Wednesday, July 22, 2009

Fred: Perspectives from a Spanish Physician

Hello, everyone! Thanks to George and Bob for their thoughts in response to mine (and to Cal for getting us all engaged in this important question!). No doubt about it, the health care issue is one of the great ones for our time, and it certainly isn't easy to understand (does anyone fully understand it?) or to solve. But, it is great to have exchanges like this, it helps me, for one, clarify my thinking a lot.

I am lucky today in that I have a house guest who is, as it happens, a physician in Spain. She's now in her residency phase and will specialize in ER care. So it was interesting to discuss some of these issues over dinner with her and her cousin (American, also staying with me now).

She was quite mystified by the American dilemma. In Spain, which has "socialized medicine," the government runs hospitals and clinics and pays doctors. If you are sick, or injured, or need nursing care, you go to a clinic, or a hospital, or wherever you need to go, and you are treated by the doctors. You don't have to pay anything because everyone in Spain is allowed to use the health care system as needed. The doctors are paid on a salary, presumably: generous enough (my visitor just bought herself a BMW--she's about 30 or 35, I would guess) but doctors there don't become millionaires. (Is that bad?). There's no question of "government bureaucrats deciding what health care you get," as the scare ads like to scream: the government collects taxes and uses them to pay for whatever health care costs the population as a whole incurs, and certainly this becomes a fairly predictable and steady kind of reimbursement because a city has a fairly stable population and its aggregate health care needs probably change little from year to year. Neither patients nor doctors have to worry about insurance claims, or filling out all kinds of forms: you go to the doctor and get treated, and that's it.

So it seems to me that the problem with our system, and with the proposed Obama solution too, is that it STILL focuses not on health care itself, which is what we need, but on health INSURANCE, which I increasingly think is just a parasitic growth that we should eliminate. Much of the screaming against any reform comes from the health insurance companies: but it's the insurance-based approach that has really created the crisis we now face. If we must keep the insurance companies (rather than move to a system like Spain's), perhaps we should make it illegal for insurers to write health insurance without also providing a death benefit/life insurance component. In other words, the insurer would, for your premium, agree to pay your health care costs and also, if you died, to pay your heirs the death benefit. This might make insurers more interested in helping the insured get the care they needed to get well, rather than in cutting costs by denying claims, because they'd be on the hook for the death benefit if you died. It would provide an incentive for the insurers to do a better job with health insurance.

But--I still think a fully socialized system of health care would be preferable. No payments, no forms, doctors get to concentrate on treating patients in what they think is the best way without worrying about cost constraints. Doctors wouldn't be tempted to take on hundreds of patients they hardly saw in order to get the per-patient reimbursements they now receive; they'd just draw their regular salary. I know many don't like the idea of a government-supported health system; you can't choose your doctor is one of the main gripes. But, I think one actually *could* choose one's doctor for routine care: if you lived in, say, Chicago, the doctors who worked in the local clinics and hospitals would probably be a fairly stable pool, and you could arrange to see a particular one you liked by appointment for anything that was not urgent: regular checkups, etc. If you had an emergency, of course, you'd have to go to the clinic/ER and take your chances on who was on duty, but that's just like what we have now anyway, so what's the difference?

Cal's concern about illegals getting health care they don't "deserve" also set me thinking. In our pay-as-you-go system of course it seems galling to have 12 million "illegals" who can get health coverage while we pay for it. But: some of these illegals actually work and pay taxes. So those people are not really cheating the system, they are helping to support it. Second: if you want to construct a system that keeps out the people who don't have the right paperwork, how do you do it? The only way is to have an elaborate system of regulations, and forms to fill out, and people to take care of that paperwork and inspect it for other words, you create a huge overhead of paperwork, in order to deny this small segment of the population (maybe 3% of our population) getting health care. I'm not sure it's worth it: it's probably cheaper just to let everyone come to the clinic to get their broken hand set, their throat culture for strep taken, etc. And it's much more compassionate, which I like to think is an important part of what America is all about: I, for one, would NOT want to live in a society where I would have to pass on the streets people with bad, but treatable, diseases or injuries. Can we turn the child with a broken arm away because his parents are "illegal"? Or an adult, for that matter? What would that say about us as a society, as individuals? ("Heartless" comes to mind.) Anyway, it's probably cheaper just to treat everyone than to try policing to keep out "illegals." It just isn't worth it.

This raises another thought, one that goes to Bob's comment "What business is it of yours what health insurance I have?" If you look at it solely from the perspective of insurance--which I think is the core of the problem-- then, of course, it's no business of mine. If you want to take big risks, have no coverage, get sick and die or pay a fortune out of pocket for treatment, that's your business and your bad luck I suppose. But we can't look at this only from the perspective of insurance and our personal money. We must also look at it from the perspective of public health/epidemiology in an increasingly dense society; if my neighbor comes down with a virulent flu or cholera, I damn well DO want him to get treatment, and quickly too, before it spreads to me and into the local schools and in the local supermarket. Even with noncommunicable ailments, I think we owe it to ourselves and our communities not to have people covered with painful oozing boils, or broken and deformed limbs, or other horrible conditions begging on our sidewalks or knocking at our doors asking for handouts; such conditions may not be medically communicable, but they're socially communicable, so to speak. On top of which, there's the broader matter that keeping the WHOLE population in a better state of health means, generally, fewer days lost to illness by businesses and a more productive economy. So, since we live in communities, I think we have to shoulder the burden of communal life to the extent that we try to guarantee that everyone has access to good medical care they can afford. The insurance approach simply doesn't provide that.

I agree completely with George that any plan that is proposed for the population at large should certainly be the one that the President and members of Congress and all public servants belong to as well. I also agree with him that tying health insurance to employment is the wrong approach, for the reasons he pointed out. But I'd go further: get not only the government out of the health insurance business, but also the health insurance companies out of the health insurance business, and just have a publicly-run health care system open to all. No insurance required. Like in Spain, tailored to our needs. Yes, we'd pay higher taxes I suppose--but maybe no higher, maybe quite a bit less, than our current health insurance premiums. It would sure take a big burden off business not to have to provide this any longer. And it would be so much simpler for everyone: patients, doctors, hospitals, who would no longer have to negotiate the current maze of paperwork.

As for the haste/waste question, which George also raised: in principle I agree. But I heard an interesting comment on the radio the other day--claiming that Obama's rush is based in his awareness that the longer the debate goes on, the more time the insurance lobby and the pharmaceutical lobby and others will have to pour money into "scare" ads to sway the population against any reform. So he wants to get something passed before these lobbyists with their billions really have time to get mobilized.

But then--this simply points out that the most basic problem we face as a country is the corrosion of democracy by money in politics. Until we have fully publicly-funded elections so senators and congressmen aren't beholden to interest groups and their campaign contributions (and hence to their lobbyists), any other kind of reform will be difficult. But...that's to open a whole new issue. Let's stick to health care for now!

Thanks again, everyone, for your comments!

Best to you all,

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