Healthcare, Curing the Disease not the Symptoms; Pt. 2: Checking the Rankings

Part 2:

Dr. Mark Hyman wrote last month in his Huffington Post article, Why Health Care Reform Will Fail: Part I -- The Business of Disease: We Pay For What Doesn't Work, "Recently President Obama's rhetoric has shifted from health care reform to health insurancereform. Getting more people access to a system that provides worse outcomes at higher costs is not an option for a sustainable health care system, nor a sustainable economy." The significance of this statement is that not only are we focusing too much energy on trying to reign in costs rather than quality and delivery, but also that if we as a country try and improve the return on our healthcare dollars that will, as a byproduct, save money. So, as with healthcare availability, first you have to evaluate why it is U.S. healthcare is ranked poorly and then determine how to improve those numbers to, in Obama's own words, use a scalpal rather than a hatchet.

The shocking figure relevant to this topic is the 2000 World Health Report ranking the U.S. healthcare system as 37th out of 191 of the world's nations. The most obvious problem with using this number in the debate is that it is nearly a decade out of date. The second problem is how the WHO ranks the systems of various countries. Redington Jahncke, in his September 1st article in The Advocate, does a very thorough breakdown of by what standards the WHO evaluates their ranking, and he points out that it uses a cumulative ranking process which is overwhelmingly weighted, 63%, towards "fairness."

To illustrate, let's use a simple 1-to-10 scale. Under the WHO's "fairness"
weighting approach, a nation whose measure for health or health care ranged
from say 3 for its least advantaged citizens to 4 for its most advantaged
would outrank a nation whose measures ranged from 6 to 10.

So even though the care provided to all citizens is better overall, the difference in quality is what brings the rankig down. He also points out that a certain level of double counting occurs, which can be seen in this method of evaluation, because as part of the ranking, the U.S. is evaluated lower for having a low rating given its advanced technology and wealth. Finally, Jahncke takes a look at how the U.S. ranks in actual health, noting that of the 8 there are only 2 absolute measures, which are responsiveness and life-expectancy. In responsivenes, defined as dignity, autonomy, confidentiality, prompt attention, quality of basic amenities, access to social support networks during care and choice of care provider, the U.S. actually ranks first, a figure not often mentioned in the healthcare debate. The life-expectancy number is not so encouraging however with a ranking of 24th. So it would seem that it would be to the advantage of Americans to focus on this problem of life-expectancy (and affordability) without making too many changes to the existing system, also keeping in mind that of the 23 countries ranked higher, only 6 have populations of more than 30 million and only 1, Japan, more than 100 million.

Obama will often talk about stories he's "read in letters and heard in town halls all across America." In reality though, if you go around enough and ask enough people you can find individual examples to prove any argument. For example, in 2005, my own mother was diagnosed with breast cancer. She had a unique and aggressive strain of the cancer that, had she gotten it less than 10 years earlier, she probably would not have survived. It was thanks to a drug called Herceptin developed in 1998, along with chemotherapy and radiation treatments, that my mom was able to fight the cancer. There was a woman whom my mom often sat next to during her weekly chemo and Herceptin treatments who also had a similar strain of breast cancer. This woman was a nurse from Canada. She had to come to the U.S., and, yes, had to pay exorbitant fees, in order to get the treatment that would ultimately save her life because Health Canada would not allow her the use of Herceptin. So it was thanks to an American drug, developed in America, and used for treatment in America that this Canadian was given the opportunity to fight her cancer.

One strategy that is often used to evaluate the quality of our healthcare more closely is to separate the serious diseases, such as cancer, from those associated with lifestyle choices such as obesity and smoking related diseases. Gary Becker in The Becker-Posner Blog, examines an unpublished study by Samuel Preston and Jessica Ho of the University of Pennsylvania that compares mortality rates for breast and prostate cancer:

Preston and Hu show that this more aggressive detection and treatment were
apparently effective in producing a better bottom line since death rates from
breast and prostate cancer declined during the past 20 years by much more in the US than in 15 comparison countries of Europe and Japan. US death rate rates from
prostate cancer went from about 7% above those of the comparison countries in
1990 to over 20 % below the average of these other countries in recent years, or
almost a 30% greater fall in US rates. American death rates from breast cancer
declined from about 10% above the average of these other countries in 1990 to
slightly lower.

This would actually indicate that the U.S. is in fact, at least with regards to serious diseases such as breast and prostate cancer, performing quite well in treating diseases. So why is our life expectancy so much lower if it seems the U.S. should be more than competant enough to treat disease and illness? The next step is to look at what brings that number lower which it would seem is largely a result of life style choices, and fixing these problems could actually be an effective way in controlling much of the runaway costs of the U.S. system.

Healthcare Debate

This is a post from another blog I have, DiscussNotArgue, and though it doesn't fit into the chronology I think it does fit with the spirit of One Dimension of looking at the facts and arguments of both sides to come to a non-partisan solution in the middle. As the big debate right now is Healthcare in the United States, it is the subject that's really caught my attention. So as I've been sifting through information during my free time, this is what I've come up with:

Healthcare, Curing the Disease not the Symptoms; Pt. 1: Crunching the Numbers
It seems as if these days politics has become a competition in fear. Rather than who can come up with the best and most comprehensive solutions, it is about which side can scare the public enough into believing that they need to somehow be protected from the other side. This strategy is very effective as a distraction from the causes of what it is we are meant to fear as well as what the proposed solutions are. Obama points to this problem very directly in his recent town hall meeting in Colorado, "whenever America has set about solving our toughest problems, there have always been those who've sought to preserve the status quo by scaring the American people." In the recent past, it was the right claiming that Democrats couldn't keep America safe, another example is when during the 2008 election it was that we needed a change it was the policies of the Bush administration that was the cause of the entire financial collapse. And so the trend continues during the current healthcare reform debate. From one side we hear about death panels and Obama's secret Marxist ambitions. Alternatively, the flip side of the debate presents fear through a sense of urgency. This can be seen in Obama's own words: "because for all the scare tactics out there, what's truly scary is if we don't do anything." The idea of this is that we have a big problem on our hands so something needs to be done as quickly as possible, the underlying implication being that it doesn't really matter what that may be. What both of these arguments do is to shift the debate away from what are the causes of our problems and as a result we get a treatment for the symptoms, or no treatment at all, rather than a cure for the actual disease.

