Sunday, May 29, 2016
The US health and social service system is evil
I have often written about how our health system is “deeply flawed”, but I realize that there are many ways in which this is a grand understatement. I initially intended to call this piece “health insurance companies are evil”, but realized that this singled out but one player. I mean, insurance companies are at least as evil as other parts of the health and social services sector, but naming only one part both does a disservice to that part, which is acting rationally in relationship to the other aspects of the system, and tends to forgive the others.
The thing wrong with our health system is that it is a mess; there are dozens or hundreds of ways to have health insurance coverage, or not, and each costs a different amount and covers different conditions, for different percentages, with different amounts of coinsurance and co-payment and deductibles. A single-payer health system, where everyone is covered with the same benefits for the same care (all that is needed, none that is not) and payments tiered to income, is the only rational and effective way to make sure that we have the possibility of quality health care. There can be no quality without equity. While I will not spend more time here making this case, because I and others have previously done so extensively, I will refer to it.
What is evil is how the system affects our actual people. However, people are not really ever seriously considered in “health reform” (or social service “reform”). Yes, people’s suffering sometimes gets mentioned by political candidates, who note that some people are paying too much or are not getting care. Indeed, this has been a big theme of Republican candidates who are critical of Obamacare, but whose only plans are ones which will make it a lot worse for most people. Actually making the system work for people is never really on the table, because when the political negotiations begin, the big players (insurance companies, providers, drug companies, device manufacturers, etc.) enter the picture.
Let’s get right down to it: people in the US, even those who are citizens, just do not get the coverage and services to which they are fully entitled, not to mention the coverage and services that they actually need. You have to sign up for Medicare, pay for Part B (which is what covers everything except inpatient hospitalization, including doctors’ fees), choose and pay for a Part D plan. If you are lucky enough to be able to afford one, you have to look through a maze of possible Medicare supplement plans and hope you chose correctly, given the multiple variables of your health status, the benefits profile, where you live, your actuarial as well as self-perceived probability of getting ill, and what you can afford. Even Social Security, a benefit that you have paid into for your entire working life, requires you to sign up and show you are eligible. This is nonsense; there is no reason it should be this way. We start with a non-system that does not cover everyone, provides inadequate coverage for those who do have it, and makes it difficult to sign up, presenting numerous obstacles which allow people to fall through the cracks.
Actually, this is more than nonsense; to the extent that people pay the price of inability to navigate the system with their health, it is evil. It would work, and be much simpler, if everyone, when they retire, got Medicare. And if Medicare covered everything for everyone wherever they live. Why not just make sure everyone gets Social Security? Why make it the responsibility of the person to demonstrate that they not only are truly eligible but that they can get through a jungle of options, often confusingly computer based, when they are getting to the end of their careers? Of course, if we had a single payer system, everyone would be in and there would be no change when you retired or became 65; you’d already be in a system in which everything you need and nothing you don’t need is fully covered.
Actually, in a good system you’d be better than “fully covered”. You’d be covered appropriately; you would, whoever you are, get the care that you need, but you would not be eligible for coverage for things that you don’t. We would have a health system that provided necessary, appropriate, and proven diagnosis and treatment for people, rather than emphasizing the provision of services which were most profitable to the providers. Insurers would not do their best to risk-select, would not be able to charge more for some people than others (and they can under Obamacare; they have to cover you even with a pre-existing condition, but can charge more), and would not even have to be for-profit. I favor a single-payer health care system such as Canada’s, a (fully-funded) Medicare for all, as does Sen. Sanders. But there are other reasonable alternatives; Switzerland, for example, has, instead of a single payer, multiple insurance companies. But these companies have to cover everyone, provide the same benefits, charge the same price, and be non-profit.
Critics of Sen. Sanders often say that a Medicare-for-All system would bankrupt us. This is also nonsense. It presumes the built-in profit for insurance companies. It presumes that we would continue to pay the most of the most complex and high-tech procedures, and let providers (via the complex system of the RUC -- Changes in the RUC: None…How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013, which essentially sets the Medicare rates on which all other payments are based) set the rates for their own procedures. The evidence is in every other wealthy country, all of which spend much, much less on health care and have much, much better outcomes. They also provide much better social services, not only for the needy and the poor, but for everyone. Retirees get their pensions. And they keep their health care.
The system works in these other countries; that is, if your interest is in ensuring that everyone gets the health care they need, the pension benefits to which they are entitled. If your interest is in maximizing the income of (some) providers and the profit for insurance and drug companies, then they don’t work as well. So I guess our system is not necessarily evil, it depends upon your values.
But, then, I would argue that the values on which the system is de facto based, though, are evil ones.