The Great Healthcare Debate
Aug. 30th, 2009 03:44 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
firebyrdHealthcare in the U.S. is without a doubt a mess. I've been reading every single post on my friends list relating to it with great interest from both sides of the fence and have been thinking a great deal on the matter. Unfortunately, there is no easy answer to the numerous problems besetting us and I do not think the proposals underway are going to answer many, if any of them in a successful manner. I wish I had links to my sources, but I began mulling this over months ago and it didn't occur to me to save them. And I'm afraid I just don't have it in me to read thousands of pages of legalese and try to make sense of it, so I'm relying on summaries written by others (including one from Obama's webpage, I might add).
Healthcare costs are soaring, and why? When I was a kid, we had no insurance, and it wasn't a big deal. My dad was making a very decent living (though he spent it so unwisely, in many ways it didn't seem that way), but it wasn't just that. Healthcare just wasn't so insane. Why the change in just twenty years or so?
First, there's the malpractice insurance issue. There's something very, very broken here. Costs are skyrocketing, but it isn't just because we're a litigious society. One of the many sources long since lost to the depths of the internet noted that OB/GYNs have a much lower rate of malpractice suits than average, however, it's well known that the rapidly rising and crippling costs are driving these specialists to move or get out of the business entirely. I don't know what's going on in the business portion of things here, but tort reform is one way of controlling costs that needs to come about. Medical malpractice is an infuriating thing, but having the misfortune of a doctor that deliberately did not treat you right isn't a reason to be set up for life either. And chronic misusers of the system should not be allowed to file suit after frivolous suit. Let's save this stuff for when someone has died or had serious repercussions and leave things like a doctor telling you to put hydrogen peroxide on a wound (which actually is very bad and kills the cells that will help close it up and heal it) to medical boards to determine if a doctor is fit to continue to practice. Additionally, more mediation systems seem warranted, as the various clinics around here claim that they've lowered costs tremendously, but I haven't heard anyone crying foul about them from the patients' perspective.
Secondly, there's drugs. There is so much wrong with this industry it makes me sick. First and foremost the marketing has got to go. A box of samples with pamplets and drug inserts sent to a doctor sounds fine (as that allows a patient to try the medication for themselves before paying an arm and a leg for it), but what actually happens? The ads on tv and in magazines, the wining and dining of doctors, and so on and so forth needs to come to a complete stop. Patients should not be suggesting to their doctors that they try random medications because of some commercial they saw during American Idol and doctors should not be opening themselves in any way to bias due to drug reps. No marketing means millions or billions of dollars saved by the industry, and thus lowers the cost of the meds being produced.
There are other problems with pharmaceuticals. While we need something to make sure that no one is selling drugs that are going to kill the general populace, the processes the FDA goes through seem extremely screwed up. Just look at the recent Tylenol debacle. Rather than simply educating people about how dangerous overdoses can be and requiring clear labeling so that people can easily surmise that acetaminophen is in a product and how much, the committee proposed a complete ban. Yet on the other hand, various pharmaceuticals that have been in safe use for years or even decades in Canada and the EU are refused approval. Either way, it costs countless millions for every drug submitted, which promotes greed as companies feel they have to squeeze every last cent possible from each discovery to make it worth the cost of approval. This leads to the problems with fighting against generics and submitting basically the same drug with just enough changes to be classified as a different one for approval (as that reduces development costs a ton). That's why I was able to switch from Lexapro to Celexa for my PPD-they're very, very close to the same thing, but Celexa has a generic and Lexapro does not. This is all messed up. We need to be sharing information with other countries that have high standards as far as approving things. Why should a drug have to be approved over and over again in every area it goes to market in?
Better international efficiency in this is essential for yet another reason. Many other countries have regulations dictating drug costs to the consumer. The U.S. does not. Guess what happens then? Prices get raised here to make up for having to take losses elsewhere. That's what always happens when there's a tariff or regulation affecting cost in one place and not another, which is why some people argue against free trade. If we can save money elsewhere, such as approval costs, it would hopefully be possible lower costs here without such development-squashing regulation.
Next up is of course insurance companies. I don't agree with Obama's proposal that everyone pay the same regardless of health in our current system. Insurance doesn't work that way. If you smoke or sky-dive, your life insurance costs more. If you have a history of causing car accidents while driving a vehicle, your auto insurance goes up. I would be comfortable with some sort of formula that would allow an insurance to only charge a set amount more based on a person's health and what the problem is, but someone who does everything right and does not put a burden on the system just shouldn't have to pay as much. There obviously has to be a limit, because plenty of problems are just bad genetic luck or due to the toxicity of our environment (case study: me), but someone who smokes a pack a day or drinks enough to fubar their liver puts a strain on the system due to their choices.
