The healthcare dilemma

Healthcare in this country is ... well ... not of the best.  Can we all agree on that?

There are statistics thrown around about our healthcare.  How we spend the most per capita of any country in the world and yet are far from the healthiest.  (I would maintain that our diet does have something to do with that, but I will agree that there are healthcare practices in our country that are neither cost-effective nor good for people's health.)  Or how many people don't have insurance, how many have it and pay through the nose for it, how much a hospital stay costs if you're uninsured.  I don't have those numbers.

What I do have is a few experiences.  Take my pregnancy with Michael.  During that time, the portion of our insurance payment that was added to cover just me was about $500 a month, I think.  That was employer-provided health insurance, but my husband's employer.  The expectation of course was that I would have my own job and not need to be on my husband's insurance, but that wasn't the life choice I made, so insurance is expensive.  (I am on a cheaper private plan now, thank goodness.)

During that time, I was informed that my insurance provider (United Healthcare, if you're curious) would cover my out-of-network home birth.  That's a smart decision for a provider to make, considering that a hospital birth can run $15,000 or more, and my home birth would cost them $3,300.  All I would have to do is request a "gap exemption" because it was out-of-network.  (There are no in-network midwives.)  And that request would have to come from my primary care provider.  I went through two PCP's before I found one that would make the request.  It took dozens of phone calls to the insurance company and to the doctors' offices to make sure they paid the bills for those two visits and to make sure the request had been sent and was being processed.

Then Michael was born.  Once I had recovered a little I went back to my job of calling UHC.  My exemption had been approved!  Hooray.  Next I had to submit the bills, which I did, having to do it twice before they were accepted.  Weeks went by, during which I called them a lot.  Finally I discovered what had become of my claim.  It had been denied.  Apparently my exemption (which I wasn't the one to request, and which I never got to see) said "nursing services" instead of "home birth services," so it didn't apply.  The entire claim was refused.

The whole experience was like beating my head against a brick wall, over and over.  I began to feel that this is not the best way, that this could not possibly be the best way.  I seriously contemplated ditching the insurance and socking the money into savings instead, because I am a pretty healthy person whose main healthcare expense is childbirth.  But John was nervous about that and we could just manage to pay up, so that's what we did.

How does the new healthcare law help this situation?  Not at all.  Not even a little bit.  Rates will go up for those who can pay them (and we just barely can now).  Those who can't are supposed to get some option they can afford.  No one any longer has any choice whether or not to carry insurance.  And everyone is still stuck playing the runaround game with the insurance companies.  A very real danger of this game is getting billed for things that turn out not to be covered and are out of your price range, so that you aren't able to pay the bill for services you've already received.  That bill will get sent again and again, you get calls from collections, and next thing you know you no longer have any credit.

For some real fun, try asking your doctor what that procedure will cost you and whether it's covered.  You will be forwarded to his billing department, who will ask the insurance company, and if you're lucky it will get approved sometime before you're dead.  But maybe after.

Okay, so we need a solution.  Here is what our solution needs to have:
1.  No one should be turned away from treatment they truly need because of inability to pay or a preexisting condition.
2.  Everyone should have free choice about what sort of treatment they want.  No one should be forced into a hospital birth or cesarean or medication they don't want.  Care should not be rationed out based on age or disability.  There shouldn't be long waits to see doctors.

I obviously lean toward a free-market solution for this, because economic freedom and civil freedom go hand-in-hand.  Unless you have a choice about what you will and won't buy, you aren't actually free.  Keep in mind that free healthcare isn't free; everyone pays for it through taxes, including those who don't want it.  In an ideal society, as I see it, a person should have the freedom to go live in the woods and answer to nobody if he doesn't want to.  With a lot of taxes, that becomes difficult to do.

