advertising for medications and medical procedures that may not be necessary. This is, in part, a result of conflicting interests when it comes to how health care is run. The industry is profit-driven. Not necessarily a bad thing, but conflicts can arise and are never kept in check.

An example illustrating the point: When I hurt my rotator cuff (twice), the doctor prescribed an MRI to confirm a tear. I looked at the MRI and I could not tell either the extent or location of the problem but deferred to the doctor. An injury was indicated by other means (weakness in the arm, pain, etc.)

Just before the second operation, I was looking at the MRI scans with the doctor and asked him where exactly the tear was, and he said something like “in this general area, but it’s hard to see on the MRI. I’ll know more when I go in to fix it.”

So, why did I have the MRI? I have one possible reason. The doctor, who was one of the partners in the practice, was also a part owner (along with his partners) of the lab that ran the MRI machine. The insurance was charged something like $3K for an MRI that basically showed my shoulder but had no benefit as far as the operation was concerned. I can’t very well accuse the doctor of unnecessary tests, but I have my strong suspicions. Maybe the MRIs helped, or maybe they just helped him buy new golf clubs.

Let’s then talk about the subsequent physical therapy. After the first operation, I went for the full number of sessions (something like 13 or 15, I can’t remember). The majority of those was just them making sure I did my exercises, meaning I went in, did my exercises, and left. The place where I went for the therapy is also owned by the partnership of doctors, and they charged the insurance for my sessions.

After the second operation, I told them I would only come in every three weeks for a check on the progress, and I did the exercises on my own at home. Each half-hour of therapy was charged at something like $75.

What I’m trying to say is that most people — me included — do not question when a doctor prescribes a test or procedure. And, to be fair, if you have a health problem, you would like to have confidence in the diagnosis, and a test can go a long way to confirming or eliminating a prognosis.

But, here’s the problem . . . there should not be any conflict of interest situations. A doctor should not receive a bonus for prescribing a given number of pills, or have a deal with a pharmaceutical company to push a particular kind of medicine, or personally profit from prescribing a given test.

“What about the insurance company?” you ask. “Don’t they have to approve it?”

Yes, and this is where it gets even more onerous.  Let me say this about insurance companies. As long as they still make money and they are not the ones to pay for something, they won’t care a whole lot. This is why the same blood tests cost $800 in Chicago versus $130 in Colorado Springs versus $300 here in Hawaii. Different insurance companies agree on different costs which they then pass on to their customers in the form of higher premium. There are oversight boards, but there too we have a lot of incestuous relationships.

I’ll give you another example, one more recent. I recently had a physical and asked about an odd-looking skin blemish that was bothering me. The doctor said he could quickly treat it right then and there. Sure enough, he grabbed a little sprayer that used liquid nitrogen to freeze the area. It took literally four minutes and that included him going to get the sprayer. I paid a $30 copay.

When I receive the statement, I saw that the insurance was charged $635 for the procedure. Spraying a bit of nitrogen cost $635.

Obviously, the insurance must have approved it . . . but, here’s the interesting part. My insurance is from Kaiser Permanente. The doctor I saw works at a Kaiser Permanente clinic which is where I got the procedure. Basically, the insurance company — Kaiser — approved the cost of a procedure performed by one of their doctors at one of their clinics.

Guess who actually paid for that procedure? People who pay their premiums. If they (the insurance or the insured) get a subsidy toward their premiums, then all of you readers and all of the taxpayers helped pay $635 for me being sprayed with some nitrogen to remove a blemish about a quarter inch across.

Is that a fair price to pay? I don’t know.

And, that’s the other problem. Where do I go to ask or complain about a given charge?

Some people would point to the government, but many of the people overseeing these things either come from or eventually go to the industries they are overseeing. It’s all on the up and up . . . but it’s frustrating because I know human nature. I know greed. I know that opportunistic behavior is not necessarily nefarious, but is nonetheless a problem.

Summary

If someone tells you fixing health care here in the US is easy, know they are idiots. I only touched on a few things but if you read the articles in the links, you know the road to get where we are was long and tortuous, and the road back is not a straight and paved highway.

There are many interconnected problems — social, economic, educational, political — few people are speaking about, and solving these problems involves rethinking our approach to health and things that go beyond health, including our expectations, and some measure of acceptance that not everything can be fixed. The system can’t be perfect, but it can be better.

