NYTimes Book Review Misses Major Points About US Healthcare

Jacob S. Hacker, Yale professor and author of many books and article critiquing the American political system, economy, and the fate of the poor and middle classes, reviewed a new book, AN AMERICAN SICKNESS: How Healthcare Became Big Business and How You Can Take It Back by Elisabeth Rosenthal (NY: Penguin Press, 2017). Most of the review takes up the question of why healthcare is not like other commodities and does not fit into the “let the market solve the problem” ideology of the last 40 years. If you are unpersuaded now, this is useful territory. towards the end of the review Hacker turns to our developed country competitors’ approaches to healthcare.

“The difference between the United States and other countries isn’t the role of insurance; it’s the role of government. More specifically, it’s the way in which those who benefit from America’s dysfunctional market have mobilized to use government to protect their earnings and profits. ….. But in every other rich country, the government not only provides coverage to all citizens; it also provides strong counterpressure to those who seek to use their inherent market power to raise prices or deliver lucrative but unnecessary services — typically in the form of hard limits on how much health care providers can charge.”

This is a great summary statement. Using a variety of tools and institutional arrangements every other government controls prices and healthcare budgets. They do not allow a one-sided market to focus on delivering as many procedures and prescriptions as possible without any systematic focus on health. My criticism is that Hacker should have provided two further data points to put the outrage of American healthcare in its true global setting: US healthcare spending compared to other developed countries and health outcomes relative to other developed countries. As the chart below demonstrates, the US spends more than 25% more than our closest competitor, Switzerland, and twice as much as most including japan, France, Australia and Canada. The health outcomes are woeful. We rank 42 in the world for longevity and 56th for infant mortality.  ((see https://www.cia.gov/library/publications/resources/the-world-factbook/)) These facts need to be front and center in our thinking about healthcare. The developed world is filled with universal healthcare systems with many different structures and approaches, all with several decades of experience at delivering better healthcare at much less expense. The only question is how will poor and middle class people in the united states gain enough political power to end this great rip-off??

https://ourworldindata.org/financing-healthcare/

Affordable Healthcare Act (Obamacare) Review – Rob Bujan

Dan Udell videotaped a presentation on the US healthcare system by Rob Bujan on 3/25/17. I could not attend so I watched Dan’s YouTube video – 

 The discussions towards the end of this presentation (about minute 50) concerning single-payer systems would have been more vigorous and perhaps useful with a little international context. We live in a world where every other developed country has universal healthcare and has had for decades. So, there is plenty of experience with a range of different structures to deliver healthcare to every person as a right. Continue reading

Congressman Faso’s Challenge

Today I received an email from Congressman Faso’s campaign committee. It read in part:

Friend,

The Democratic Congressional Campaign Committee (DCCC) today released a memo claiming Democrats are “starting the 2018 election cycle on offense.” This is an alarming statement on many levels. For one, they really do see the future of our nation as nothing more than a political game. They are also choosing to completely ignore the American people by not acknowledging the sweeping Republican victories from just two months ago.

The most worrisome item in the memo is that the DCCC listed my seat as a “Round One Target.” I was sworn in less than a month ago and already the Washington Establishment is targeting my district as one to pour hundreds of thousands of dollars into in order to install the liberal candidate of their choice.

The email then went on asking me to donate to his re-election campaign!

Here is my reply: Continue reading

1 Our Situation

Our Situation button

For some time I have been thinking, writing, and gathering information, not necessarily in any good order, about our situation here in the US. For more than a decade I have thought that we are in a protracted crisis.

This crisis can be felt at the personal, family, local and national level in all areas of life. Some of the sources are systemic to technological change and the global dynamics of capitalism. Some find their roots in fundamental failures in humans – racism, sexism, religion, etc. Some flow from our political system, some from our economy.

The focus of this work has been to try to identify what this crisis is about within the US context, to describe it, without any real notion of even suggesting solutions.

Where Did This List Come From and Is There an Order?