Something has got to be done about the system that has formed, though. Now, the stereotype that all insurance companies are greedy bastards that refuse to pay for anything is not true of all companies. Some of them are terrible, but some of them are wonderful for the most part. For example, the BC/BS PPO we belong to through [shipping company] have denied exactly two claims once processed correctly despite my laundry list of problems and procedures done related to them. One was a stupid hearing test that was done to Enoch at the hospital, required by state law, and the other was Bea's homebirth thanks to the wonderful actions of certain medical associations and doctors (but that's something I'll get into later). Everything else, labs, MRIs, surgery, you name it, it's been covered. At the same time, they are expanding coverage, such as now covering non-pill methods of birth control, and they are doing exactly the sort of preventative care measures the administration wants to see. They even send a check to cover the copay of the first preventative care visit each person in the family receives each year, they allow for multiple preventative care visits for those with chronic illnesses such as diabetes, and they have programs set up to help with the control and maintenance of the top chronic diseases like heart disease and again diabetes.
At the same time, though, the numbers are pretty screwed up. I have in front of me a bill for labwork. The total charge is $1762.05. The insurance discount is $1540.03. Then the insurance paid a mere $177.67 and what was left for me to pay was $44.35. W. T. F? Why does 87% of the bill disappear into Never-Never Land because the insurance says so? If it costs $1700 to run the tests, then that should be the cost for anyone. If it doesn't cost that much to run them, then that number should not be anywhere. This is the sort of thing where the transparency talked about /has/ to happen. I know some people are able to negotiate lower prices than listed when it comes to doctors visits when they pay cash, but I think that is likely going the way of the dodo with the rise of the megaclinics. I'm just guessing there, but the inflexibility and bureaucracy in the megaclinic I go to doesn't seem like it would allow any sort of negotiation at all.
Unfortunately, the system as currently implemented is funneling things into those megaclinics. Where once doctors would set up their own small practices or partnerships, costs on their ends have spiraled out of control. There are the malpractice insurance costs as previously noted. The real estate market bubble created problems with buying or leasing an office. There are the incredibly expensive self employment taxes. Then you also have to pay for office people. Billing is incredibly complex due in part to some pretty harsh regulations required of insurance companies (a comment on a blog I came across recently noted that if a claim comes in with an O in place of a 0, by law, they have to reject it. They can't fix the obvious mistake, they have to reject it, which leads to more work on the end of the doctor's staff as well as the patient) and in part to...I don't know. I don't know why there are so many different plans that have few or no differences, so I can't comment further on that issue. Add that into schooling costs (another issue I believe I'll go into later), and it's really not as easy to make a living as a doctor, particularly on your own, as people believe it is.
Maternity care is another huge problem in this country. Some insurance won't cover it at all (another WTF issue). At the same time, costs are skyrocketing thanks to treatment that bases decisions on fear and acting as if pregnancy is a disease. The c-section rate in 2006 was 32% where the World Health Organization notes that it should not be medically necessary more than 10-15% of the time. A recent statistic I read noted that it was either 80% or 90% of women in Utah have inducing drugs such a Pitocin during at least some of their labor, which is absolutely insane. Our society's culture and the medical industry both are failing women, as interventions are not needed anywhere near as often as they are tried. Interestingly enough, the simple presence of a doula to help advocate for a woman when she is not in a position to rationally consider options herself (I can't remember the number, but it was shockingly high. 30-something percent, I think?) reduces the number of interventions in birth while still allowing good outcomes. When considering outcomes here as opposed to other countries, you find there tends to be much more reliance on midwifery in many, if not most, of the countries that have the best numbers. OB/GYNs are absolutely necessary, but their training biases them towards interventions that are not appropriate in the average labor. The costs rise both because of the price of the interventions and because of the price of the doctor. While I in no way think everyone should emulate me (though given the difference in my experiences, I can't imagine why someone would want to be in a hospital if not medically necessary-at least go to a birthing center!), we need to move away from the cultural bias towards midwifery started by doctors early in the 20th century to drum up business.
Now, what does Obama want to do and why won't it work?
