We’re going to start off the discussion about universal healthcare with one of the more common concerns voiced by opponents – Universal ‘coverage’ does not mean universal care, as it will lead to rationing of care, either overt or via extended waits for care.
Before we begin, lets not confuse ‘universal healthcare’ with ‘single-payer’. Single payer is one mechanism to deliver universal healthcare, but it is by no means the only one – as has been demonstrated by many European countries where private insurers are active and significant players in the market.
Let’s start with a key – if obvious – statement. No one I know would assume that universal coverage means anyone can get any medical service at any time from anyone they choose for free. Some ‘strict-intrepretarians’ may call that rationing, but the vast majority of people would undoubtedly say, “well, of course it isn’t!”
There’s a difference between rationing and appropriate buying behavior. According to Wikipedia, “Rationing is the controlled distribution of resources and scarce goods or services. Rationing controls the size of the ration, one’s allotted portion of the resources being distributed on a particular day or at a particular time.”
The operational word is ‘controlled’, and the question is by whom?
‘Rationing’ in today’s US health care system
In today’s non-elderly market, health plans ‘control the distribution’ of care; big insurance companies like United HealthGroup, Aetna, Wellpoint, CIGNA, Humana. Through their pre-certification processes, reimbursement arrangements, summary plan documents, provider agreements, and other business policies they try to make sure they only cover what they are legally required to cover (no cosmetic stuff) allow only those procedures that are appropriate for that condition delivered by an appropriate provider, and pay only what they have to for those procedures and services.
But there’s a big group of folks who don’t have access to any insurance (although they can access care on a limited basis through EMTALA) – the uninsured, a population that is likely pushing close to 50 million these days. Is their care ‘rationed’? No, they just can’t get any that’s not driven by an emergent condition. Hypertension medications, COPD treatment, asthma prescriptions are all not available (except in a few cases where provided by charity) unless and until the patient has to be admitted to an ER.
So, what do the data show? We’re living in a very expensive glass house. In 2007, Troy Brennan, Medical Director of Aetna, Inc, said “the (U.S.) healthcare system is not timely…” citing “recent statistics from the Institution of Healthcare Improvement … that people are waiting an average of about 70 days to try to see a provider. And in many circumstances people initially diagnosed with cancer are waiting over a month, which is intolerable…”
Conclusion? Today, Americans with coverage do not have unfettered access to any type of care.
‘Rationing’ in countries with universal healthcare
Opponents of universal healthcare often make the logical leap that somehow it will inevitably lead to extended waiting times. I’ve never understood the connection. How better access to care, leading to more preventive care, will lead to waiting lines for procedures has never been made clear to me. Moreover, the data refute that opinion.
The logic (an admitted misuse of that term) appears to go something like this: “In Canada (or the UK or France or wherever) they have universal healthcare and people have to wait forever for care, especially costly types of care”. We’ll leave aside the delays that exist in this country even for those with health insurance, the difficulty in finding a primary care doc who is still taking new patients, the waits to see specialists (god forbid you need specialty care from a chronic Lyme expert, the delays are months).
Or perhaps we won’t. In fact, A Commonwealth Fund study of six highly industrialized countries, the U.S., and five nations with national health systems, Britain, Germany, Australia, New Zealand, and Canada, found the United States ranked last on four measures of continuity of care and access problems reported by patients.
Here’s what a bit of specific data show (excerpted from the Commonwealth Fund report).
* The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.
* Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.
* U.S. patients were less likely than patients in Canada (12% v. 24%) but more likely than patients in Germany (4%) to wait four hours or more to be seen in the emergency department.
* U.S. patients were less likely than patients in four countries (except Germany) to wait four weeks or longer to see a specialist (23% v. 40%-60%) or to wait four months or longer for elective surgery (8% v. 19%-41%) (Schoen et al. 2005).
Another way to look at rationing is the volume of care delivered to those patients that actually receive care. Tom Lynch did a terrific comparison of the US to other OECD countries, within which he said this:
“Hospital discharges per 1,000 people in the US are 25% lower than the average for all OECD countries, and doctor visits are 42% lower.
