Let’s talk about healthcare. It’s one of those topics that seems to bring out the worst in us. So let's ask and answer some common questions related to it.
" Healthcare is a right; there should be a single payer, Medicare for All!"
We might all agree that treatment for an injury or illness is a basic right in our society. We might also agree that food and shelter are basic rights as well. The issue though is that even basic rights have a cost that has to be paid by someone. We'll address the cost issue later. Right now, I want to discuss illness as illness is the compelling reason for having a healthcare, really a treatment, system. With very, very rare exception, all babies are born with everything in place and working as designed. Illness, therefore, is the result of how we behave, how we take care of or abuse our bodies and minds. There are congenital illnesses but the overwhelming majority of medical problems, my safe guess is 99+%, are secondary, meaning that machinery is OK, it's how we’re treating the machinery that causes the problem. An example might be a knee. The knee joint itself is fine but if we ask it to carry an extra fifty pounds for twenty or thirty years, it gives out and we need surgery to repair or, today, to replace it. Another is the pancreas. It produces insulin so that we can regulate our blood sugar. It's doing a bang-up job until we ask it to handle a half dozen Dunkin' Donuts each morning and follow that up with hundreds upon hundreds of grams of carbohydrates and probably little to no exercise. Add a few drinks of alcohol and we now have Type II diabetes. How about asthma. People are born with that. True but if you smoke cigarettes like 25% of asthmatic do, your asthma will be a lot worse.
You get the picture and these are only a few of the myriad of secondary illnesses that clog our healthcare system every day. What I really love is the modern use of acronyms to describe symptoms and side effects as actual diagnoses. OIC, opioid induced constipation, is one of these. Constipation is a side effect of the drug, not a symptom of an illness. I'm waiting for ACI, alcohol caused intoxication, or AIDM, antihistamine induced dry mouth. Just silly but in keeping with our near obsession with identifying and treating symptoms instead of changing our behavior. Drugs have side effects which are now identified as treatable symptoms, treated with other drugs that have side effects and so on. Kinda like a gerbil on a wheel.
A very interesting study by a very interesting physician, Wayne Katon, found that 50-70% of all visits to a primary care physician (PCP) were for complaints, symptoms, for which there was no medical diagnosis. Let that sink in. At least half of the millions and millions of office visits each year in the U.S. present problems that can't be linked to a diagnosable illness. But that doesn't stop providers from treating them, first with expensive and unproductive tests and then with expensive medications of very questionable efficacy, most of which are prescribed indefinitely. Among the most prescribed drugs in the U.S. are antidepressants, insulin, opioids, anti-anxiety agents, anti-hypertensives and statins. These drugs are all related to lifestyle issues like overweight and emotional stress.
So, is healthcare a right when the problems are directly related to behavior or when they are not linked to a diagnosable condition or illness? We're not talking about Type I diabetes or BRCA gene breast cancer. We're talking about COPD after decades of smoking cigarettes, Type II diabetes fueled by carbohydrate-laden diets and overweight/obesity that stresses every joint and organ in the body. Add alcohol to the mix and we account for the vast majority of all medical problems.
"Health insurance costs too much. It's those greedy, profit-oriented insurance companies."
Bernie Sanders and others are fond of extolling the virtues of Medicare as the panacea for our problems in healthcare in the United States. What most people don't realize is that Medicare does not pay the full cost of covered services. In reality, it pays for about 80% of the real cost of care. This should not be confused with the percentage that Medicare pays for office visits which is coincidentally 80% and which is often combined with a supplement to make up the other 20% so that the patient has no out of pocket expense. No, the 80% I'm talking about is the sometimes astronomical cost of care in hospitals. So, if Medicare only pays 80%, who pays the other 20%? Blue Cross and Blue Shield and other commercial insurers, that's who. When I was working at Blue Cross of Rhode Island in 2012, approximately $2,000 out of the $10,000 average family premium did not go to pay for the insured families' care, it subsidized the shortfall from Medicare, Medicaid and the uninsured. The State of RI even levied a healthcare tax on the commercial insurers on top of those subsidies. Good deal for the State but not such a good deal for those with commercial insurance.
In addition to the fact that government health insurance pays a discounted rate, they also use the networks established and managed by the commercial insurers so they do not have the overhead associated with regulating providers. One of my first recollections of working at Blue Cross was realizing that thousands of square feet of office space were devoted to meeting the regulatory requirements of government agencies, including Medicare. The point is that without commercial insurance, the Blue Crosses, the Uniteds, the AETNAs, etc., Medicare and Medicaid costs would skyrocket. And you need to factor the additional expense of OB/GYN and pediatrics which don't exist today in Medicare. Medicare fraud is estimated at $50-60B a year but that is only an estimate and is probably much greater. Do you know any government program, state or federal, that is not rife with abuse?
"Medicare for All"
At Blue Cross of RI, we used to ask what could be done to reduce healthcare costs. As 87% of the premium dollar was paying claims and 3% went to reserves, there really wasn't much to save on the administrative side. Providers, including hospital systems, were addressing the issue as well. At one point in a large gathering of executives, I asked our CEO: if we're able to cut healthcare costs by 10%, who gets paid less? Guess what? There was no answer. Nobody ever volunteers to get paid less. Almost everyone inside healthcare thinks they are not being paid enough. And efforts to reduce costs, like managing care or improving "quality" always seem to increase them. Remember when Obamacare was going to lower premiums? They not only did not go down, they went up almost exponentially. Putting the federal, or any government, in charge of healthcare will increase cost and lower quality in my opinion. Remember your last visit to the DMV, any DMV, or telephone call to Social Security. As a provider, any contact with Medicare is like shouting into the darkness. Do you really think it would be different if all healthcare were administered by Medicare? I don't.
Bernie Sanders and others talk as if the only problem in healthcare is access. If anything, we overuse services a la Dr. Katon. The real problems in healthcare occur in the medical offices, the hospital rooms and the pharmacies. The single largest category of illness is called "iatrogenic". Iatrogenic means "treatment caused". It was true in the time of Hippocrates and it's true today. The private sector, even with a profit motive, is far more capable of producing effectiveness and efficiency than any government. My opinion. What's yours?