The most distinctive and defining characteristic of the US healthcare delivery system is how poorly it serves people, and the number of hoops, obstacles, and downright obfuscation people need to work their way through to get care. The most important problem is that we have worse health outcomes and more premature death than any other industrialized country, and the excessive cost of achieving those worse outcomes (the only place where we’re #1!). But the sheer difficulty, pain, and low yield of going through the information needed to make the wisest decisions (actually wise, we will see, is virtually impossible in our system) takes a – completely unnecessary – toll on all of us.
The reason for this situation, very simply, is that the healthcare system in the US is not structured to deliver maximum health benefit, but to deliver maximum profit to the major players – and that is very few of us. It is absolutely critical to remember this core fact, because every other characteristic of our healthcare system derives from it. Worried about surprise medical bills when some of the doctors at your in-plan hospital are out of plan? Worried about paying for the wonderful new medicines advertised on TV that promise you cure for thousands of dollars a month? Worried about whether you can afford the premiums for the plans your employer offers, especially if you need to cover your family? Or the premiums for the better ACA-plans? Whether you can bet on your current health status, if it is ok, continuing into the future? Whether you can survive until you are old enough to get Medicare? And then, when you are, whether Medicare will cover enough of your bills, or if you need – and can afford – a Medicare supplement plan? How about choosing a “Part D” drug plan? Why are the websites and information so opaque and difficult? Is there any plan that is truly of value? And even if “of value”, can YOU afford it?
These questions just touch the surface. Then, you actually need
to access healthcare services. Then it gets worse. Primary care doctor? Can you
get an appointment? Use urgent care? Is your problem on the list of things that
they can competently manage? Emergency room? Wait until you are so sick they
have to take care of you? And what about those drugs…?
The specific problems that this system creates for
individual people are often overwhelming, and become the focus of people’s
lives when they do have chronic diseases or ongoing health needs. Politicians
and their policy advisors who keep talking about addressing them one at a time
are at least intellectually corrupt (setting aside the question of whether they
are also financially corrupt) in believing that a patchwork of – patches – can make
people, at least temporarily, think that they are doing something to help while
maintaining a predatory structure. Let’s just look at a few recent examples and
Upshot in the NY Times recently had a piece on how the pandemic has increased the
use of telemedicine, and how this might lead to better access to emergency
care, citing a very positive study
done by the Veterans Administration. The study shows, among other things,
that same-day access to primary care can obviate the need for emergency care.
Beyond that, having a regular source of primary care, and being able to get in
when you need to, decreases hospitalizations and mortality. Of course, it is
important to remember that the VA is (like the military) a single-payer health
system and works better than the rest of US health care within the constraints
of continually decreasing funding, part of a general Congressional and
executive effort starve it for funding, specifically to ensure it doesn’t work
as well as it could. Those same legislators then blame the VA rather than
themselves for veterans not getting the best possible care, a tried-and-true
tactic for evil politicians. Except the VA, and military health care, do work better than the private sector. (For
more on the VA, see the excellent article “Shaping the Future of Veterans’
Health Care” by McCauley and Ramos in the New
England Journal of Medicine, Nov 5, 2020, which requires a subscription.) The
comments by the brilliant and incisive Dr. Don McCanne, found at the above
link to the Upshot article, clearly
makes these important points. And why
can’t you get same day visits, or even prompt visits, with your primary care
provider? Remember the key factor in all US
healthcare; it is usually not that your doctor is unwilling; it is that
they also work for a corporation whose policies are about maximizing income and
profit, not about improving your health.
In a recent conversation with a friend – also a senior citizen knowledgeable about health care policy, who was long on a medical school faculty and now lives in a relatively rural area – we discussed the best choice for a Medicare Part D plan. I noted that in 2020 I had assumed that my insurer would, absent my making a change, continue me in the lowest-cost plan as it had the two years previously. It didn’t; it automatically bumped me up to the highest-cost plan. With no added benefit, because of Catch-22 – I could never make my deductible, and thus have the plan kick in, because all of my drugs were “tier 1” and didn’t count (the calculators offered are only of use if you use high-tier high-copay drugs like those advertised on TV). This year I made sure to change back to the cheap one, so I can pay $17.50 instead of $55 a month for no benefit. My friend agreed and will choose the same plan. But did note that if a family doctor and a health economist had trouble figuring this out, it might be hard for a lot of people! It is this characteristic of our health insurance system that makes the claims of those who advocate for private health insurance because it gives you, the consumer, “choice” are completely bunk. Almost no one can read, digest, understand, and utilize the information that is (sometimes) provided, in all different places, to get to a decision on what will work best for them. And, for the few who can, it usually turns out not to be very good! Remember: this is not some quirk, it is how our healthcare, and health insurance, system are purposely set up: To be confusing, opaque, and beneficial only for the sellers, not the consumers.
My friend and I also talked about several interactions he recently had with the health system his primary care doctor is part of. One involved his receiving (as an ex-smoker) a scanning CT scan and suggesting that they obtain an older one, from the medical school where he used to work, to compare the new one to. “We don’t do that,” he was told by the person at the other end of the phone. Another was about finding out how he could get documentation to be in an early group to get COVID-19 vaccination when it becomes available, given that he is high-risk not only by age but by having chronic diseases. They don’t do that either. These are unacceptable answers, as he told the office of the vice president he complained to, and who agreed to make things happen. This is not a flaw in the system; it is how it is structured, for everyone. Most people, you see, will not complain, and thus will, well, get screwed. But it saves the company money. This is a core way health insurers function. The higher the bill from a doctor, the more routine it is to just deny it, making the doctors work to prove they should get paid. Clearly, this is a particular issue for surgeons, who usually have staff who routinely fight with the staff of the insurance companies to appeal these denials.
There is an old saying that “this is no way to run a business” But, for most companies involved in health care – insurance companies, pharmaceutical manufacturers, long-term care companies, hospital systems, and increasingly large physician groups owned by corporations, it is the way they run their business. And it is a very profitable way to do it.
It is just no way to provide healthcare.