Well, maybe people have significantly more intense and aggressive service while they are hospitalized in the US? One indicator of intensity is the average length of acute care hospital stay. In the US, the length of acute hospital stay is 5.6 days, which is less than all but eight of the other 29 OECD countries. But shorter stays could mean higher efficiency. A better way to look at it is to look at specific causes for hospital stays, like heart attacks, for instance. The US average hospital stay following acute myocardial infarction is 5.5 days, the lowest in the OECD.”
Clearly folks in countries with universal healthcare are not getting kicked out the door, or discharged “quicker and sicker” as we in the US do so well. Nor are they subjected to waiting times significantly different from those in the US.
What does this mean?
In several areas the US already has longer waiting times and poorer access to care than countries with universal healthcare. If the US adopts universal healthcare as practiced in other countries, the evidence indicates access will go up and waiting times may well go down.
Apr
10
Joe– Logic seldom deals effectively with fear. What are we really afraid of as soon as anyone talks about universal coverage? We are not, I think, afraid of having Franch or German style healthcare. That’s not the point. I think what we are really afraid of is how totally, 100% bollixed up any such system imposed in the US will turn out to be. By the time Congress gets through trying to please every constituency with a checkbook and the administration gets through writing its several thousand pages of impenetrable regulations, we will have something which is completely unwieldy and unworkable and it will result in far worse conditions for medical care than we have today. The real obstacle is not the concept, it is the US government’s lavishly demonstrated incompetence and inability to execute that people rightly fear. Yes, other countries have done a pretty good job of making it work. Is that any reason to think that we will? We all know the answer to that question. That’s the real issue and all the examples of successful systems in other countries are utterly beside the point. Our system of governance is broken, badly broken. Until that is fixed, handing even more of our daily welfare to the bozos who have given us TARP and AIG, for example, seems fundamentally unwise.
While I hesitate to disagree with my good friend, Gary Anderberg, a very, very smart man, by the way, I have to do just that in this case.
Gary’s position seems to be: We shouldn’t move to universal care, because we’ll more than likely screw it up. And he may be right. Perhaps we will,
but how much worse, how much more costly, could poorly implemented universal care be than what we’re oppressed with now? Americans spend more than double the average and 25% more than any other country in the OECD. And for what? Americans don’t live any longer and their quality of care is no better than the average in OECD countries.
Frankly, I think if America put its collective mind to it, as we did when John Kennedy challenged us to “land a man on the moon and return him safely to earth within the next decade,” we could make American universal care an icon in global health care.
I don’t diminish the humongous challenge inherent in goring current health care oxen. However,we are living in a health care house that Jack built, and it’s in serious need of a major rebuild. If we have the will, not the “won’t,” it can happen.
While I seldom post on this site, I have to agree with both Joe and Tom. Over the course of the past two weeks I’ve gotten to personally experience just how inefficient and ineffective the current system is. After looking at the data Joe presented above, how can anyone say that the status quo is better than trying something else?
Tort reform would help, too.
I followed the EMTALA link behind this post and almost stumbled past a nugget that could be bigger than my initial impression.
“ER visits for non-urgent care (which, despite the technical provisions of the law, occurs often under EMTALA) cost two to five times more than if the care was delivered in a primary care setting.”
Since we are going to be looking under rocks and dead stumps for savings to pay for health care reform, this little inefficiency seems like it could be significant. Unfortunately, I’ve been around the block a few times and I know that even if we could quantify this type of hidden inefficiency, the “vested interest” crowd would engineer a savings shift that will line their own pockets instead of making Health Care more affordable for the consumer. Call me cynical, I guess.
Many thanks to Joe for citing my monograph on American health care compared with other nations in the OECD. But a better link to the paper is: http://www.lynchryan.com/resources/best_healthcare.pdf.
Joe – From the reading I’ve done and the numerous people I’ve met from other countries over the years, I’ve learned that healthcare systems in Canada, Western Europe, Japan, Australia, etc. are very good at primary care and quite good at emergency care. However, if you need to see a specialist or need a non-life threatening surgical procedure such as a hip or knee replacement, there is likely to be lots of waiting beyond what would be typical in the U.S.