First up, the insurance model as practiced here started up due to companies trying to attract workers without paying higher wages (I believe this was after WWII). They still don't want to pay more wages. So what's going to happen if Obama's proposal of every large employer having to provide x benefits or pay towards the public system passes? Every employer is either going to drop their benefits to the lowest allowable or drop insurance entirely and pay the required money to the public system, whichever ends up by being cheaper in their books. But they're certainly not going to raise wages to make up for the difference in the case of those who end up with far inferior care (which I daresay I would, which I don't disagree is selfish, but I don't need my hellish life and health to get worse due to lack of coverage). This is going to put a huge strain on the public system that was not anticipated, because that's what always happens (see: Hawaii). The money paid towards the system by employers will not be enough, because it will again spiral. The insurance companies, due to less business, will have layoffs, putting more strain on the system, not just in healthcare, but unemployment and the like. A half-baked measure like this will cause problems because it's based on only some people being on public healthcare, which history has shown in this country is not how things last. These things always cost way more than people plan, which leads to more deficits and/or higher taxes. Additionally, the tax burden is already so high in this country for businesses, one of the highest in the world, it will lead to more large companies to move elsewhere, as has been happening for a number of years now.
Other parts of the plan just won't work for a variety of issues. The costs of the public plan will go up due to illegal immigration, just as that affects healthcare costs now. Our immigration system is, in a word, stupid, but no one ever suggests what needs to be done to fix it-lift the restrictions, not make more of them! If someone can pass a background check that proves they're not a violent criminal (rape, murder, and the like as opposed the Jean Valjean sorts of crimes), they should be able to become legal residents of the U.S., and if they don't bother to go through that single step, enforce laws kicking them out. Not amnesty, but just something in place to protect the citizens here from being subject to more rabid dogs in human form. That would allow people to be hired legally, and thus be contributing to the system in the form of taxes like the rest of us, while fostering better integration that will keep them from being terrified of going for help for minor issues (of any type, not just healthcare) lest they get deported. That in turn will improve elementary schools so ones in immigrant-dense areas can focus on essentials in addition to language skills instead of English as a second language being the king of all subjects.
Another cultural problem is that of preventative care. The default socialization, particularly in men, is to refuse to go to the doctor unless there's a missing limb, someone is bleeding to death, or someone is in a coma. Most people don't want to go to the doctor. I'm no exception. If someone in the family has the sniffles, I have no desire to haul two kids under the age of three to a waiting room full of sick people (so if they're not sick already, they're going to be), wait for ages in the waiting room, then go back and wait for ages in an exam room while trying to keep them out of stuff for a doctor to breeze in, look at the sick individual for two minutes, say it's a cold, and sweep out again for a total time of maybe five minutes with us. It doesn't matter if preventative care works-the majority of us dread the crap that comes from going to the doctor, so we don't want to do it unless something seems serious. It's not just the money-it was all I could do to get Eric to get his toe checked out when it got squished by a very heavy metal object at work once, and that was covered by worker's comp!
Now, even if we were able to wave a magic wand and change our socialization, we would be faced with another issue-doctor shortages. There's already a huge lack of health providers in general, and doctors specifically in many areas. If everyone started going in like they're supposed to, general practitioners, family doctors, and pediatricians would be overwhelmed. However, even less people would go into these specialties, because aside from the lack of accolades, many if not most people would be on the public system (as discussed earlier), which would lead to poor wages.
Yes, doctors would be getting paid very little if the public system were king, because they already do with the public system. That's right, Medicare, Medicaid, the VA, Tricare, and the like pay crap. If there hadn't for people paying cash or having other insurance, I don't think the chiropractor I worked for could have even stayed in business. As I recall, he only got a few dollars per Medicaid patients, and only slightly more for Medicare. Tricare didn't cover it at all. That's why so many doctors refuse to see patients on these programs even now.
People aren't going to become general practitioners if that's what they have to look forward to, in part because of the rapidly rising tuition costs at the university level. No one seems to know why costs are increasing the way they are, but it's crazy. It's not just lack of funding, as private tuition is rising too, though not quite as much. At the same time, universities are increasingly eliminating tenure track positions and instead hiring adjuncts that they pay very little money and provide no benefits to. The cost for the university I live by increases by about 15% /every year/. It's even worse for post-grad and professional schools. With the kind of debt load a person takes on for tuition and living during classes and later residencies and internships, they just won't be able to afford to go into general practice or become doctors out of the desire to help people if they can expect to be crippled with tens or hundreds of thousands of dollars worth of debt before they even get started.
