Sara Robinson continues her assault on the lies surrounding healthcare. One target--'rationed' healthcare.
We'll have rationed care
Don't look now: but America does ration care. And it does it in the most capricious, draconian, and often dishonest way possible.
Mostly, the US system rations care by simply eliminating large numbers of people from the system due to an inability to pay. Last year, one-quarter of all Americans didn't go to a doctor when they needed one because they couldn't afford it. Nearly that many skipped getting a test, treatment, prescription, or follow-up appointment recommended by a doctor. In Canada, those same numbers are in the 4-5% range; in the UK, 2-3%. Also: nearly 20% of all Americans had a hard time paying a medical bill last year; and these stresses now trigger over half of all personal bankruptcies in the country.
Furthermore, nominally having health insurance is no guarantee against financial ruin, as Sicko amply illustrated. Being cut off or denied by your insurance company is rationing, too. And there are vast numbers of fairly well-off Americans -- many of them middle-aged, and too young for Medicare -- who have pre-existing conditions that render them uninsurable at any price. They're one heart attack, one diabetic event, or one bad turn away from financial disaster. Please don't insult these people by telling them that the American system doesn't ration care.
Another persistent (and ridiculously mendacious) rationing myth about the Canadian system is that old people are cut off from treatment and left to die. I've never heard about a single case of this in Canada; but it happens routinely to Americans on Medicare and many private policies, which have strict limits on how long you can stay in the hospital with an acute illness. When the benefits run out, ready or not, they send you home. If you die, you die. The Canadian plan has no such limits: you stay for as long as you need to. But in the US, these limits fit the very definition of "rationed care."
Effectively shutting one-quarter of the population out of the medical system entirely, and putting many of the rest on short rations, certainly does make things so much nicer for those happy few who are still in it. In fact, Americans have these missing millions to thank for their system's impressively short wait times. Only 4% of American have to wait more than six months for non-elective surgeries, while 14-15% of Canadian and Britons do. (Don't blame this on government care, though: in Germany and the Netherlands, the number is closer to 2%.) When conservatives start bellowing about Canada's terrifying wait times (which, by the way, are carefully triaged: it's rare for people to die waiting, though it happens), we need to remind them that there are 75 million Americans who have been wait-listed forever.
Of course, there's the pithy Mad Biologist version:
Despite conservative claims to the contrary, we do ration healthcare: many lower middle-class and unemployed people don't get to have any.
Robinson also makes a good argument about containing infectious disease outbreaks:
Getting everyone insured is, unequivocally, a clear matter of national security.
Our every-man-for-himself attitude toward health care is a security threat on a par with unsecured ports. In Canada, people go see the doctor if they're sick for more than a day or two. It was this easy access to early treatment, along with the much tighter public health matrix that enables doctors to share information quickly, that allowed the country's health care system to detect the 2003 SARS epidemics in Toronto and Vancouver while they were still very localized, act within hours to stop them before the disease spread any further, and track down and treat exposed people before they got too sick to be helped. In both cases, the system worked flawlessly. The epidemic was stopped within days and quashed entirely in under a month, potentially saving of millions of lives.
In the U.S., that same epidemic might easily have gone unnoticed for critical days and weeks. If the first people to get sick were among those 75 million without adequate insurance, they probably would have toughed it out a few extra days before finally dragging their half-dead carcasses into an ER somewhere. Not only would they be much farther along in the course of the disease -- and thus at greater risk of death themselves -- every one of them could have infected dozens or even hundreds of other people in the meantime, accelerating the spread of the epidemic.
Worse: America's underfunded public health system might have taken several days to piece together the whole picture of an epidemic; and perhaps another week or two might have passed before the E. Coli conservatives in charge (having thrown out the science-based management plans thoughtfully developed by the bureaucracy) cooked up some kind of half-assed ideology-driven decision about how to proceed. (It would, of course, involve spectacular amounts of lying to the public.) By that point, tens of millions could have been infected, leading to a death toll that would make 9/11 and Katrina look like minor statistical blips.
Think about superbugs and the ongoing waves of immunological imports from the world's swamps and jungles. Think about terrorists with bioweapons. And then think again about the undeniable fact that every single underinsured American is a gaping hole in the safety net that protects us all from a catastrophic epidemic. This really is one of those cases in which none of us are safe as long as even one of us is left at risk.