There is no denying, by anyone in the debate really, what the problems are that the United States healthcare system faces. The numbers are pretty clear: Americans pay more, fewer are covered, and the results are worse than in any other developed nation in the world. But what is the cause of such a bad performance in the country that is supposed to be leading the rest of the world? A good place to start, I believe, is to first look at where the numbers come from and then figure out why they are the way the are particularly in comparison to other countries.
One of the more shocking numbers is the number of uninsured in the United States, somewhere between 40 and 50 million people, nearly as big as the populations of Canada and Australia combined. However, according to the Census Bureau, in 2007, 18 million of the uninsured lived in households with annual incomes of $50,000 or more and an additional 14 million uninsured adults qualified for government health care programs in 2004. This means that somewhere around 70% of the uninsured population in the U.S. could be covered but have chosen not to. So the largest contributor to the problem of the massive amount uninsured is not necessarily affordability or lack of government presence. One contributing factor to these statistics are those people that are young and healthy and so choose not to pay for health insurance as they don't believe they need it. In fact, in 2007 there were 18 million people between the ages of 18 and 35 without health insurance (unfortunately I couldn't find information on what income bracket this group fits into, but for the sake of an educated case let's say 70%, taken from above, could be covered, which comes out to 12.6 million). It's often mentioned in the health care debate that if everyone or at least more people were included in the U.S. health care system, it would bring down costs, and though this may not be true of those with pre-existing conditions, at least for this group of presumably healthy 18-35 year olds it is, especially because if one of these individuals is suddenly met with an emergency, the burden really falls on those who have been contributing, an unfortunate situation that could be avoided if they had already been contributing to the insurance pool.

So looking at these numbers, it seems as if there are three issues that need resolving. The first is to deal with that 30% of people who can't afford nor qualify for coverage. This can be dealt with through a combination of bringing down costs, expanding Medicaid coverage, and tax cuts/rebates to make it more affordable. Second would be to bring in the people that either can afford their own or qualify for government coverage. And third, a large number of these uninsured have probably been denied coverage as a result of preexisting conditions, even though they may be able to afford a standard insurance plan. One possible solution for both of these problems is to take a page from the Australian system. In Australia, they use a combination of community rating, which helps to get rid of discrimination against the sick and elderly, and tax incentives for those who have insurance when they're young and healthy. Australia's system increases the surcharge on Medicaid by 1.5 percent each year if you make more than $50,000 per year and don't have private insurance. John Hempton in his blog Bronte Capital offers a detailed description of the Australian system as well as how it applies to the situation in the U.S. Hempton explains that this strategy brings in those who otherwise wouldn't get insurance (or collects revenue from those who don't) as well as saves on the legal and administration costs of denying coverage which, he says, account for 10 percent of costs in America.

There is another statistic that deserves some attention, one that Obama has put a lot of focus on, that 14,000 Americans lose their insurance each day. I think this figure can be a little misleading though and falls in line with the fear strategy. It's important to note that the census actually recorded that the total number of uninsured declined by nearly 1.5 million in 2007 from the previous year and the proportion of people without any health insurance actually fell by a full percentage point from a decade earlier, from 16.3 percent in 1998 to 15.3 in 2007. In addition, the Congressional Budget Office estimated that in 2002 the people who had been uninsured for a year or more was between 21 and 31 million. This means that 10 to 30 million were only temporarily without insurance. So how to account for the 14,000 Americans who lose their insurance each day? The figure itself is misleading because more Americans as opposed to less are being covered each year. It seems safe to assume that many of these people are losing their coverage as a result of either losing their jobs, changing jobs, or moving to a different state. A couple options to solve these problems would be to provide similar and equal tax incentives for individual coverage as there is for employee coverage. In fact, one of the arguments President Obama has used in favor of the public option portion of the health care reform is that it creates a portable alternative that you could keep no matter where you lived or where you worked. If this is one of the President's goals, one which he seems to think is part of the solution to our healthcare woes, why not encourage rather than penalize people for getting their own insurance, which they could take from job to job and state to state?

I think that when you take a look at the numbers the problem of health insurance coverage in the United States is more than just a problem of insurance companies being bullies and not offering competitive prices or Americans simply not having access to affordable care. Why not try and address these individual problems, such as bringing in those that simply choose not to get insurance or those that lose coverage while inbetween jobs, rather than considering the whole system a failure. That's what we would do if we had a universal health care system; it wouldn't be scrapped if it proved to be ineffective. What I want to write about next is another issue that people seem ready to dump the blame onto the failure of the free market: higher costs for seemingly lower quality care. To examine that, you have to look at why the American system seems to get worse results and how that is reflected in costs.

Sources:
National Center for Policy Analysis: Crisis of the Uninsured: 2008
Bronte Capital: Health Care Reform and single payer- an Australian perspective
Census: U.S. Census Bureau
Obama's Grand Junction Townhall transcript

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