Friday, July 17, 2009

The employer-based health care model is flawed

My response to commenter Mike: Health care becomes an issue of national security and interstate commerce when it has such far-reaching consequences for businesses and the well-being of our workforce, thus it comes under the purview of the federal government. This may be a stretch, but it's the opinion of economists from the frugal Pete Peterson to advocates of single-payer.

The Safeway stores' employee plan, as outlined in one of your references, has merit and should be pursued. No question. The health insurance market in the US will always be a mix of public and private plans and the more efficient will win out... We need to pursue innovation, that's how markets work, and that is why my initial post had the wording single-payer "option" that covers all. There is a baseline level of care that has been accepted as necessary, a de facto right, and this needs to be covered financially somehow or we need to express unequivocally that health care in NOT a right. If you seriously believe that uninsured and underinsured should be left to die (and that is a valid philosophical stance), then your gripe is not with the proponents of single-payer, rather you should be advocating for the rights of hospitals and doctors not to participate in the care of the uninsured. As it stands now, acute care hospitals are required to accept all patients according to EMTALA statutes regardless of their ability to pay, and hospitals in turn require physicians to take emergency call for these patients in order to maintain privileges. Seriously, fight for the rights of the indentured hospitals and physicians! This would definitely lower health care costs dramatically since the uninsured will no longer be a burden to us all.

Opponents of big government health care, such as Rep. Ron Paul, have long held that the implementation of Medicare was flawed from the beginning, and that may be a valid opinion, but we cannot turn back the clock 40 years. My opinion is that Medicare served a severe need at the time it was introduced and has covered people who were unable to get insurance coverage otherwise. Non-union retirees and the disabled were essentially left without any options for private insurance and thus the need for Medicare was born. Opinions of hard-liners such as yourself, Mike, and Rep Paul, should be respected, but realize that Medicare has filled a dire need, done it reasonably well, and could have a place in an expanded role. You may never be convinced and I'll listen to any alternatives you can present*.

My question is why a grocery store like Safeway would even want to be in the business of providing health insurance at all, but if they are concerned with their employees' health, then more power to them and they should be able to continue their plan. Another question is what happens when a Safeway employee gets sick enough to lose his/her job? Does his entire family go without insurance, or would they then be thrust onto the public dole? Finally, if the Safeway plan is so efficient and beneficial, then what is stopping all employers from going to this model now? Mr Burd, the CEO, should not be going to Capitol Hill, but rather the Better Business Bureau and the Chamber of Commerce. We have been living in an environment of free market employer-based private health insurance, now covering 180 million of us, for a couple generations and have only seen costs rise exponentially. Why is that? Furthermore, the current employer-based insurance model drastically limits the mobility of the workforce, which leads to decreased productivity and a stifling of the labor market.

You said previously that Medicare does not "add value." I never said it did; and I would add neither does private insurance. For the most part these entities are benefit administrators-- they collect premiums and send out (or deny) reimbursement checks-- using actuarial data. Incentives to withhold coverage are rampant and care should be dictated by health professionals and standardized evidenced-based data in either model. The corporate executives are very well paid for doing nothing more than collecting premiums and writing reimbursement checks, which is a rather utilitarian function.

You said you worked in a large unwieldy government bureaucracy which has obviously affected your opinion. Have you ever sat in on a private insurance company board meeting? There are just as many cases where private insurance has chosen not to cover life-saving treatments due to cost considerations. The recourse in such a situation is just as dire as when Medicare does it. I'm not saying the profit motive is evil, only that it is no better than the alternative.

My opinion is that there is no way the average Joe or Jane can really know the efficacy of various treatments and screening tests-- heck most physicians are confused once they stray away from their specific specialty-- and the standards need to be more uniform. Pap smears yearly and per a protocol; High blood pressure medicine under a certain protocol based on evidence; Heart transplants when the ejection fraction goes below a certain percentage, etc.
I'm all for websites for cost comparison, but I'm suspicious on where this leads: "Come down to Crazy Lenny's for your colonoscopy! We can't be undersold!" Maybe that has merit, just don't say you weren't warned. The classic example nowadays is "robotic surgery" for prostatectomy and hysterectomy. I know of no reputable non-proprietary study that shows significantly improved results, yet we are inundated with patient requests for "robotic surgery" due presumably to an active marketing campaign by the manufacturer of the robot. The CNN story shows a guy riding a bike who says he wanted this type of surgery, which costs more than double the standard surgery, because he wanted to ride his bike a couple weeks earlier! Now, maybe two weeks of bike riding is worth $10,000, but we should at least pause and stop wondering why health care costs are rising so dramatically. Note the quote by the urologist at the University of Kansas: no evidence that robotic surgery is better. I guess the Intuitive Surgical, Inc. marketing representative hasn't taken him out to dinner yet!

The same goes for a plethora of other screenings and treatments from vaginal mesh to coated cardiac stents to herbal supplements to erectile dysfunction pills, which become popularized, not so much by evidence-based data, but by marketing. And consider pharmaceutical advertising on the evening news: by my recent count the percentage was over 70% of the ads are for drugs. What do you think the odds are that Katie Couric or Charlie Gibson will present a negative story about the pharmaceutical industry? Bought and paid for, my friend. Sure this happens with government lobbying too, but let's not be naive in either camp.

I take this debate seriously. It has been brewing since 1992 when Hillary Clinton was first tasked with the implementation of health care reform. I was a medical resident at the time and I remember having discussions then about the perceived need for such reform. Other thoughtful people were opposed and said emphatically that the failure of Hillarycare was a good thing and that costs would come down by free market mechanisms. Now we are 16 years on and the costs have gone parabolic-- and perhaps they would be even higher had the Clinton proposal passed, but I doubt it, and it's long overdue to try something different.

If someone asked me, and nobody has, I would vote emphatically for a single-payer option for acute care and screening. People would have the option of purchasing further coverage if desired, and employers could certainly offer additional benefits, but a basic care plan needs to be in place for everyone. Our economic survival requires it.

*The WSJ cites the GOP Health Care Alternative, and I admit this has merit. However, it keeps intact the employer-based model and has other flaws that I can point out in a longer post.

1 comment:

Hamster said...

A parable

One day a poor pregnant woman came to Ron Paul
“Oh, wise one” cried the woman. “My husband was killed in an auto accident. I cannot support this child in my belly. I want to have an abortion. ”

Ron Paul gazed upon the poor woman and replied “No. Woman. The baby in your belly has a right to life. Go and have your baby and forget about an abortion”
So the woman had her baby.
The baby was born gravely sick.
It needed a doctor and expensive medical care.
So the woman returned to the Congressman
“Oh wise one. My baby is sick. But I am poor. I have no means of support and no health insurance. My child needs expensive medical care.”
Ron Paul took the the poor woman’s hands in his.
“Health care is not a right. My child. It is a good.” He reminded her . “You chose to be a wife and mother instead of learning a trade to support yourself. We are all responsible for our choices. If your child is sick and you cannot afford a doctor you have no one to blame but yourself.

The child died after much suffering