The Amazing Maze of US Health Care

When you are up to your neck in alligators, its hard to remember that someone needs to drain the swamp.

The American Alligator

Last week, I wrote about the tax on “Cadillac plans”.  This past week, BHO reached an agreement with labor unions, the primary voice of the opposition to taxing so-called “Cadillac plans”.  The tax is still there.  My suggestion didn’t seem to make it into the discussion.  I was busy dealing with alligators.  That’s my day job.

One of our carriers had a computer glitch (a nice euphemism) that disrupted coverage for many people.  Here is a typical example of the kind of fires we had to put out – a woman went to the doctor’s office and the doctor could feel a lump in her breast but would not order a mammogram because the office had contacted the insurance carrier and had learned (incorrectly) that she had no coverage.

These incidents prompted me to wonder.  If we had a single payer health care system, couldn’t we have the same problems?

After all, we will certainly still have computers.

But we won’t have people moving from plan to plan because they changed jobs.  We won’t have people losing coverage because they lost their job, or because they got sick, lost their paycheck and therefore could not afford their health insurance premium.

Doctors and hospitals will know who is paying their bills and therefore might show a bit more patience with administrative errors.  After all, if a computer error like that should occur in a single payer system, it likely would affect a high percentage of their patients.

There would hopefully be a sense of shared crisis, not one that abandons people in a time of acute need.

Oh, and the tax compromise reached recently.  It is still a bad idea.  Now it is just an acutely complicated bad idea.

And it will do absolutely nothing to make our health care system less fragmented, less chaotic, and more humane.

It just lets in more alligators and stops up the drain even more.

This morning driving to work I listened to a story on NPR Morning Edition.  It described the effort to build Charles Babbage’s Difference Engine – a mechanical predecessor to today’s computer.  Babbage died before he could ever complete his machine but modern engineers have recreated it.

The analogy with health care struck me.  Congress is building a Babbage machine in an era of super computers.

And we dare to call it progress?

Charles Babbage Difference Engine

In a recent report on National Public Radio (NPR) about a gang  rape in Rcihmond, CA, one person asked the question. “Where has all the humanity gone?”

The same question  can be asked in the current debate on national health care reform.

Is this our big tent? Photo by JL McGee

Where has all the humanity gone?

We are talking about Americans here

The politicians are wiling to deny undocumented immigrants access to the proposed Health Insurance Exchange.  But that is not enough for some.  They are afraid that hospitals will use federal funds to treat undocumented immigrants in the emergency rooms.

Aren’t some of these very same conservatives, also Christians?  Aren’t they familiar with the story of the Good Samaritan?  In case they forget, the moral of that story is doing good to your enemies.  Oh that’s right, Christian values don’t apply to government, because government funds are involved.  Unless, of course, its abortion.  Then then “Christian” values apply because government funds are involved. Read the rest of this entry »

There is nothing simple about our health care maze.  Fixing it is not easy.

I prefer to look for the simple.  The complexity will evolve naturally.

Congress prefers to start with the complex and make it more so.

Spreading the medical risk

There  are two major challenges to fixing the customer side of the health care mess – spreading the medical risk and spreading the financial costs.

Spreading medical risk requires that everyone be in the system.  That spreads medical risk evenly between the sick and the healthy.  That can be accomplished by a system of automatic eligibility or a system of required enrollment.

Automatic eligibility describes a single payer system.  All citizens are enrolled by virtue of their citizenship.  To draw from known models, automatic enrollment describes Part A Medicare, Department of Defense medicine, and to a lesser extent, the Veterans Administration.

Funding for those programs is separate from enrollment and may or may not rely on direct participant financing.

A system of mandatory enrollment implies a system of mandatory participant financing.  That is where we bump into the second challenge.

Spreading the financial costs

How do we transfer money from those who have it to those who need it? Read the rest of this entry »

How often have you heard the phrase, “The United States has the best health care system in the world.”?

What is wrong with that statement is the word “system”.

We could rephrase it – The United States can deliver some of the best health care services in the world (to those who can pay for it).

We could even argue  – The United States has some of the best health care systems in the world: the Mayo Clinic, the Veteran’s Administration, the Department of Defense.

But to assert that we have a system or that Americans (all Americans) receive the best care in the world is a stretch.  Why?

Over the last two weeks I wrote about our fragmented health care system and the closely related fragmented payment system.

I wrote about how patients are equally fragmented, migrating during their lives through several health plans, what I call patient delivery systems.

Why does this matter?

In most measures of health system performance the United States ranks embarrassingly near the bottom or at the bottom among industrialized countries.  From 2000 to 2009 male life expectancy fell six slots to 24^th in the world and female life expectancy fell from 28^th to 35^th.  Some would counter that life style, diet, or poverty had more influence on those drops than health care.

Isn’t that fragmented thinking?  If we had a health care “system” then it would take comprehensive approach to population health.

What are the incentives for doctors and hospitals?  Just as sunflowers follow the sun, health care providers, like the rest of us, follow the money.  And the money is paid for doing stuff, surgeries and tests, for example.  It is not paid for talking with or listening to patients, giving them lifestyle or treatment compliance assistance.

What are the incentives for patients?

Patients often lack the freedom to choose just any doctor.  Their incentive is to change doctors to conform with their current health plan rules. Read the rest of this entry »