Some of the problems with healthcare could be solved through the free market.  For instance, right now, the government certifies doctors.  If you want medical care, you have to go to a person who has completed a certain educational regimen and has passed certain tests.  Because of this, they all tend to have similar opinions (learned in school), they all spent a lot on that education (which means high prices for you), and there aren't as many of them as we might like.  Sure, you could go to an alternative practitioner of some kind.  However, they will not be allowed to prescribe medication or do surgery.  (In Virginia, at least, a midwife can't carry Pitocin or methergine (both lifesaving medications in the event of a hemorrhage) or stitch small lacerations (which happen pretty much always).)  There also may not be a clear certification for trustworthy practitioners.

In an ideal free market, there can be multiple certifying organizations, and you could educate yourself and choose what sort of doctor you preferred.  If you were poor or not very ill, you might choose someone more like a licensed practical nurse or physician's assistant, both of whom are quite qualified to treat most commonly-arising illnesses, but who are legally not allowed to practice without the oversight of a "real" doctor.  Recently I read Middlemarch, and there's a bit in there about the different kinds of doctors available.  Apparently there were some major disagreements between the physicians and apothecaries, and you could get a different kind of care from each.  (This would be so interesting to research if I had the time.)

Overall costs would go down.  It costs a huge amount to keep all these insurance companies and medical billers in business.  And prices are jacked up by the hospitals because you don't always read the bill.  I believe that hospitals and insurance companies are colluding to raise prices.  The hospitals raise theirs so they can make more money, and the insurance companies agree to pay (though they often pay less, through their "special discounts," than the listed prices).  In return, the hospitals discourage cash patients.  Usually, the high prices are enough to do it, but I've even seen posted signs saying that cash patients will be charged a $75 surcharge.  What for?  Cash patients cost them nothing.  But they're hoping this will encourage you to buy insurance so they can start billing for more.  The insurance companies obviously benefit from this.  Overall, healthcare is taking a larger and larger percentage of our paychecks every year.

Ending this whole scheme would save most of us a lot of money -- but it would also put a lot of us out of work.  Healthcare is a very profitable, and growing, field.  Pharmaceuticals are America's single most profitable industry.  What if we only paid the amount it actually costs to produce those pills, instead of the steep markups the insurance companies agree to pay?  The economy would adjust, but it would take some time.

But what about the really serious problem of those too poor to pay?  Even if costs go down, there will be some people who can't pay.  How do you deal with this?

Some say the solution is really simple.  You just  make a law that says you can't deny treatment to anyone who can't pay, and you can't charge anyone a cent if they live below the poverty line.  Of course this isn't a purely free-market solution, but it seems a small enough law not to disrupt the general libertarian idea very much.

But it would cause problems.  First off, you couldn't just claim to be poor.   You'd probably have to have some registry and get your poor-person card.  (And then people would insist that everyone with a poor-person card has to be drug tested or sterilized or actively seeking a better job or whatever.  The way people would like to do with welfare recipients now.  It seems modern Americans do not believe in the deserving poor.  But say that didn't happen.)  Would you show it before receiving care, or after?  If you showed it before you were treated, do you think that might affect the care you received?  If you'd presented proof of your ability to pay, they'd be happy to wheel out the expensive MRI machine for you, but if all you had was a poor-person card, more likely they'd feel your broken wrist, say, "Feels like a sprain to me!" and slap it in a brace.

Okay, say how much money you have is confidential and they have to treat you all the same.  Money no object, everyone gets the MRI.  Eventually, the MRI machine begins to wear out and has to be fixed.  So the hospital gets it serviced.  MRI machines are expensive; the repairs cost a lot.  Suddenly we realize that the hospital in Alexandria, where almost everyone pays cash, gets a new MRI machine; while the hospital in Front Royal, where half the population has a poor-person card, gets an "out of service" sticker till further notice.

Heck, that is already where we are.  Our local hospital is painfully understaffed and undersupplied.  Every time I've ever been there, I've regretted it.  They left John waiting for hours for pain meds when he went there in agony with diverticulitis.  He was hospitalized for two days.  The whole second day was just spent waiting to be seen by a doctor so he could be okayed to start eating by mouth again.  A friend of mine went there after passing out, and was left alone in a room with her friend for hours.  It was only when the friend noticed the patient had stopped breathing and yelled for someone to come that she actually was cared for.