I first started this list two or three years ago while we were still in the deepest part of the Great Recession. Most of the early entries related to the political system and economic inequality. As I have returned to it I have broadened the coverage of social and political topics. Most recently I have added ones that relate to the mythology underlying our approaches to life in the US.

Here is my current list of topics:

  • Underperforming, expensive healthcare system
  • Political system controlled by big money, private and corporate
  • Distorted role of corporations
  • Quasi-religious faith in “free market” capitalism
  • Race, sex, ethnicity, klans….
  • Myth of social mobility
  • National and State Political Systems Designed to Be Anti-democratic and Dysfunctional
  • 30+ year stagnation of income
  • Disappearance of living wage jobs
  • The rich are at their feeding troughs
  • Expensive, underperforming K-12 educational system
  • Expensive, underperforming higher ed system
  • Web access and infrastructure
  • Homelessness and poverty
  • Bloated, dysfunctional global military and empire
  • Our longest war – the war on drugs
  • Criminal justice system – aka the judicial-incarceration gulag
  • Persistent income disparities
  • Super rich vs. everyone else
  • Intrusion by organized religion into government and politics
  • Energy policy focused on consumption instead of efficiency

 

More Blather about Healthcare from "Experts"

Acknowledge the basic facts about how the healthcare system is working today.

Yesterday in a radio interview, “How to conquer health care challenges”, with Professor Glenn Melnick  from the Rand Corporation and USC, we were again offered up “expert” opinion that does not even acknowledge the basic facts about how the healthcare system is working today.

Here are a couple of examples from the interview lead by Kai Ryssdal:

“RYSSDAL: Well, let me make sure I understand that. If doctors and hospitals are making less money, what is that do for the quality of care? I’m just trying to think about the argument that’s going to come up on Capitol Hill on this one.

MELNICK: Quality will have to suffer in some way. Whether it’s through reduced access, whether it’s through slower development of new technology…….”

The US spends nearly 50% more on healthcare than the next closest country (Switzerland) and more than twice most developed nations. Yet our basic outcomes of infant mortality and longevity remain at near third world performance. These are the facts of our situation. Money is not the problem. It is what we spend our money on that is the problem. To say that quality will inevitably decline as a result of spending less money is just nonsense. This flies in the face of the facts of the performance of all of the developed countries in the world, except us.

Within the current US performance there are clear demonstrations of how superior performance is not driven by spending more money

Even within the current US performance there are clear demonstrations of how superior performance is not driven by spending more money. Just read “THE COST CONUNDRUM: What a Texas town can teach us about health care.” by Atul Gawande in the New Yorker. Here is part of Gwande’s discussion of this point:

Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care.

Melnick is not done demonstrating his lack of awareness of further basics about how healthcare works in the US.

There are a number of economists who feel that health-care is expensive for good reason. And the reason is that it’s valuable. That new innovation and new technology, while it may add to the cost of the health-care system, also brings with it tremendous benefits. The real challenge is can we develop a system to do the research to identify those things that are going to be high value in the first place, and to screen out those things that are low value and not adopt them as quickly as we have in the past. And that will be a challenge, but I think there’s potential savings there. I don’t know any country that has done it very well so far, because new innovation is just so complex and hard to predict.

One of the well reported facts about “innovation” in American medicine is that there is no requirement for new technologies, new procedures, new medical devices, or even new drugs to prove their efficacy. This is well known and examples of the consequences are abundant. If we only knew which of all these “innovations” really provided improvements in healthcare outcomes we would all be better of and probably at a lower cost.

I am not sure who Professor Melnick is, but, based on his performance during this interview, he would appear to be another example of that alternative text for PhD.


Health Care Crisis – the data

Be sure to scroll down to the “Yellow” coded scores for the US.

