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.
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