First, I notice that your FIRST premise for this conversation was “cost control.” How can we have costs before we have a program? In my view the first step has to be describing the kind of health care system America wants. Is it one where wealthy people obtain the world’s best coverage, while millions go unserved? Is it one where fundamental medical decisions are made by neither doctors nor patients but self-interested third parties? Is it one where 1/3 of all health expenditures go to managers and shareholders? I assume the answers are no, of course.

This is not mere sophistry: If we approach health outcomes from a primarily (or exclusively!) economic perspective we will inevitably find ourselves putting dollars and cents on people’s lives and welfare. A system that begins with healthy outcomes does not put a price on everything; it prioritizes outcomes but on a health, not economic, basis.

Or, from a slightly different perspective, I would say that a public system will see expanding overhead eating away at health budgets when administrators are doing a poor job; for-profit providers and insurers will see their own expanding overhead eating health budgets when they are successful at enhancing their revenue and profits. In one case, diversion of health money to administrators is a mistake (transparent and correctable by taxpayers), and in the other it is the purpose (hidden and encouraged by managers and shareholders). This is why a public option is necessary and a public system will inevitably outperform the present system in BOTH outcomes and costs.

Second, you quote your colleague: “as Bala Ambati mentions on his blog, Daylight’s Mark, the U.S. has larger minority populations than many European countries riddled with issues well known to compromise health outcomes (poverty, increased crime, higher risk of death by homicide to name a few).”

This is commonly repeated but essentially false information. There is no support whatsoever for the alleged connection between the US minority groups and health outcomes. First, Canada, France, and Germany all have public health systems with superior outcomes and similar proportions of immigrants (Canada has substantially more than the US). Second, it is obviously the social inequality and poverty of these groups that is the problem, not their ethnicity: there is a correlation, but the causation Ambati and others conclude is entirely false.

The presence of minorities is an *excuse*, not a reason. It’s factually incorrect and racist and should not be repeated by reasonable people, in my view. Ditto goes for America’s murder rate—while Americans do kill each other with remarkable regularity (3x as frequently per capita as we Canadians, for example) that shocking figure is still insignificantly small compared to the overall number of deaths and does NOT warp the national statistics. Americans die younger than Canadians not because of guns, but because they eat too many big macs and maybe 10% have no health coverage at all. Show me any country where 10% of citizens have no health care, and I will show you a country with worse outcomes than Canada, no matter how many people carry guns (and PS per capita gun ownership is higher in Canada than the US, little known fact).

The evidence is clear that most wealthy western nations obtain as good or better outcomes with a smaller investment as a proportion of GDP. Americans pay more and get less, and that is the problem the US needs to solve; making spurious (and racist) excuses for the data is not going to be helpful. Americans deserve the best care, and they don’t get it, and one of the main things stopping them is their firm but mistaken belief that their system is “the best in the world.” It’s not. It *includes* the best health care in the world, but that’s not the health care that most in the system get. Overall, Americans are being ripped off, period. They should be mad as hell about the coverage they are getting, and instead they are fighting to keep it!?

Finally, re: Tort reform. Since most people don’t know someone who has been crippled or killed in surgery, this is a no-brainer from a political perspective, but from a practical perspective, I believe TOTAL costs from lawsuits and payouts is less than 1% of system costs—hardly a dent! Again, this is an easy target to pick on, and indeed as a Canadian lawyer I agree the US remedies system is way out of whack in all domains, not just malpractice, but imagining that this is a significant or even necessary plank in an overall health package is in my view disingenuous. It also requires substantial reform of the entire legal system including the throwing out of years of precedent, so even if I am wrong about the figures I think I am right about not linking the health care wagon to judicial reform, which is not on the American political agenda at all. One of those carts will be heavy enough to push all by itself.

Thanks again for your post and for your thoughtful responses to readers’ comments. I think your comments on overuse are bang on, in particular in identifying the dual doctor/patient nature of the overuse problem. Patients are usually motivated by ignorance, whereas doctors are usually motivated by inappropriate economic incentives (from pharma, for example). Preventative medicine even more so: in a health system making choices based on health outcomes, the low cost preventative approach makes public choices (like eating too many big macs) that are currently considered “private.” If an epidemic of diabetes is a public health problem, then big macs are a public health problem; ONLY a public system can ever recognize and deal with this and other fundamental drivers of health outcomes.

G

This is a moral issue and that is why there is not another industrialized country in the World that has given private health insurers such latitude in running its health care system. Citizens in other countries can see a doctor (not just the ER) even if they don’t have money, or have a pre-existing condition. Even those countries that provide a place at the table for private insurers only do so with regulations no insurance company in America will every tolerate. Regulations that no Congress will ever impose in the face of lobbyists throwing money at their campaigns.