None of that is even getting into the question of how we're going to pay for the proposed system nor how we can trust the government to actually run it right when their track record is so poor. Obama himself admits that there the savings earned by various of his proposals isn't enough to fund everything. Additionally, at least part of the coverage suggested is supposed to be done by increasing the numbers on Medicare and Medicaid, which are both administered in an absolutely terrible fashion. My mom worked with the disabled for a very long time and the rigmarole they went through in order to get their clients, most of whom were mentally disabled and unable to advocate for themselves, was horrible. Forcing more people to be placed on the mercy of government bureaucrats for their healthcare seems to be unconstitutional as cruel and unusual punishment.
It also makes me very uncomfortable that Obama is proposing a government agency that will help people find and buy health insurance. There's a very obvious bias there that doesn't seem like would actually promote the competition that he claims is the goal.
A huge problem I see with the proposed system and many of the oh-so-vaunted systems in other countries is...what about eyes and teeth? Someone on my friends list in favor of Obama's proposals has talked about a kid who died when he had an untreated cavity turn into a system-wide infection because he didn't want to tell his parents he had a toothache because they didn't have the money for a dentist. The same person has complained about the recent cost of a crown. The care provided by eye and dental insurance in the U.S. is not covered. Not in Canada (as admitted by one of the links provided by the aforementioned friend), not in most of the U.K. (I believe Scottland is the exception, but England most certainly does not-see Robin McKinley's blog for proof of that), and not here. The problems mentioned here would still happen! If a public system does not include those things, you are being fooled. It is not a good system. Good eye and dental health are imperative to overall health, as shown by the tragedy of the boy (even more tragic because, under the current system, if the family had known in time they ought to have been able to find a dentist or group to help them find someone to do it as a charity thing, whereas those on the right on my friends list are claiming there is language that would restrict or forbid charitable work like that in the monstrosity of a bill being considered).
Another thing that isn't covered in many of the systems looked to as a model is prescription drugs. While there are the regulations restricting prices, most of it falls on the consumers. As someone with a chronic illness, let me tell you, the thing that ties us to the [shipping company] job more than anything is the monthly cost of meds. I think it's obvious why this is an essential that needs to be covered.
There are numerous other medical services that should be covered. One of the articles I read said that physical therapy is not covered in Canada. Being able to stay in the hospital longer isn't going to help you much if you don't get the therapy that will allow you to return to your normal life afterwards.
Not everything he's said is bad. Electronic records seem so incredibly obvious I'm horrified that there hasn't been a standard set and a national system set up. A national system of records would make patient treatment far safer and reliable, as it would give every physician they see easy access to the info of what other doctors have done. It would greatly reduce problems currently experienced with giving drugs that counteract each other or have other bad interactions because there would be a clear record detailing what a patient is taking right then rather than putting the burden on patients to give that information correctly. While I believe in personal responsibility, a person who needs to be on many different medication simultaneously will often have genuine issues with their mental capacity in some way or another, either caused by the drugs or by the illness(es) itself. For all that I keep meaning to take all my meds with me or a list of them, I never remember when it comes time, and then I have to rely on my obviously poor memory to correctly tell medical professionals my correct dosages. Not good. If you've got an old person with dementia, obviously the problem gets a lot worse. Because of keeping better track of medications, a national records system would also reduce the number of people successfully faking medical problems in order to get drugs, making it so that a person who genuinely needs them doesn't have to risk jailtime in order to simply get relief from chronic pain.
I certainly agree that the administration costs need to be cut down, but I'm not getting how Obama's suggestions are going to do that. I agree drugs should be allowed to be imported, but I think altering how the FDA works would be a more useful long-term change. Generics should not be blocked or bribed away once drug patents expire. People ought to be able to be eligible for insurance regardless of condition if they're not actively trying to kill their bodies through things like smoking or taking various other drugs in such a way that will damage their body without medical supervision (i.e. heroin or drinking your liver to death is bad has consequences, having problems because of following medical advice such as taking Tylenol in too high of doses would be covered). School lunches are a travesty that absolutely need to be fixed, and there's some anecdotal evidence that doing so could factor into improved performance.
Basically, I have been sold that a system similar to Australia's (very nice public insurance for all plus the possibility of private insurance for better coverage) if it would cover everything I've mentioned-doctors, dentists, physical therapists, optometrists, drugs, that sort of thing. I can see how it could fall under the "life" part of life, liberty, and happiness. I can also see the argument that not having such a system diminishes innovation and entrepreneurship, as my family has become very tied to Eric working for [shipping company] due to my poor health and need for such great insurance. However, Obama's plan is not this. Frankly, I don't think there's any way to make it come about in America without scrapping the system we have altogether. This would be hard at any time, terrible during a recession, and I don't think the citizens, politicians, or businesses in this country are able to plan things in the longterm enough to ever make it come to pass. It wouldn't require just throwing out the health system we have now, but changing how our society views a number of things, how the schooling system works, and how immigration works. I just don't see a clear way to make it happen. I think trying to fix our current system with some of the ideas I've presented here would be a more realistic way to go.