A related point to this is that no one should ever have to pay (or co-pay) for a vaccination. A system that internalized the failure to sufficiently vaccinate for the annual influenza epidemic (which in an average year kills twice as many people as AIDS does) would save lives and develop the infrastructure to rapidly vaccinate in case of an even more serious epidemic.
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Another persistent (and ridiculously mendacious) rationing myth about the Canadian system is that old people are cut off from treatment and left to die.
I have just recently retired (in Canada), and had the option
of purchasing a continuation of my employer's medical plan wehich provides supplementary coverage (drugs/dental/air lift/ private rooms, etc.). The standard rates for a couple under 65 were between $130 and $180 a month, but the rate for a couple age 65 was $65 to $85 (this was a few years ago). The reason, of course , is that health coverage improves for senior citizens, mainly because a lot of drugs are now provided free, even if not administered in a hospital. In other words, for seniors there is just not that much theat a supplementary plan can offer.
Very nice posts (here and there). Although I don't know what poor old E. coli did to deserve being slandered.
One quick comment on the Sara's claim that with Medicare and private insurance payment for hospital care "When the benefits run out, ready or not, they send you home. If you die, you die":
This has not been my experience as a physician. Yes, at a certain point, the utilization review nurse will tell me that the patient's payment coverage is running out. The implication is the patient should be sent home before that happens.
If the patient is not ready to go home yet, I ask the hospital administration if they would rather eat the cost of another couple days' stay or face the prospect of a malpractice suit if the patient is sent home early and has a bad outcome.
I have NEVER had a patient sent home before I felt that it was safe to do so. Neither Medicare nor any private insurance has the authority to discharge a patient from the hospital. All they can do is deny payment beyond their coverage period. If a spineless physician caves in to a pushy bean counter, that's another matter.
Robinson makes a fundamental mistake, however: "Getting everyone insured is, unequivocally, a clear matter of national security."
Even in a widespread outbreak of infectious disease, the wealthy, i.e. the top 1% or 2% of the country for whom protection forms the whole of national security, would not be at substantial risk. And even the top 1-2%, who are mostly servants of the very tip-top 0.01% elite, can be sacrificed and replaced without too much trouble.
It has been uniformly the case that all "national security" measures passed during the Bush Administration have been targeted not towards protecting the general population; they have been targeted towards reducing civil rights, advancing totalitarian control, and making ordinary economic activity more and more difficult, thus promoting the transfer of wealth to the top.
The most obvious measures to take to ensure real national security is a plan to quarantine and, if necessary exterminate, large numbers of people in the event of a widespread outbreak of infectious disease. I will bet you dollars to donuts that such a plan is already in place in the Bush administration.
Yes, I am very cynical. Why do you ask?
The scenario of an epidemic that spreads because people "tough out" an illness and go to work is not at all unusual. Anyone who lives from paycheck to paycheck, and has little or no sick leave or health insurance, is going to wind up in that situation from time to time. Many people without paid sick time drag themselves in to work with communicable diseases like norovirus, colds, and flu. And, if their jobs involve handling food or consumer merchandise -- well, guess what.
People who depend on disability services have an especially difficult time -- what they go through for that "free" care is appalling. I've driven a disabled acquaintance with a nasty dental emergency on a 160-mile round trip so that he could see an oral surgeon who accepted Medicaid. Another friend spent months dealing with paperwork and bureaucratic turndowns before finally being approved for two surgeries that would cure her disability. (She's now able to work for the first time in years. I wish someone would explain why it's good fiscal policy to keep someone unhealthy and dependent, when paying for an effective treatment will not only reduce future health care expenses, but also get that person back into the workforce.)
And, when people start ranting about waiting six to eight weeks for non-emergency surgeries: In the U.S., it often takes that long or longer even for fully insured patients in the absence of bureaucratic obstacles, because the surgeon, hospital, and patient all have to have room in their schedules at the same time. For truly elective surgeries, this is a non-issue.
Great post, Mad Mike. My own pithy version would have been, We totally suck.
very
very thanks for article