Medicynic

Economist Simon Johnson observes: 

The world’s largest banks have been accused of many things in recent years, including taking excessive risk in the run-up to 2008, doing great damage to the American economy by blowing themselves up and then working hard to resist any sensible notions of financial reform.

All of this is true, but it misses what is likely to be the most profound negative impact of the banks’ behavior on most Americans. The banks’ actions led directly to an increase in government debt, which in turn has made the reduction of that debt by “cutting runaway spending” a centerpiece of the Republican presidential campaign to date.

As a result of this pressure, Medicare now stands on the brink of being eliminated as a viable form of social insurance. Yet the executives who lead these banks – and the politicians with whom they work closely – will not be held accountable this election season.

Read the entire piece.

Medicynical Note:  The republicans longstanding dream has been to undo the social programs of the New Deal and Medicare.  They’ve worked unceasingly over the past 50 years to accomplish this goal and thanks to the banking disaster believe they can reach their goal—if they control congress and the presidency after the next election.

Imagine rolling back the programs that allowed unprecedented prosperity and security to our population.  In the end we’ll get what we deserve, and are willing to fund. 

Uwe E. Reinhardt at Economix notes: 

For decades, Americans have lamented in vignettes published by various news organizations the families, stricken with serious illness, who find themselves unable to procure health insurance at premiums they can afford or are refused coverage altogether.

The Affordable Care Act was written to solve this problem by subjecting private health insurers to community rating and guaranteed issue.

But if Americans want the benefits of these two strictures, they must also be willing to countenance the mandate to be insured. It is not legislative hegemony. It is an actuarial necessity.

He also notes that virtually all other industrialized nations have found a way to offer coverage to everyone and all of them one way or another have the equivalent of a mandate to have insurance as part of their system.

As noted previously, the health industry is driven by expectations. Patients expect everything to be done no matter the cost,  the limited benefit of the intervention, whether they can pay or not or for that matter whether or not they have insurance.  It’s the American way.  They also largely expect that no matter the severity of the illness and difficulty of treatment that they will be the ones cured–that’s what it said on TV or the Internet. 

Doctors expect a handsome income to pay off their overhead, loans and to maintain their standard of living.

The medical technology industry including insurers expect double digit yearly returns on investment.

Hardly anyone in the non-system bothers with value, comparative efficiency, or the cost of all this.

The U.S. is an outlier.  Health care here costs more than anywhere in the world by far.   We have 50 million plus uninsured with limited to no access to care.  We lead the world in bankruptcy from health care and yes given how much we spend, our health care quality is marginal. 

Entering into the fray, some members of the Supreme Court, perhaps a majority, seem to feel that it is a shame that people “have” to have insurance.  That their free choice should allow them to have no insurance but leave unstated what happens if they should get sick.  How they would access care?  Who would pay?  In their cocoon of wealth and privilege the Supremes seem ignorant of the fundamental issues of health care and the economic disaster we have created.  Quite an amazing scene. 

Medicynical Note:  Let me clarify my view on quality.  When people eventually get care in the U.S. it’s quite good, as good as other places—albeit at twice the price.  Our problem is the delay often experienced from lack of insurance and money to pay our inflated price for care. 

It’s a bit unnerving to watch the Supreme Court’s deliberations on health care reform and in one’s mind graft their comments onto our narrow superstitious belief systems. 

Yes this is the country where there are large numbers of people who believe in miracles, doubt evolution, global warming and believe in American Exceptionalism– a  “city” on the hill.  We are a country who can defy gravity.

Why not also believe that there is something “unamerican” in sharing risk of health care costs through insurance.  After all we are responsible for our own lives and well being.  Why share—we can always go to an ER for free.

Sadly, the battle at the court was not about health care, well being or assuring access to care for sick American citizens but rather about making ideological points.

How else to explain Scalia’s and some of his colleague’s apparent other worldly view of insurance (shared risk) and the notion that people will buy it when they “need” it. 

He’s never seen patients who can’t get or afford coverage because of pre-existing illness;  or patients who delay care because of lack of funds; he’s never seen neglected breast cancer masses on the chest of women with incurable disease; he’s never had to tell families they have to divest themselves of assets to become eligible for medical assistance; he’s never seen families go bankrupt from health care costs.  He’s quite a guy.

Medicynical Note:  The U.S. is unique.  We are the only industrialized county without a national health insurance scheme (all other countries have a mandate, one way or another)  We are the only industrialized country that has bankruptcies from health care costs.  We have the most expensive and inefficient health care non-system in the world.  We are indeed a City on a Hill….

Does anyone need more proof of the total dysfunction of our non-system of care.  Consider that we have over 50 million people without health insurance, and it appears that  a decreasing number of employers offer health coverage. 

One might ask where all the money paid by insurers for coverage went?    Certainly not in the pockets of the employees. 

It is a fact that proportion of our population covered by insurance from employers declined from about 70% in 2001 to 53% in 2010. (see the above link)

Medicynical Note:  Employer based coverage was a convenient modus but it has become obsolete. 

Our conservative friends like the idea of “free” markets that allow choice.  But they neglect to point out that “choice” goes both ways.  Insurers in their “system” are free to choose who they cover and how much they charge.  If you are sick and/or elderly forget it. 

Their approach undoubtedly will decrease spending on health care…………

Fine article in the NEJM by Victor Fuchs reviewing the relentless increase in health care costs since 1950. 

The most important explanation for the increase in real per capita health expenditures is the availability of new medical technology2 and the increased specialization that accompanies it. Between 1974 and 2010 alone, the number of U.S. patents for pharmaceutical and surgical innovations increased by a factor of six. Second in importance is the spread of public and private health insurance, which diminishes the effect of health care prices on demand.3 There is a positive-feedback loop between new technology and the spread of health insurance: new technology stimulates the demand for insurance, and the spread of insurance stimulates the demand for new technology.4 Finally, a small portion of the increase, typically 0.1 or 0.2 percentage points per year, is attributable to the aging of the population. It’s not possible to estimate how much of the increase in expenditures reflects higher health care prices and how much reflects greater quantities of care, because the content of a day in the hospital or a visit to a physician keeps changing. No doubt some of the increase in expenditures reflects an increase in the quantity of medical care, if quantity is adjusted for improvements in the quality of care.

Read the article. It’s complete text is available at the above link. 

Medicynical Note:  Of interest, since 1950 the largest proportion of  costs was and is for hospital care.  Shorter stays over the time period were balanced by higher charges and increase use.  Physician and drug costs also increased exponentially.  A catch-all category of including “public administration and the net cost (premiums minus benefits paid) of private health insurance, nursing homes, and dental services” also followed the trend

The tone of the article is not optimistic with reference to the current grid lock of political philosophies that interferes with an honest careful discussion and resolution of the issue.  There may be still some hope, as the author notes quoting de Tocqueville on America “events can move from the impossible to the inevitable without ever stopping at the probable”  

Disconcerting disclosure by one of those suing the government about the health insurance mandate: 

Mary Brown, whose case against the 2010 healthcare reform law is pending before the Supreme Court, argues that the government shouldn’t be able to force her to carry health insurance.

But:

The couple have filed for bankruptcy protection, asking a federal court to wipe out close to $60,000 in consumer debts. Significantly, their unpaid bills include $2,750 owed to a local hospital and physicians group and $1,735 to out-of-state medical specialists.

Medicynical Note:  The Brown’s are not unique, something like 60% of those filing for bankruptcy in the U.S. have medical debts as part of their problem. 

We lead the world in this cause of bankruptcy which is essentially unknown in industrialized countries with health insurance mandates.