And don't expect me to pull your crushed, broken body out from beneath those bricks of words. I warned you!
Healthcare costs are soaring, and why? When I was a kid, we had no insurance, and it wasn't a big deal. My dad was making a very decent living (though he spent it so unwisely, in many ways it didn't seem that way), but it wasn't just that. Healthcare just wasn't so insane. Why the change in just twenty years or so?
First, there's the malpractice insurance issue. There's something very, very broken here. Costs are skyrocketing, but it isn't just because we're a litigious society. One of the many sources long since lost to the depths of the internet noted that OB/GYNs have a much lower rate of malpractice suits than average, however, it's well known that the rapidly rising and crippling costs are driving these specialists to move or get out of the business entirely. I don't know what's going on in the business portion of things here, but tort reform is one way of controlling costs that needs to come about. Medical malpractice is an infuriating thing, but having the misfortune of a doctor that deliberately did not treat you right isn't a reason to be set up for life either. And chronic misusers of the system should not be allowed to file suit after frivolous suit. Let's save this stuff for when someone has died or had serious repercussions and leave things like a doctor telling you to put hydrogen peroxide on a wound (which actually is very bad and kills the cells that will help close it up and heal it) to medical boards to determine if a doctor is fit to continue to practice. Additionally, more mediation systems seem warranted, as the various clinics around here claim that they've lowered costs tremendously, but I haven't heard anyone crying foul about them from the patients' perspective.
Secondly, there's drugs. There is so much wrong with this industry it makes me sick. First and foremost the marketing has got to go. A box of samples with pamplets and drug inserts sent to a doctor sounds fine (as that allows a patient to try the medication for themselves before paying an arm and a leg for it), but what actually happens? The ads on tv and in magazines, the wining and dining of doctors, and so on and so forth needs to come to a complete stop. Patients should not be suggesting to their doctors that they try random medications because of some commercial they saw during American Idol and doctors should not be opening themselves in any way to bias due to drug reps. No marketing means millions or billions of dollars saved by the industry, and thus lowers the cost of the meds being produced.
There are other problems with pharmaceuticals. While we need something to make sure that no one is selling drugs that are going to kill the general populace, the processes the FDA goes through seem extremely screwed up. Just look at the recent Tylenol debacle. Rather than simply educating people about how dangerous overdoses can be and requiring clear labeling so that people can easily surmise that acetaminophen is in a product and how much, the committee proposed a complete ban. Yet on the other hand, various pharmaceuticals that have been in safe use for years or even decades in Canada and the EU are refused approval. Either way, it costs countless millions for every drug submitted, which promotes greed as companies feel they have to squeeze every last cent possible from each discovery to make it worth the cost of approval. This leads to the problems with fighting against generics and submitting basically the same drug with just enough changes to be classified as a different one for approval (as that reduces development costs a ton). That's why I was able to switch from Lexapro to Celexa for my PPD-they're very, very close to the same thing, but Celexa has a generic and Lexapro does not. This is all messed up. We need to be sharing information with other countries that have high standards as far as approving things. Why should a drug have to be approved over and over again in every area it goes to market in?
Better international efficiency in this is essential for yet another reason. Many other countries have regulations dictating drug costs to the consumer. The U.S. does not. Guess what happens then? Prices get raised here to make up for having to take losses elsewhere. That's what always happens when there's a tariff or regulation affecting cost in one place and not another, which is why some people argue against free trade. If we can save money elsewhere, such as approval costs, it would hopefully be possible lower costs here without such development-squashing regulation.
Next up is of course insurance companies. I don't agree with Obama's proposal that everyone pay the same regardless of health in our current system. Insurance doesn't work that way. If you smoke or sky-dive, your life insurance costs more. If you have a history of causing car accidents while driving a vehicle, your auto insurance goes up. I would be comfortable with some sort of formula that would allow an insurance to only charge a set amount more based on a person's health and what the problem is, but someone who does everything right and does not put a burden on the system just shouldn't have to pay as much. There obviously has to be a limit, because plenty of problems are just bad genetic luck or due to the toxicity of our environment (case study: me), but someone who smokes a pack a day or drinks enough to fubar their liver puts a strain on the system due to their choices.