These aren't awful people.  They're just terribly, horribly understaffed.  And why?  Because the people here are poor.  The hospital sends out bills, but the people don't pay them.  Mostly they just come to the emergency room because they can't be turned away, but they're always there with infections that must have taken weeks to get that bad.  Being seen sooner might have helped, but no one will give them an appointment because they know they can't pay.

Elsewhere, the same thing is happening.  In Philadelphia, hospitals are closing due to lack of funds.  There is no longer (or wasn't, when I was there) a hospital within the city limits that still had a maternity ward.  It's too expensive.  Risk of lawsuit too great.  Too few people can pay.  So everyone either went to the suburbs, if they could pay, or went to the emergency room, if they couldn't.  The emergency room is no place to have a baby.

Okay, so we're back to the drawing board.  Where is the money to come from so that the poor can get healthcare?  Healthcare in America today is expensive.  That's because of the technologies available.  When your friendly doctor had nothing but a couple of bottles of penicillin and some suturing silk and plaster casting, he didn't have much overhead and could charge you a few dollars for a visit if it suited him.  Nowadays, there are so many expensive machines and medications available -- which do save lives -- but which cost a heck of a lot.  I read a blog post recently in which the mother of a preemie said that her daughter's care cost $100,000 a week.  And she had been in the NICU for a year.  Her insurance covered it.  What if she'd been uninsured?  Would they refuse to treat her daughter?  Or would they keep sending her bills until she was out on the street?  What, do we just pull the plug on anyone whose care is more expensive than we can afford? What exactly is the cost on human life?  I am all for paring down unnecessary care, stopping doing tests and surgeries just for fear of a lawsuit, but what if your choice is only to give the expensive treatment or watch a person die?  Who could ever make that choice?

A single-payer system, i.e. socialized healthcare, honestly sounds much more attractive to me.  Yes, I know that this is very un-libertarian of me.  But there has to be some special solution for healthcare, because it is a legitimate need, and because need for it does not correlate with income.  That is to say, you might be a millionaire, healthy as a horse, and never have to see a doctor; or you could be a homeless beggar and have lymphoma.  I believe the free market is the best solution to most problems, but a system is unacceptable if people have to go without food, shelter, clean water, sanitation, or medical care.  Without these things, people die.  No one should die of poverty in a country as wealthy as ours.  Private charity can handle the first four needs pretty well, and a very limited government safety net could probably handle the rest.  But the last is really, really expensive.  Only a lot of government expenditure could do it.  No charity has the budget.

Socialized healthcare has three problems:
1.  There has to be enough money to pay for it.  If there isn't, you end up with Greece.
2.  There have to be enough doctors to provide it.
3.  You may not have complete free choice of what kind of care you want.

For the first problem, there are always taxes.  But would that do it?  Canada and Great Britain seem to manage fine.  Except of course neither of those countries is the police force for the entire world.  That might be something to examine, ahem, ahem.  In other words: if we taxed everyone something roughly equivalent to what they now pay for insurance, only staggered based on income, and we ended foreign wars and occupations, we might be able to swing it.

For the second, different countries handle this in different ways.  From what I hear, Great Britain hasn't handled it all that great.  (I'd love to hear from some actual Brits on this one.)  I heard there were long wait times and the hospitals are understaffed.  But I have also heard that this isn't true in Canada.  John tells me this is because Canada has made itself something of a mecca for foreign medical students, and encourages them to come for education and a good job.  That sounds pretty clever.