Comparative Health System Data

Health Spending per

Capita 2002


Infant Mortality per 1000 Births 2003


Life Expectancy in Years at Birth 2003


1

United States

$4,271

1

Sweden

3.44

1

Andorra

83.49

2

Switzerland

$3,857

2

Iceland

3.53

2

Macau

81.87

3

Norway

$3,182

3

Singapore

3.6

3

San Marino

81.43

4

Denmark

$2,785

4

Finland

3.76

4

Japan

80.93

5

Luxembourg

$2,731

5

Japan

3.84

5

Singapore

80.42

6

Iceland

$2,701

6

Norway

3.9

6

Australia

80.13

7

Germany

$2,697

7

Andorra

4.07

7

Guernsey

80.04

8

France

$2,288

8

Netherlands

4.31

8

Switzerland

79.99

9

Japan

$2,243

9

Austria

4.39

9

Sweden

79.97

10

Netherlands

$2,173

10

France

4.41

10

Hong Kong

79.93

11

Sweden

$2,145

11

Switzerland

4.42

11

Canada

79.83

12

Belgium

$2,137

12

Macau

4.44

12

Iceland

79.8

13

Austria

$2,121

13

Slovenia

4.47

13

Cayman Islands

79.67

14

Canada

$1,939

14

Belgium

4.64

14

Italy

79.4

15

Australia

$1,714

15

Germany

4.65

15

Gibraltar

79.38

16

Finland

$1,704

16

Luxembourg

4.71

16

France

79.28

17

Italy

$1,676

17

Spain

4.85

17

Monaco

79.27

18

United Kingdom

$1,675

18

Australia

4.9

18

Liechtenstein

79.25

19

Israel

$1,607

19

Liechtenstein

4.92

19

Spain

79.23

20

Ireland

$1,569

20

Guernsey

4.92

20

Norway

79.09

21

United Arab Emirates

$1,428

21

Canada

4.95

21

Israel

79.02

22

New Zealand

$1,163

22

Denmark

4.97

22

Jersey

78.93

23

Spain

$1,043

23

Gibraltar

5.4

23

Faroe Islands

78.9

24

Greece

$965

24

Ireland

5.43

24

Greece

78.89

25

Portugal

$859

25

United Kingdom

5.45

25

Aruba

78.83

26

Slovenia

$746

26

Czech Republic

5.46

26

Netherlands

78.74

27

Singapore

$678

27

Jersey

5.52

27

Martinique

78.72

28

Argentina

$654

28

Northern Mariana Islands

5.61

28

Virgin Islands

78.59

29

Uruguay

$621

29

Malta

5.72

29

Malta

78.43

30

Bahamas, The

$612

30

Monaco

5.73

30

Germany

78.42

31

Barbados

$601

31

Hong Kong

5.73

31

Montserrat

78.36

32

Korea, South

$470

32

Italy

5.76

32

New Zealand

78.32

33

Lebanon

$469

33

Portugal

5.84

33

Belgium

78.29

34

Saint Kitts and Nevis

$408

34

San Marino

6.09

34

Guam

78.27

35

Czech Republic

$380

35

New Zealand

6.18

35

Austria

78.17

36

Bahrain

$358

36

Greece

6.25

36

United Kingdom

78.16

37

Hungary

$318

37

Aruba

6.26

37

Saint Pierre and Miquelon

78.11

38

Brazil

$308

38

Man, Isle of

6.3

38

Man, Isle of

77.98

39

Chile

$289

39

Guam

6.58

39

Finland

77.92

40

Slovakia

$285

40

Faroe Islands

6.66

40

Jordan

77.88

41

Costa Rica

$257

41

United States

6.69

41

Luxembourg

77.66

42

Poland

$248

42

Taiwan

6.8

42

Guadeloupe

77.53

43

Panama

$246

43

Croatia

7.06

43

Bermuda

77.41

44

Estonia

$243

44

Cuba

7.27

44

Saint Helena

77.38

45

Mexico

$236

45

Israel

7.55

45

Ireland

77.35

46

South Africa

$230

46

Korea, South

7.58

46

Cyprus

77.27

47

Colombia

$227

47

Martinique

7.62

47

Puerto Rico

77.26

48

Dominica

$208

48

Cyprus

7.71

48

United States

77.14

49

Trinidad and Tobago

$204

49

Montserrat

7.98

49

Denmark

77.1

50

Grenada

$193

50

Saint Pierre and Miquelon

8.18

50

Taiwan

76.87

51.