Something has got to be done about the system that has formed, though. Now, the stereotype that all insurance companies are greedy bastards that refuse to pay for anything is not true of all companies. Some of them are terrible, but some of them are wonderful for the most part. For example, the BC/BS PPO we belong to through [shipping company] have denied exactly two claims once processed correctly despite my laundry list of problems and procedures done related to them. One was a stupid hearing test that was done to Enoch at the hospital, required by state law, and the other was Bea's homebirth thanks to the wonderful actions of certain medical associations and doctors (but that's something I'll get into later). Everything else, labs, MRIs, surgery, you name it, it's been covered. At the same time, they are expanding coverage, such as now covering non-pill methods of birth control, and they are doing exactly the sort of preventative care measures the administration wants to see. They even send a check to cover the copay of the first preventative care visit each person in the family receives each year, they allow for multiple preventative care visits for those with chronic illnesses such as diabetes, and they have programs set up to help with the control and maintenance of the top chronic diseases like heart disease and again diabetes.
At the same time, though, the numbers are pretty screwed up. I have in front of me a bill for labwork. The total charge is $1762.05. The insurance discount is $1540.03. Then the insurance paid a mere $177.67 and what was left for me to pay was $44.35. W. T. F? Why does 87% of the bill disappear into Never-Never Land because the insurance says so? If it costs $1700 to run the tests, then that should be the cost for anyone. If it doesn't cost that much to run them, then that number should not be anywhere. This is the sort of thing where the transparency talked about /has/ to happen. I know some people are able to negotiate lower prices than listed when it comes to doctors visits when they pay cash, but I think that is likely going the way of the dodo with the rise of the megaclinics. I'm just guessing there, but the inflexibility and bureaucracy in the megaclinic I go to doesn't seem like it would allow any sort of negotiation at all.
Unfortunately, the system as currently implemented is funneling things into those megaclinics. Where once doctors would set up their own small practices or partnerships, costs on their ends have spiraled out of control. There are the malpractice insurance costs as previously noted. The real estate market bubble created problems with buying or leasing an office. There are the incredibly expensive self employment taxes. Then you also have to pay for office people. Billing is incredibly complex due in part to some pretty harsh regulations required of insurance companies (a comment on a blog I came across recently noted that if a claim comes in with an O in place of a 0, by law, they have to reject it. They can't fix the obvious mistake, they have to reject it, which leads to more work on the end of the doctor's staff as well as the patient) and in part to...I don't know. I don't know why there are so many different plans that have few or no differences, so I can't comment further on that issue. Add that into schooling costs (another issue I believe I'll go into later), and it's really not as easy to make a living as a doctor, particularly on your own, as people believe it is.
Maternity care is another huge problem in this country. Some insurance won't cover it at all (another WTF issue). At the same time, costs are skyrocketing thanks to treatment that bases decisions on fear and acting as if pregnancy is a disease. The c-section rate in 2006 was 32% where the World Health Organization notes that it should not be medically necessary more than 10-15% of the time. A recent statistic I read noted that it was either 80% or 90% of women in Utah have inducing drugs such a Pitocin during at least some of their labor, which is absolutely insane. Our society's culture and the medical industry both are failing women, as interventions are not needed anywhere near as often as they are tried. Interestingly enough, the simple presence of a doula to help advocate for a woman when she is not in a position to rationally consider options herself (I can't remember the number, but it was shockingly high. 30-something percent, I think?) reduces the number of interventions in birth while still allowing good outcomes. When considering outcomes here as opposed to other countries, you find there tends to be much more reliance on midwifery in many, if not most, of the countries that have the best numbers. OB/GYNs are absolutely necessary, but their training biases them towards interventions that are not appropriate in the average labor. The costs rise both because of the price of the interventions and because of the price of the doctor. While I in no way think everyone should emulate me (though given the difference in my experiences, I can't imagine why someone would want to be in a hospital if not medically necessary-at least go to a birthing center!), we need to move away from the cultural bias towards midwifery started by doctors early in the 20th century to drum up business.
Now, what does Obama want to do and why won't it work?
First up, the insurance model as practiced here started up due to companies trying to attract workers without paying higher wages (I believe this was after WWII). They still don't want to pay more wages. So what's going to happen if Obama's proposal of every large employer having to provide x benefits or pay towards the public system passes? Every employer is either going to drop their benefits to the lowest allowable or drop insurance entirely and pay the required money to the public system, whichever ends up by being cheaper in their books. But they're certainly not going to raise wages to make up for the difference in the case of those who end up with far inferior care (which I daresay I would, which I don't disagree is selfish, but I don't need my hellish life and health to get worse due to lack of coverage). This is going to put a huge strain on the public system that was not anticipated, because that's what always happens (see: Hawaii). The money paid towards the system by employers will not be enough, because it will again spiral. The insurance companies, due to less business, will have layoffs, putting more strain on the system, not just in healthcare, but unemployment and the like. A half-baked measure like this will cause problems because it's based on only some people being on public healthcare, which history has shown in this country is not how things last. These things always cost way more than people plan, which leads to more deficits and/or higher taxes. Additionally, the tax burden is already so high in this country for businesses, one of the highest in the world, it will lead to more large companies to move elsewhere, as has been happening for a number of years now.