We can debate the merits of reforming the private system while tens of millions of our citizens die because they have no insurance, or go bankrupt because they cannot pay the bills. It says something about the moral makeup of a country that is the richest in the world, yet cannot provide basic care to all citizens.

I understand these are complex questions, but please, other countries have systems that provide care to everyone. We can argue about whether their systems are as good as ours, but if you cannot gain access to health care (not just the ER), it really does not matter the degree of difference. Private health insurance is unsustainable, and if you have children, it should scare you to death that they will be forced into such an inhumane system.

I feel so lucky because my internist acts as if he has plenty of time to talk with me. i think the reason for this is that he is a high-level, highly-paid hospital executive and practices part-time.

Re: pricing of tests:

They are totally opaque to doctors as well as patients. They depend on which insurance you have, or don’t have. How is that reasonable?!

I am months late in responding to this. I’ve just discovered your site. Apologies for being late; I can’t wait to see the rest of the site.

By way of background, I recently (July ‘09) got on the patient list of a wonderful PCP who works for a medical school. It took > three months to do so and my PCP would never have accepted me as a patient were it not for her friendship with someone we mutually know. She is overloaded with patients, utterly overwhelmed. She sends me emails at 10 PM to volunteer to get me lab test scripts, but she cannot see me unless I somehow figure out how to break a bone with at least two month’s advance notice.

All my doctors now work at the same medical school. If I understand this correctly, that means they get paid a salary and don’t get paid for ordering extra tests. I’ve never had so many damn tests in my life! Is it possible that because they don’t have to worry about what insurance companies will reimburse them that they actually order more tests than a doctor in private practice? Just asking.

I am appalled at the medical care I get—I guess I grew up in an era where your local doctor was the go-to-guy or gal if you broke a wrist or a rib. I can’t do that today. The ER has become my de facto PCP. I have insurance. $710/mo insurance and it is not widely accepted because my plan reimburses at Medicaid rates. It comes with a high deductible and high out-of-pocket limit. It also comes with the nightmare condition that BCBS can cancel my insurance immediately if I am ever late on a single premium payment. They’ve done it once when a December 2004 check was “never received.” I was perfectly healthy at the time, so the caller told me I could be re-enrolled, but my premium would be hiked 20%. After the medical problems I have had this year (minor, but they lost money on me) I know I won’t be offered that option again should another payment miss by a day.

I’ve learned the hard way never to go to the ER by asking a friend to drive you. It’s farcical, but calling 911 and arriving in an ambulance means you will be seen in minutes and not ten hours, as happened the last time I made that mistake.

This system is not working. It can’t possibly be a good use of ER doctors and staff to mend slightly-fractured bones. It can’t be a good use of our (hey, tax-payer-funded) ambulance services to drive people who are not seriously ill to ERs.

Next, the paperwork and the faxing. Both have to stop. Every time I see any doctor at this school, I need to allocate 30 minutes to the paperwork. They are so afraid of a lawsuit, they print out 40 labels every visit and then affix them to multiple duplicate copies of forms that will help them avoid lawsuits. They routinely ask each other (in late 2009) to fax reports. Is the medical community unaware of the power of, say, the PDF file format and the existence of email?

Finally, we need more PCPs and walk-in-clinics staffed by P.A.s or RPNs. We need so many more of these. I don’t think the folks who are writing this bill have any clue about that. They of course have the best health insurance in the world and probably schedule appointments with their PCPs when they sneeze.

1—US dollars per capita is very misleading because all other countries you compare yourself to have coverage for 100% of population. 50+% of Americans declaring bankruptcy due to health expenses have coverage of some sort. I have never seen statistics showing % of Americans with partial coverage or caps to coverage.

2—It isn’t just the profit of the private insurers that is an expense above that of a public system. Public insurance systems don’t employ people to reject claims or people to check when coverage limits have been reached or people to reject applicants. Canadian doctors don’t have to sort out which insurer to bill or to receive permission from or worry about whether this is a collectable account.

3—Because of single payer, fraud is less.

4—Technical innovation is a double-edged sword. I read that there is resistance in the US to new recommendations on mammogram testing for women under 50. These recommendations have been the Canadian standard for years. Not because we can’t afford US standards but because in women under 50 without a family history of breast cancer the false positives outweigh the benefits. MRIs are wonderful machines but the average human body is riddled with blebs and blobs that require further and more invasive and expensive examination.

5—Canadian system is not really single payer. The federal government gives each province a per capita sum based on population which is inadequate to provide health care to a federal standard. The shortfall is made up from provincial resources. Thus we have 12 health providers from which to derive a “best practices” check. And, of course, 12 different standards of health care though certainly less than that between Wisconsin and Louisiana.

6—I am happy with the health care I get for my $624 annual fee. Are you?