Lithuania

$183

51

New Caledonia

8.23

51

Cuba

76.8

52

Antigua and Barbuda

$179

52

Reunion

8.31

52

Anguilla

76.7

53

Venezuela

$171

53

Slovakia

8.76

53

French Guiana

76.69

54

Latvia

$166

54

Hungary

8.77

54

Kuwait

76.65

55

Jamaica

$157

55

French Polynesia

8.95

55

Costa Rica

76.43

56

Turkey

$153

56

Chile

9.12

56

Portugal

76.35

57

Saint Lucia

$151

57

Poland

9.17

57

Chile

76.35

58

Maldives

$150

58

Virgin Islands

9.21

58

Northern Mariana Islands

76.16

59

El Salvador

$143

59

Bermuda

9.28

59

Libya

76.07

60

Namibia

$142

60

Puerto Rico

9.3

60

British Virgin Islands

76.06

61

Peru

$141

61

Guadeloupe

9.3

61

Uruguay

75.87

62

Jordan

$139

62

Cayman Islands

9.89

62

Jamaica

75.85

63

Iran

$128

63

American Samoa

10.09

63

American Samoa

75.75

64

Botswana

$127

64

Nauru

10.52

64

Slovenia

75.51

65

Gabon

$122

65

Costa Rica

10.87

65

Argentina

75.48

66

Mauritius

$120

66

Kuwait

10.87

66

French Polynesia

75.45

67

Syria

$116

67

Netherlands Antilles

11.06

67

Netherlands Antilles

75.38

68

Thailand

$112

68

Barbados

11.71

68

Korea, South

75.36

69

Tunisia

$108

69

Estonia

12.32

69

Czech Republic

75.18

70

Burma

$97

70

Macedonia, The Former Yugoslav Republic of

12.54

70

United Arab Emirates

74.75

71

Dominican Republic

$95

71

French Guiana

13.22

71

Macedonia, The Former Yugoslav Republic of

74.49

72

Paraguay

$86

72

Jamaica

13.71

72

Slovakia

74.43

73

Fiji

$86

73

Tonga

13.72

73

Tunisia

74.4

74

Romania

$86

74

Fiji

13.72

74

Paraguay

74.4

75

Belarus

$85

75

Brunei

13.95

75

Croatia

74.37

76

Belize

$82

76

Belarus

14.12

76

Brunei

74.3

77

Malaysia

$81

77

Bulgaria

14.18

77

Dominica

74.12

78

Guatemala

$78

78

Uruguay

14.25

78

Turks and Caicos Islands

74

79

Honduras

$74

79

Lithuania

14.34

79

Serbia and Montenegro

73.97

80

Bolivia

$69

80

Grenada

14.63

80

Poland

73.91

81

Kazakhstan

$62

81

Saint Lucia

14.8

81

Venezuela

73.81

82

Bulgaria

$62

82

Latvia

14.96

82

Bahrain

73.72

83

Ecuador

$59

83

Sri Lanka

15.65

83

New Caledonia

73.52

84

Nicaragua

$54

84

Saint Kitts and Nevis

15.83

84

Reunion

73.43

85

Guyana

$51

85

Dominica

15.94

85

Qatar

73.14

86

Swaziland

$46

86

United Arab Emirates

16.12

86

Saint Vincent and the Grenadines

73.08

87

China

$40

87

Saint Vincent and the Grenadines

16.15

87

Saint Lucia

73.08

88

Congo, Democratic Republic of the

$40

88

Palau

16.21

88

West Bank

72.68

89

Cape Verde

$37

89

Mauritius

16.65

89

Sri Lanka

72.62

90

Philippines

$37

90

Seychelles

16.86

90

Oman

72.58

91

Zimbabwe

$36

91

Bahamas, The

17.08

91

Albania

72.37

92

Albania

$36

92

Argentina

17.2

92

Panama

72.32

93

Bhutan

$36

93

Greenland

17.28

93

Mexico

72.3

94

Kenya

$31

94

Serbia and Montenegro

17.36

94

Bosnia and Herzegovina

72.29

95

Nigeria

$30

95

Turks and Caicos Islands

17.46

95

China

72.22

96

Turkmenistan

$30

96

Romania

18.88

96

Hungary

72.17

97

Sri Lanka

$29

97

Bahrain

19.18

97

Solomon Islands

72.1

98

Ukraine

$28

98

British Virgin Islands

19.55

98

Lebanon

72.07

99

Cote d’Ivoire

$28

99

Panama

19.57

99

Ecuador

71.89

100

Papua New Guinea

$25

100

Jordan

19.61

100

Barbados

71.84

Data  for Spending: World Bank. 2002. World Development Indicators 2002. CD-ROM. Washington, DC

Data for Infant Mortality: CIA World Factbook, December 2003

Data for Life Expectancy: CIA World Factbook, December 2003

All data courtesy of http://www.nationmaster.com/index.php (09/29/04)











Healthcare Crisis

Originally written in 2005

 