Other parts of the plan just won't work for a variety of issues. The costs of the public plan will go up due to illegal immigration, just as that affects healthcare costs now. Our immigration system is, in a word, stupid, but no one ever suggests what needs to be done to fix it-lift the restrictions, not make more of them! If someone can pass a background check that proves they're not a violent criminal (rape, murder, and the like as opposed the Jean Valjean sorts of crimes), they should be able to become legal residents of the U.S., and if they don't bother to go through that single step, enforce laws kicking them out. Not amnesty, but just something in place to protect the citizens here from being subject to more rabid dogs in human form. That would allow people to be hired legally, and thus be contributing to the system in the form of taxes like the rest of us, while fostering better integration that will keep them from being terrified of going for help for minor issues (of any type, not just healthcare) lest they get deported. That in turn will improve elementary schools so ones in immigrant-dense areas can focus on essentials in addition to language skills instead of English as a second language being the king of all subjects.
Another cultural problem is that of preventative care. The default socialization, particularly in men, is to refuse to go to the doctor unless there's a missing limb, someone is bleeding to death, or someone is in a coma. Most people don't want to go to the doctor. I'm no exception. If someone in the family has the sniffles, I have no desire to haul two kids under the age of three to a waiting room full of sick people (so if they're not sick already, they're going to be), wait for ages in the waiting room, then go back and wait for ages in an exam room while trying to keep them out of stuff for a doctor to breeze in, look at the sick individual for two minutes, say it's a cold, and sweep out again for a total time of maybe five minutes with us. It doesn't matter if preventative care works-the majority of us dread the crap that comes from going to the doctor, so we don't want to do it unless something seems serious. It's not just the money-it was all I could do to get Eric to get his toe checked out when it got squished by a very heavy metal object at work once, and that was covered by worker's comp!
Now, even if we were able to wave a magic wand and change our socialization, we would be faced with another issue-doctor shortages. There's already a huge lack of health providers in general, and doctors specifically in many areas. If everyone started going in like they're supposed to, general practitioners, family doctors, and pediatricians would be overwhelmed. However, even less people would go into these specialties, because aside from the lack of accolades, many if not most people would be on the public system (as discussed earlier), which would lead to poor wages.
Yes, doctors would be getting paid very little if the public system were king, because they already do with the public system. That's right, Medicare, Medicaid, the VA, Tricare, and the like pay crap. If there hadn't for people paying cash or having other insurance, I don't think the chiropractor I worked for could have even stayed in business. As I recall, he only got a few dollars per Medicaid patients, and only slightly more for Medicare. Tricare didn't cover it at all. That's why so many doctors refuse to see patients on these programs even now.
People aren't going to become general practitioners if that's what they have to look forward to, in part because of the rapidly rising tuition costs at the university level. No one seems to know why costs are increasing the way they are, but it's crazy. It's not just lack of funding, as private tuition is rising too, though not quite as much. At the same time, universities are increasingly eliminating tenure track positions and instead hiring adjuncts that they pay very little money and provide no benefits to. The cost for the university I live by increases by about 15% /every year/. It's even worse for post-grad and professional schools. With the kind of debt load a person takes on for tuition and living during classes and later residencies and internships, they just won't be able to afford to go into general practice or become doctors out of the desire to help people if they can expect to be crippled with tens or hundreds of thousands of dollars worth of debt before they even get started.
None of that is even getting into the question of how we're going to pay for the proposed system nor how we can trust the government to actually run it right when their track record is so poor. Obama himself admits that there the savings earned by various of his proposals isn't enough to fund everything. Additionally, at least part of the coverage suggested is supposed to be done by increasing the numbers on Medicare and Medicaid, which are both administered in an absolutely terrible fashion. My mom worked with the disabled for a very long time and the rigmarole they went through in order to get their clients, most of whom were mentally disabled and unable to advocate for themselves, was horrible. Forcing more people to be placed on the mercy of government bureaucrats for their healthcare seems to be unconstitutional as cruel and unusual punishment.