We should provide a level of care to everyone from the moment they are born to when they die. We should hold people responsible for a portion of their overall health even as we help people manage things they have no control over. We should understand that as long as the system is run for profit, nothing will change (look at the defense industry if you want an example). We should strive to educate and offer incentives reinforcing positive behaviors and punishing negative behaviors (a contentious notion).

We should do things differently, we should discuss novel solutions, push the comfort zone in our thinking, and admit no solution can ever work if it doesn’t deal with the totality of the problems we have.

And here’s why I’m pessimistic . . . We should be talking about a comprehensive approach, and we’re not.

I estimate the solution requires a slow progression of improvements — some we’ve not even thought of — in a large number of interconnected areas, often with some trial and errors and with continuous oversite with an eye toward optimization.

Unfortunately, a realistic estimate for how long it might take to overhaul health care in this country is “decades, ” but people present solutions tied to election cycles, and no one is calling bullshit on these opportunistic bastards.

I further estimate a lasting solution requires compromises across political parties and social groups by people willing to put the issue of healthcare for everyone ahead of personal, political, or monetary gains.

In other words, I think we are royally screwed.

That’s it. This post has ended . . . except for the stuff below.

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About disperser

Odd guy with odd views living an odd life during odd times.
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13 Responses to We’re not having the right discussion

  1. It is like that joke isn’t it – “If I was going there I wouldn’t start from here!” Of course I know nothing about the US health system but the data in the linked charts did come as a surprise.
    The health system in the UK is broken, underfunded and over subscribed. People want a better service but are not really prepared to pay more for it. Politicians dare not raise direct taxation for fear of a political backlash. It makes me mad when I hear people say “The Government should pay for this, the Government should pay for that” etc. etc. Don’t people understand – the Government has no money, it isn’t a business making a profit for reinvestment, the only money it has is ours – the taxpayers. And the tax system is something else than needs a complete overhaul!

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    • disperser says:

      I didn’t touch the oft-presented argument that everyone else is doing better than we are because that gets into other things. One of the articles does mention that we can’t really use systems from other places as models because each place is unique.

      That said, the costs here are much higher. The question — oft argued by both sides of the healthcare debate — is whether they are justified or not.

      On the one hand, while living in Colorado, we had what I would call excellent insurance and facilities and I could go see a doctor literally with a day’s notice (a specialist a tad longer but seldom more than a week). On the other hand, I don’t know how much of a premium we paid for that.

      Here, in Hawaii, the cost for insurance is roughly the same but I typically have to wait a month or more to see any specialist. I can usually get to see a doctor’s assistant within a day or two and they have a lot of emphasis on preventative care.

      I like the idea of preventative care but what I know about here, in the US, is that people are not all that invested in preventative care. That seems a matter of educating the population and I don’t understand the propensity for people to not worry about the consequences of their actions.

      What you mention with health care in England is similar to what I know about Canada, but there are people who swear up and down that, that system is working well. Even then, are those problems the same we would have here for a similar system? No one knows. The population sample and distribution is vastly different. The logistics are completely different.

      One thing that stands out when looking at US numbers is the obesity rate. We know that has health effects, but what can we actually do about it? Can you force people to act in their own self-interest?

      Finally, yes, the whole of the system needs an overhaul because it wasn’t set up at a time when we faced today’s problems or had this population level. But, that too is in the hand of people who respond not to the needs of the population, but to the needs of special interest groups.

      As I said, I’m not optimistic.

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  2. I read ALL the links as per your orders, I must admit a lot of the stuff went right over my head.Numbers percentages charts might be right up your alley but fortunately for me, not mine.
    I assume all those figures for the costs of operations and procedures in Australia are for what the Government pays through our Medicare system.

    This is financed through everybody that’s in employment, paying a small % of their annual income by way of a tax, It amounted to 1½% when I was still actively working (I worked for myself and the amount I paid was the exact same as those working for an employer). It may have gone up a little since.
    There are clinics here that are similar to the one you mention, some are owned and run in the exact same way. Australians if they want can take out additional “Private Health” cover over and above their Medicare levy, and they can go to private hospitals, (owned and operated by the private health care funds/insurers and doctors who like the one you mentioned are in it for the money).

    As you know I’ve had two major operations for cancer, two for a stroke, and our Medicare system covered all the costs involved, I imagine that is what those figures in that first link was showing the costs to the Government; directly or indirectly. The treatment I’ve received has been second to none but we don’t boast about it here.