Hospital stays are longer elsewhere but treatment is much more intensive during a typical U.S. hospital stay. Many patients treated in hospitals elsewhere often get care that they would get in a rehabilitation center in the U.S. I don’t think many useful conclusions can be drawn except that to hold costs to a percentage of GDP that the society determines it can afford requires care to be rationed somehow, whether it’s artificial constraints on the supply of imaging equipment, hospital beds and the like, rationing of care by age, not paying for treatments that can’t pass a QALY metric or withholding care at the end of life that would probably be offered (and expected) in the U.S. Our medical tort system also probably results in much more defensive medicine than in other systems a well.
There is no silver bullet to bend the medical cost growth curve but lots of silver pebbles. If there were a silver bullet, we would have found it a long time ago.
“but how much worse, how much more costly, could poorly implemented universal care be than what we’re oppressed with now?”
It could be considerably worse. It could be bad enough to bankrupt the country and kill 10 times the people lack of insurance or under-insurance does. What’s really annoying is how advocates of Universal Care completely ignore the present government systems. Medicare and Medicaid are complete failures. Any honest discussion about healthcare reform would start by admitting that the push for Universal Care now is to save Medicare and Medicaid. Medicare is financially unsustainable and Medicaid is a poor excuse for insurance or care delivery. The private employer market is sustainable, 80% of people are happy with their employer insurance and don’t want the changes being proposed. Employers rather fix the system we have then go with the proposals on the table.
Universal Coverage is a government plan to fix the broken government plans currently in place. If they have failed to run a plan every time they have tried since the 1960s why should we trust they will do any better?
“Americans spend more than double the average and 25% more than any other country in the OECD. And for what? Americans don’t live any longer and their quality of care is no better than the average in OECD countries.”
This is an invalid argument. You can’t compare the aggregate results of thousands of US plans to the results of a couple European plans. Our Private insurance plans stack up against any other country out there. Medicare, Medicaid, MA, NY and other similar plans drag down the averages for our entire country. We have a failure of public plans. To fix the failure of public plans you want to put in it’s place another public plan. Compare the Midwest States, UT, ID and such to your Universal Plans and see the difference.
“Is their care ‘rationed’? No, they just can’t get any that’s not driven by an emergent condition. Hypertension medications, COPD treatment, asthma prescriptions are all not available (except in a few cases where provided by charity) unless and until the patient has to be admitted to an ER.”
This argument is completely misleading to downright dishonest. This sort of rhetoric only confused and misleads the public to support something they would not if honestly debated.
Hypertension medications
http://sites.target.com/site/en/health/generic_drugs.jsp
About 20 drugs costing $4 for 30 days $10 for 90 days
COPD treatment often self inflicted with smoking can be treated for $60 a month a thousands of clinics, there are also numerous online resources for basic treatment and advise, like stop smoking.
asthma prescriptions
Also plenty of treatments in generic and the expensive drugs are available for free from the Pharasutical company.
To further disprove your claim
38% of the uninsured make over 50,000 per year meaning most could afford insurance, or $4 care and $60 office visits but choose to not have insurance, by no definition are they UNABLE to get care, they choose not to.
25% of the uninsured are below the poverty line and qualify for Medcaid but CHOOSE to no enroll, presumably because they don’t need it. Again though by no measure are they UNABLE to get care.
About another 15-20% of the uninsured are between 100% PL and 50,000 and qualify for subsidized care but CHOOSE to not take it. There are not 50 million people in America UNABLE to get care as you claim, there are not 10 million. At most there might be 3-5 million Americans unable to get the care they need.
An honest discussion of how to care for those 3-5 million would look a lot different then a discussion on how to cover 50 million that don’t have access. Covering 3-5 million wouldn’t justify the radical changes being proposed so people propagandizing for change throw out the 50 million number and try to confuse people.
This is the same game plan used to pass Medicare, the public was hoodwinked to get it through and the politicians are trying to hoodwink us again.
“I’ve never understood the connection. How better access to care, leading to more preventive care, will lead to waiting lines for procedures has never been made clear to me.”
How can you in one paragraph claim 50 million people are being denied access to care, then jump down to another argument and claim giving them access won’t drastically effect wait access? Who do you plan on your 50 million newly covered people seeing? With 16% of the population excluded we have wait times of X, you don’t understand how adding those 16% back in will lengthen wait times? If those supposedly denied 16% over utilize care like the 84% with access you can expect a 19% increase in visits and consumption. Where is the excess capacity to handle it?