It also makes me very uncomfortable that Obama is proposing a government agency that will help people find and buy health insurance. There's a very obvious bias there that doesn't seem like would actually promote the competition that he claims is the goal.
A huge problem I see with the proposed system and many of the oh-so-vaunted systems in other countries is...what about eyes and teeth? Someone on my friends list in favor of Obama's proposals has talked about a kid who died when he had an untreated cavity turn into a system-wide infection because he didn't want to tell his parents he had a toothache because they didn't have the money for a dentist. The same person has complained about the recent cost of a crown. The care provided by eye and dental insurance in the U.S. is not covered. Not in Canada (as admitted by one of the links provided by the aforementioned friend), not in most of the U.K. (I believe Scottland is the exception, but England most certainly does not-see Robin McKinley's blog for proof of that), and not here. The problems mentioned here would still happen! If a public system does not include those things, you are being fooled. It is not a good system. Good eye and dental health are imperative to overall health, as shown by the tragedy of the boy (even more tragic because, under the current system, if the family had known in time they ought to have been able to find a dentist or group to help them find someone to do it as a charity thing, whereas those on the right on my friends list are claiming there is language that would restrict or forbid charitable work like that in the monstrosity of a bill being considered).
Another thing that isn't covered in many of the systems looked to as a model is prescription drugs. While there are the regulations restricting prices, most of it falls on the consumers. As someone with a chronic illness, let me tell you, the thing that ties us to the [shipping company] job more than anything is the monthly cost of meds. I think it's obvious why this is an essential that needs to be covered.
There are numerous other medical services that should be covered. One of the articles I read said that physical therapy is not covered in Canada. Being able to stay in the hospital longer isn't going to help you much if you don't get the therapy that will allow you to return to your normal life afterwards.
Not everything he's said is bad. Electronic records seem so incredibly obvious I'm horrified that there hasn't been a standard set and a national system set up. A national system of records would make patient treatment far safer and reliable, as it would give every physician they see easy access to the info of what other doctors have done. It would greatly reduce problems currently experienced with giving drugs that counteract each other or have other bad interactions because there would be a clear record detailing what a patient is taking right then rather than putting the burden on patients to give that information correctly. While I believe in personal responsibility, a person who needs to be on many different medication simultaneously will often have genuine issues with their mental capacity in some way or another, either caused by the drugs or by the illness(es) itself. For all that I keep meaning to take all my meds with me or a list of them, I never remember when it comes time, and then I have to rely on my obviously poor memory to correctly tell medical professionals my correct dosages. Not good. If you've got an old person with dementia, obviously the problem gets a lot worse. Because of keeping better track of medications, a national records system would also reduce the number of people successfully faking medical problems in order to get drugs, making it so that a person who genuinely needs them doesn't have to risk jailtime in order to simply get relief from chronic pain.
I certainly agree that the administration costs need to be cut down, but I'm not getting how Obama's suggestions are going to do that. I agree drugs should be allowed to be imported, but I think altering how the FDA works would be a more useful long-term change. Generics should not be blocked or bribed away once drug patents expire. People ought to be able to be eligible for insurance regardless of condition if they're not actively trying to kill their bodies through things like smoking or taking various other drugs in such a way that will damage their body without medical supervision (i.e. heroin or drinking your liver to death is bad has consequences, having problems because of following medical advice such as taking Tylenol in too high of doses would be covered). School lunches are a travesty that absolutely need to be fixed, and there's some anecdotal evidence that doing so could factor into improved performance.
Basically, I have been sold that a system similar to Australia's (very nice public insurance for all plus the possibility of private insurance for better coverage) if it would cover everything I've mentioned-doctors, dentists, physical therapists, optometrists, drugs, that sort of thing. I can see how it could fall under the "life" part of life, liberty, and happiness. I can also see the argument that not having such a system diminishes innovation and entrepreneurship, as my family has become very tied to Eric working for [shipping company] due to my poor health and need for such great insurance. However, Obama's plan is not this. Frankly, I don't think there's any way to make it come about in America without scrapping the system we have altogether. This would be hard at any time, terrible during a recession, and I don't think the citizens, politicians, or businesses in this country are able to plan things in the longterm enough to ever make it come to pass. It wouldn't require just throwing out the health system we have now, but changing how our society views a number of things, how the schooling system works, and how immigration works. I just don't see a clear way to make it happen. I think trying to fix our current system with some of the ideas I've presented here would be a more realistic way to go.
And don't expect me to pull your crushed, broken body out from beneath those bricks of words. I warned you!