    I do believe that the boast about having the best in the world is an idle boast to cover up the many deficiencies in the US system and to fool the natives. The number of people who can’t get top service because of no insurance or financial constraints doesn’t seem to get a mention in all those statistics or links; and I’d be interested to know just how many are suffering needlessly because of the greed of the medical/insurance/ business interests of the 1% who own & control the American money.

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    • disperser says:

      Yeah, yeah, I get it. Australia is great. Your own experience is top notch.

      What I will do is remind you that things are not often scalable. Can you tell me that your system would work as well if your population was ten times larger (your 25M people versus 330M here)? Compare population densities and the number of individuals not near metropolitan centers. In Australia, people in rural areas suffer from poorer health and availability to health care, much like we do here. Various economic and ethnic groups also face challenges and your indigenous population has poorer health care and lower life expectancy. You can certainly claim empathy for people here suffering from lack of services and insurance, and I’m with you in that. But, don’t paint the picture everything in Australia is rosy based solely on your own experience.

      But, even that’s beside the point. Your own system had growing pains when it was implemented and there are still question about sustainability. Plus, you still have private insurance and practices that essentially means different coverages for people in different economic classes. Here, we face different challenges than Australia faced and one of the greatest challenges is a reluctance of handing control over to the government. There are reasons for that and perhaps that’s how it will eventually have to go, but looking at current government-run systems, I’m not convinced the outcome would be great.

      Many people have been burned by the ACA and essentially no longer trust the government (the promise of a $2K deduction in premium across the board while increasing coverage was a flat-out lie, and it wasn’t the only one).

      I will repeat that the challenges here are many and diverse and touch on all manner of issues from how we tax individuals, to education, to political and social will, and so on and on and on. One other aspect Australia does not have to deal with (because they are brutally callous in keeping them out and also because as an island, it’s easier to do so) is the issue of illegal immigrants. Their impact on US health cost are contentiously argued with pro-immigration groups arguing for a figure half of what anti-immigration groups claim, but the point is that it’s not small and it’s something we have to deal with that you don’t (again, because Australians are essentially xenophobic when it comes to immigration).

      In naval-speak (you seem to like nautical references) I can tell you that it takes a lot longer and it requires more planning and knowhow to steer a huge oil tanker through a difficult passage than to do the same with a 30′ boat, no matter how loudly the captain of the 30′ boat brags how easy it is.

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  3. Thanks, Emilio, for sharing this good info, facts, and your thoughts/opinions.
    I will check out the links.
    Your estimation/conclusion concludes what I have been thinking. Sigh.
    I think The Head Turkey (or as I like to call him The Grand Poo…Bah!) has most people so baffled, angry, sad, etc…in other words DISTRACTED…so most people are not focusing on what is most important…and nothing worthwhile is getting talked about or accomplished.
    (((HUGS)))

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  4. Emily Scott says:

    No system will ever be perfect, but which, based on the data you link to, is the least worst? The main challenge I see facing the American healthcare system is what appears to be a cultural dislike of centralised government policies and taxation generally – even if you end up paying more through huge insurance premiums that don’t cover you for everything.

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    • disperser says:

      Copying someone else’s system is probably not the right approach, especially when lacking understanding of the underlying assumptions and drivers for other people’s decisions.

      But, until we honestly look at what we can do — a compromise between what we want and what we can afford — and until we have everyone focused not so much on denigrating each other but actually help solve problems and overcome obstacles, not much will happen.

      Our current system is inefficient and driven by the suppliers as opposed to being customer focused and results-oriented. Even that is not entirely true because people demand certain things that sometimes (to me) sound unreasonable. But, there again, a much broader discussion than what we’re having, especially when it comes to the areas of medication and preventative medicine and people’s education about health and healthy living.

      As for the comment of cultural dislike, it’s somewhat true, but also remember that by voting, we can agree on the limits of what the government can and can’t do. It requires a different way of looking at the role of government, but that’s not what the news and the two parties are selling. It’s also not what the people want to particularly think about because that’s more work than electing someone who tells them they will fix all of their problems.

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      • Emily Scott says:

        You’re right that it would be much more productive for politicians to work together rather than against each other. I get very frustrated by how much time decision makers spend arguing and point scoring rather than getting on with the job of improving things.

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