For the third, the best you can really do is say, "Well, these are the services that the national system will cover for you.  If you want something different, you will have to pay for it yourself."  Of course, you may not even be able to do that because all doctors are employees of the government, and if you don't like the doctor you have, too bad, you may not be able to get a different one for love or money.  But if you want a procedure that's not covered, you could set up some kind of a system where people could pay extra for that.  And of course you can always go to an alternative practitioner if you want and can afford it.  However, with those higher taxes, you may not be able to afford it.  This is the dilemma of socializing anything: if you pay for it with taxes instead of directly, you can't choose what you get.  Whereas in a free market, everyone can choose something different without harming other people's freedom.  (That's why we say that personal freedom is best expressed in a free market.  Milton Freedman explains it much better than I do.)  But in the final assessment, I think it is more important that a mother in dire poverty can give birth in a sanitary environment with someone to hold her hand and a doctor to help her out if she needs one, than it is for me to be able to deliver with the location and attendant of my choosing.  You can die without any healthcare; you are merely inconvenienced by having healthcare not of your own choosing.

If you consider the doctors, however, freedom will be necessary for them too.  That is to say, I believe it is morally wrong to require a doctor to do anything he objects to.  I think a fair system will allow doctors to opt out of performing abortions, for instance.  This would be the wise thing to do, if you want to attract doctors to the system, to make sure you are not driving away large segments of the population from considering medicine as a career.

So, I think I just sort of endorsed socialized healthcare?  It's not an ideal solution at all.  However, it seems to be better than what we have.  You couldn't do it overnight, though, because of the huge medical and insurance industry and all the jobs that would be lost.  Sooner or later, though, I think the economy will have to transition away from that sector a bit, because it is bloated beyond sustainability, and because I don't think you can ever guarantee healthcare to everyone at current prices.  You're not only paying for treatment for sick people, but also for "economic stimulus" to keep the vast UHC call center, with which I am so intimately familiar, employing people.  That's too much, and that's one reason why I think the new healthcare law isn't going to work.  As I see it, instead of doing away with the collusion of hospital and insurance company, it's getting in on the monopoly and making it a collusion of hospital, insurance company, and government, using force to make sure we hand over our money to insurance companies who will hand it over to hospitals who hopefully will use some of that to treat the sick.

Ahem.  Didn't mean to rant.  I do not care for the new healthcare bill.

Here is an idea that's been knocking around in my head lately, though.  When I was in Italy, I was told that there were two kinds of hospitals: public hospitals, paid for through taxes, and private hospitals, paid for by those who could afford them.  In a way it was a hybrid system.  (I don't know any details beyond what I just said, but wouldn't that also make a fascinating research topic?)  I like the idea of being able to choose whether to go to a hospital that just treated everyone, with a basic package, for free, or to a hospital where you had more choice but would have to pay for it.

The concern here is that you would have horrible, dirty, run-down, overstaffed public hospitals to which no one who could help it would ever go; and nice hospitals for the rich.  (The Italian public hospitals certainly didn't look very nice, although I only saw the graffiti and broken windows on the outside, and I don't know what they look like on the inside.)  My solution is to make the public hospitals teaching hospitals.  If you want to be a doctor in the United States, you would have to do, say, five years in the public hospitals first.  (Ideally this would be considered part of your tuition for med school, making med school cost less and be more available for poor smart kids who wanted to be doctors.)  You'd get trained, you would give back for awhile, and after you'd done your rotation at a public hospital in a backwoods area like where I live, you could try to get a job at a private hospital in a wealthier area that supports it.  What this would mean is that enough of a free market would survive that you could still sustain some level of profit to motivate people to research new technologies, develop new medications, and of course go into medicine in the first place.  Your paycheck at the public hospital might be low (for a doctor), because the government can't afford to give you six figures, but you'd have the promise of maybe making more money later on in your career.  And there would still be a sector of the economy that makes its profit on health insurance, brand-name drugs, and so forth.

I am not an expert on healthcare by any means, but if I were queen of the world, I'd like to try a system like that.

What are your thoughts, you lucky few who have read down through this whole thing?  (This is what happens when I can't blog often.  I just build up a bigger deposit to dump on you all at once.)  Of the solutions I've mentioned, which do you prefer -- or have you thought of a better one?