Pluralism, the Profit-driven Healthcare Market, and Health.

With the new incoming president and administration, many are clamoring for an end to the affordable care act. If they’re honest, politicians would admit that the act was neither affordable, nor really focused on health care so much as pork projects, and was not so much an act as a law designed to force the sale of a service. Currently Americans spend over 17% of our nation’s wealth on medical care, the vast majority of it focused on treating existing conditions, with very little spent on preventing those same conditions. Not that we would listen anyway. We are not really big on prevention, as that would require us to modify our behaviors.  Meanwhile, most public health organizations are forced to beg money to keep even their basic prevention programs afloat, while fast-food (an oxymoron if there ever was one), and junk-food sales have reached an all-time high. Sounds more than a bit self-defeating doesn’t it?

Our nation currently ranks number one in healthcare costs per person and America tops everyone in cost of care relative to gross to GDP. The U.S. scores poorly on many fronts, ranked 11th out of 11 in the Commonwealth Fund (2014) while outspending all other first-world nations in terms of the amount it spends on healthcare. You would think that for this enormous cost, we would be receiving the best health care in the world. Not if we use life quality, infant mortality, longevity, and general health as measures.

If we take even a tertiary look at the three highest rated nations for healthcare in the world (according to the World Health Organization), at least currently, we can formulate some idea of how we might go about replicating these top healthcare systems, rather easily and relatively cheaply, at least compared to what we have now.

What we need then, or so it would seem, are some examples to use from among the top healthcare nations, a “Best of the Best.” According to many researchers, the top ten healthcare nations are, in order, #10-Sweden, #9-Switzerland, #8-South Korea, #7-Australia, #6-Italy, #5-Spain, #4-Israel. All share similarities, for example a focus on prevention, public health, and patient responsibility. But let’s just look at the top three.

#3. The Japanese health system is based upon universal healthcare, which is backed by mandatory participation through payroll taxes by both employer and employee. These are income based for self-employed. Add to this long-term care insurance required to be carried by citizens over 40. Japan has controlled cost by setting flat rates for everything from checkups to surgery to medications. This has the obvious effect of removing competition among insurance companies. And while most hospitals are privately owned, as in the United States, there are smart regulations to ensure they are focused primarily on egalitarianism.

#2. Singapore has an even better health care system, largely funded by individual contributions and based on preventative medicine, public health, and individual responsibility. Individuals are required to contribute a percentage of their salary based on age, although the government does provide a safety net to cover expenses beyond those that the individual person may be able to afford. While private healthcare plays a significant role in the Singapore system, it is secondary to public health and public hospitals which employ the vast majority of doctors and other health professionals.

#1. Hong Kong, at least currently, has the best health care in the world as well as arguably the free-est economy. Hong Kong manages this by offering universal health care, which includes significant government participation. Hong Kong’s health secretary calls public health the cornerstone of their system, and public hospitals account for 90% of all inpatient procedures. There are private hospitals in Hong Kong; however, these are generally used by the wealthy.

Currently at least, the U.S. does provide the best medical training in the world; however, our healthcare, although the most costly. is far from the best. For population health, infant mortality, maternal health, longevity, and chronic disease, we are somewhere near 20th place. What can we do to improve healthcare in America?  That’s a bit complicated and will take some explaining. Warning: Personal Opinions ahead. 

Step 1: Provide Basic Health Maintenance to all Americans.

The adage “An ounce of prevention is worth a pound of cure” is no truer than in health care. Public Health and Preventative Medicine has lengthened the lifespan by decades, reduced fatalities in traffic accidents and accidental poisoning, and in combating environmental disease. Yet the funding for preventive medicine and public health is infinitesimal compared to the overall healthcare budget. While Preventive Medicine has been a specialty for over half a century, it comprises only 0.8% of the physician workforce. There is an inadequate focus on prevention in medical school curriculum, and physician training in preventive medicine as a specialty is an economic catastrophe due to the lack of funding. When you combine this with the profit-driven treatment ideology of American medicine, and the very small amount of financing the US Federal Government Health Resources Service Administration funds for preventive medicine training programs, we end up with a treatment, rather than prevention, focus. Treatment focused medicine is very advantageous for hospital administrators, highly profitable for pharmaceutical companies, yet less so for the folks who actually treat the illnesses, and of course, often financially devastating for those unlucky enough to find themselves on the receiving end. If we know that prevention is the best method to reduce healthcare costs, morbidity and mortality, why not create a single payer basic coverage for Americans? It has worked in every other first world nation, why not here? (To guarantee success, do not repeat what bureaucracy and administration-heavy ideologies have done to the American Public Education system).

Step 2. End malpractice insurance requirements and introduce Tort Reform.

The claims have been that without the right to file suit, patients are vulnerable to bad doctors and bad procedures. Yet the cost of frivolous suits, often paid rather than fighting due to the cost of lengthy legal battles, and the resulting increase in medical care due to high premiums for liability insurance have a detrimental effect on health care providers. Combine this with the realization that America is a very litigious society, and you have a recipe for costly healthcare. There can be no question that malpractice lawsuits have drained the system for decades. Americans once accepted that there are certain involved risks in every serious medical procedure, and when things went wrong they did not immediately look for an attorney and someone to blame. This is especially ridiculous in a culture that places so little emphasis on preventative medicine and public health. We eat what we want with little regard to how healthy it is, we are sedentary, and the majority of us do not get regular exercise. And should we have complications from open-heart surgery due to life choices, we immediately look for someone to blame. Make no mistake; things do go wrong in some medical procedures, these are called risky for very good reasons. Yet today’s OB/GYN’s are paying $100,000 per year for insurance, often to protect themselves from grieving parents and emotional juries seeking to hold them responsible for outcomes that no one could possibly have prevented. I am not suggesting that people with a legitimate right to sue a physician for screwing up badly should be eliminated, only that some system of reform is desperately needed. Going hand-in-hand with legal reform, the need for huge malpractice coverage drives up the cost of healthcare.

