I don’t ordinarily write about health care reform here, partly because it isn’t my expertise, partly because other interests come first, partly because others do it much better. But I have been thinking a good deal about what needs to be done for our public health infrastructure and that necessarily brings health care reform into the picture, whether I want it there or not. My view of it is primarily as a consumer. I pay ridiculous health insurance premiums and still feel underinsured. But I also see it from the provider’s point of view, where the current system, while lucrative for some, is a major factor in provider work dissatisfaction. It isn’t fun to deal with the paperwork and transaction costs on either end (although it’s better to bill than be billed, of course). But the health care reform train is leaving the station and it better be on the same track and going in the same direction as public health. So I am starting to think about it.
I’m not the only one. The current crisis of 47 million uninsured n the US, almost a doubling of premiums in the last decade, the squeeze on businesses big and small coping with risking health care costs and the huge cost to each an every American is now a scandal, the more so because the insurance industry and Big Pharma are reaping record profits. In yesterday’s LA Times Ezra Klein has some revealing figures:
The American health system, put simply, is a mess. An expensive one. Indeed, in 2002, we spent $5,267 per capita on healthcare — $1,821 more than Switzerland, the nearest runner-up. And yet we had higher infant mortality, lower life expectancy, more price inflation and an actual uninsured population, a phenomenon virtually unknown in the rest of the developed world, where universal healthcare is, well, universal. (LA Times)
We have many readers outside the US, so it bears repeating for their information: alone among industrialized nations of the world, the US doesn’t have universal health care. When I say this to my European colleagues (usually in a conversation where they are grousing about their own national health service) they are first startled, then incredulous. In ten years, though, I’m guessing the last hold out will have given up its supremely anachronistic ways, too.
Already several states (Vermont, Massachusetts) and one city (San Francisco) are moving toward universal coverage, although in different ways, most of them partial and with many flaws. But the universal coverage genie is out of the bottle, at last, and it won’t go back in. Even the health insurance industry knows this. As Klein points out, is busily floating their own self-serving version of health insurance reform.
The reason for this inevitability is that the stars are finally lining up. Reacting to Klein’s op ed, Bonddad at The Agonist sets out what he thinks are the three drivers that will force universal care in the United States.
- Universal care is cheaper, at least judging by the per capita costs of every other advanced industrical country that has it:
The Organization of Economic Cooperation and Development studied the health expenses of all member countries – 29 in all including the United States. The median amount of GDP spent on health care of 29 countries has fluctuated between 7.9 and 8.4 for 2000-2003. For 2000-2003, US health expense as a percentage of GDP was 13.1%, 13.8%, 14.6% and 15% respectively – by far the highest total of all countries. Germany was the next most expensive country and their totals for the same years (2000-2003) were 10.6%, 10.8%, 10.9%, 11.1%, respectively. So, as a percentage of GDP basis, the US spends between 34% and 75% more as a percentage of GDP than countries that rely primarily on public funds to provide health service.
The OECD also breaks health expenses down into amount spent per capita. For the last four years (2000-2003), the median per capital expense for 29 OECD countries ranged from $2010 to 2248. Over the same years, the US once again spent more than any other OECD country, with figures for 2000-2003 of $4539, $4888, $5287 and $5635. Over the same time, Switzerland ranked second in per capita expenditures and Germany third. It’s important to notice that the US’s private health care system routinely spends at least twice as much per person than other countries with public health systems. (The Agonist)
As Ezra Klein noted, we also don’t get the benefits of greater expenditure, actually faring worse in most health indices than countries spending far less.
- Transaction (administrative) costs are far less for government administered health coverage. Bonddad offers this, from The Angry Bear:
We have a couple of estimates of how high administrative costs are – i.e., expenses incurred by the health care system to do things other than to provide health care services. One prominent study that appeared in the New England Journal of Medicine in 2003 estimated that the cost of administering the US’s health care system was about $300bn in 1999. A more recent study in the International Journal of Health Services found that in 2003, administration costs in the US health care system ate up about $400bn, or about 25% of total health care spending.
By comparison, national health care systems incur administrative costs of a few percent of total health expenditures: according to the NEJM study Canada’s national health insurance system spends just 1.3% on overhead, and the US’s Medicare and Medicaid programs have administrative costs of between 2-5%.
Currently, the US health system is a hodge-podge of numerous insurance companies with differing layers of paperwork that work against efficiency. The US public system spends 80% less on administration costs. (The Angry Bear)
- An additional factor is that American businesses from small to large are finally realizing that it is better to have taxpayers foot the bill for their workers’ health care costs than that they do. It is becoming an intolerable expense and a major cause of labor unrest. Yesterday we cited the example of the seven times greater cost of worker health care in an American built car compared to a Japanese or Canadian car. It’s not just cars. American-based workers are at a competitive disadvantage if their employer pays health insurance, and if that disadvantage is made up by trimming their benefits they wind up uninsured or underinsured on their own nickel.
None of these factors are part of a specifically progressive view of health care reform. These are all issues a “sane Republican” could accede to. Progressives have this as a base to build on, but how to craft an effectie and equitable system of universal coverage and access and delivery of care to everyone will take much additional thought.
Meanwhile, it is important to acknowledge it isn’t possible to have a truly robust and resilient public health system if we are unable to provide services and distribute the fruits of preventive medicine to our communities. Vaccines have to be distributed and administered; for surveillance to work there has to be a system that “sees” the cases; if sick and infectious people aren’t to be walking our streets and workplaces they need to be treated and cared for; if children are to be healthy enough to withstand a bout of influenza we’ll need to provide prenatal care, well baby care and acute care. That’s just for starters. All of this articulates intricately and necessarily with the health care system.
Which is currently broken beyond repair. While we rebuild our public health infrastructure, we’ll need to do it in coordination with fixing our dysfunctional health care system. The rest of the industrialized world has a huge head start on us. They’ll do better than we will if there is a pandemic in the near future for this reason alone.
Then there’s the rest of the world.