The healthcare crisis in the US is growing in severity and yet is not the subject of any real public debate. More than 44 million Americans are without health insurance and almost 65 million will experience a lack of coverage during the year. Emergency rooms are the primary care provider of necessity. All of this despite the fact that, as a nation, we spend more than any other country in the world; 11% more than the next closest country; 90% to 100% more than countries like Germany, Japan, Canada, Australia, and France. Yet the outcomes for our healthcare system are completely second tier and nearly third world.

You may be shocked to see exactly how poorly our phenomenally expensive health system is performing. Just to add some further context, note that Sweden (1st in Infant Mortality to the US 41st position) has a per capita income roughly equal to that of Mississippi (the poorest US state) and spends almost exactly half of what the US does per capita on health care. Examine the Comparative Health System Data in which I have color-coded a few countries for quick comparison.

During our quadrennial presidential personality sweepstakes, neither candidate offered real solutions, really not even a discussion of the issues. We are stuck in a political environment in which neither the Republicans nor the Democrats are offering, and I would argue, are capable of offering real solutions.

Lets make a one basic observation about the situation:

This is not a money problem. As demonstrated by the data on the Comparative Health System Data chart, we clearly are spending enough money in aggregate.

But, this crisis is about money, namely, who gets it and what do they do with it. And, starting from the last serious attempt to tackle the problem during the first year of the Clinton administration, it is very clear that the political system is completely in the pockets of the various interests who have the money now, namely insurance and drug companies, hospitals, and doctors.

It seems obvious to me that we just need to look at any of a number of the top performing countries for the solution. Then, we need to have the political forces in place to tell some of the current participants that the rules have changed.

Central to any solution will be the participation of all US residents in the system. Healthcare is a basic human right and we should not be treated as “risk” factors in insurance company profit calculations. If everyone is part of the healthcare system, then we can effectively share the individual risks and expenses of healthcare across the whole population. Healthcare should not be an actuarial game to derive profit. It should be a system that delivers a reasonable level of service to everyone in the society.

Two players clearly are at the top of the hit list. First, most assuredly the insurance industry, which adds no value to our health care, but consumes by many estimates 15% to 20% of the resources, must go. Second, the drug companies can be brought into reasonable competition for prices that will bring market forces to bear.

Ironically, given the long history of doctors opposing national or single-payer systems in the US, doctors have now been reduced to the status of wage slaves like the rest of us. Many, if not a solid majority of doctors, will support real reforms to the system.

I close here with two basic notions:

  • our healthcare problems are not about a lack of money, and
  • we need to develop political forces that can overcome the control of government (Federal and state) health policies by the current players in the healthcare system.

Given the current Bush administration, I believe the focus of reform must be at the state level. It seems feasible to envision a single-payer system that covers all residents in a state like Massachusetts. We should try it.