Here’s an idea: during the 1980’s, one could purchase “Accidental Death” insurance before flying on a commercial airline. Why not make this a part of medical care? No need for costly malpractice insurance for the annual check up; however, if you have to undergo a risky procedure or an operation, why not purchase coverage for that event only? The policy would be temporary and would cover the outcomes of the procedure only. There is little need for the average family practitioner that seldom wields a scalpel or ventures near an operating theater to pay out tens of thousands of dollars for liability insurance. Of course, the insurance companies are quite happy to take the money.

Step 3. Make people responsible for their own preventative health.

Benefits of a healthy diet and even a modicum of exercise result in a moderate reduction in the risk of stroke, cardiovascular disease, diabetes, certain cancers, and coronary artery disease. These five maladies alone account for 74 percent of the total fatalities attributable to the U.S.’s top 10 leading causes of death according to a report by the Centers for Disease Control and Prevention. Going along with providing basic coverage for things like childhood vaccines, wellness checkups, and annual physicals, making people responsible for their own behavior may have fallen out of favor in America today, but it makes sense, both physiologically and financially. If patients refuse to take responsibility for their healthcare, for example, refusing to participate in prevention or wellness check ups, they could be dropped from the program, thus providing significant motivation to maintain their own health. Ultimately, you and you alone are responsible for your health care. We must remember that here in the U.S., hospitals are duty-bound to treat emergency cases, and government spending pays for a surprisingly large share of visits to medical practitioner and treatments through a patchwork of public programs. These include Medicare for the old, Medicaid for the poor, and still other programs for kids. This being said, there are no incentives to try to remain healthy, no responsibility expected from patients, and any suggestion on diet or behavioral changes are often met with derision.

Step 4. Put Healthcare experts in charge of healthcare.

As Americans we rail against the administrative heavy bureaucracy of politics, and rightly so, but why then do we accept it in healthcare? Currently the experts state that physicians account for roughly 8 to 9% of healthcare costs, yet ultimately they shoulder the responsibility of accurate diagnosis and treatment. The same bureaucratic take-over that has diminished public schools in America (when districts once got by with two principles and a superintendent for 1,000 students, the same student population today may have two superintendents, three assistant superintendents, four principles, and four assistant principals as well as two educational directors, for example), is currently running wild in American medicine. A recent study for the State of California broke down the Healthcare Dollar this way: 31 cents went to hospitals, 22 cents to physicians, nurses, and treatment staff, a dime went to pay for prescription drugs, another 10 cents to dental care, 9 cents to nursing homes, 7 cents to administrative costs and 10 cents to items like medical equipment and hospital construction. The two biggest gainers were prescription drugs (up 15 percent) and administration (up 16 percent).

Step 5. Introduce product competition.

This goes hand-in-hand with making patients responsible for their own healthcare. Instead of requiring standard co-pays, make patients responsible for seeking the most cost-effective treatment. Changing from a copay system, for example $25.00 regardless of the doctor you visit to a percentage, for example 20%, would reduce healthcare costs. If a visit to Dr. A were billed at $200, the patient would pay $40.00. However, if Dr. B offers the same service at $125, the fee would be $25.00. This is how many patients purchase prescription medications; why not create a completion among service providers to reduce costs? Currently, if the doctor you see charges $300 per visit, and you pay a copay of $20.00 regardless, why do you care how much they charge? Lets introduce some competition. While even the best (so-called Cadillac) insurance policies have huge deductibles, few can escape the often crushing weight of medical related bills due a combination of bureaucracy, risk-averse medical practices based on the fear of a litigious culture, and a refusal of average people to take responsibility for their own health.

So how come we cannot just model a healthcare system after, say Japan or Denmark?

Well, it’s not that easy. A big part of it is cultural. Take teen pregnancy for example. Americans have the highest rate in the world, and in our culture we have decided to reward it (and even have reality television shows about it); in other cultures, for example Japan or Hong Kong, it’s seen as something to be avoided at all cost. In Denmark and Norway, people do not have to be forced to practice preventative medicine; they seek the information. Finally, bad behavior and the negative health impact that goes along with it is often rewarded or at the least, excused in our culture. So long as American medicine remains a profit-driven rather than care-led culture, where trivial health-related lawsuits are put before vindictive, emotional juries, and where public health and prevention are not incentivized, we will continue to have emergency departments clogged with chronic conditions, mental illness, and preventable illness. Through a combination of under insurance for most, over insurance for a few, and a disregard for public health and prevention by most, the citizens of the U.S. will continue to suffer the highest healthcare costs in the developed world, combined with some of the worst health outcomes, particularly if you are poor, female, or a child.

In the end, simply doing things the same way and hoping for improvement is ineffective at best, and dangerous at worse. Let’s get medical experts back in charge of medicine, reign in profit-crazed insurance companies, and our litigious population, and accept that maybe, just maybe, we are responsible for how crappy, sick, and unhappy we are.

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