What is wrong with our healthcare system? Part 1--Insurance.
People often ask me, “What do YOU think should be done about health insurance?”
“Oh,” I quickly reply, “That’s easy, abolish it. It’s a horrible model for health. Clearly.”
As you can imagine, I get a lot of shocked looks. This is especially because I’m known as something of a “soft heart”, wanting to take care of the poor and miserable, making sure that everyone has access to enough food, medical care, and good schools, regardless of income. As a Christian, that’s what I think God wants us to do, and I’m all for it. The problem is, insurance isn’t the model for that. It doesn’t work, it has led to conglomerate medicine, poor outcomes and generalized patient and doctor dissatisfaction with the entire system. What should we do when something isn’t working? Should we go in for even more-of-the-same? Or just get rid of it and start over?
The US currently has the highest per-capita spending on health in the world, yet, we score relatively poorly on actual health outcomes. According to the Commonwealth Fund, in 2014 we came out 11th, of 11, wealthy countries in health outcomes despite having the highest spending.[i] These outcomes are things people actually care about, such as life expectancy, child mortality and medically-preventable death. If you want to be particularly appalled about our level-of-care, go here and look at the chart. It’s embarrassing to be comparable to the Slovak Republic on the care of asthma despite having the world’s largest health-care budget.
How did this all happen? Well, for that we have to go back to the advent of Medicare in 1965. At that time, overall care for seniors was poor, with only about 55% having any health insurance.[ii] Although they could pay doctors for care, hospitalization was out of the question. Medicare provided them a real opportunity for quality health-care. The problem is, it also provided doctors with the opportunity to make a lot of money, more than their usual fee-for-service practices. It provided hospitals with a guaranteed paying population that would pay whatever was charged. At the same time, HMO’s came on the scene in a major way.[iii] HMO’s began soaking up patient-dollars and enrolling doctors in their panels, just so the doctors could have access to paying patients. The medical-industrial complex exploded into what you see today.
Why is this a problem? Well, my brother Frank, ever pithy, expresses it this way:
Insurance isn’t for everyday problems; it’s for unexpected problems, things we can’t foresee coming, like fires and earthquakes. What if you had insurance for your car maintenance? Would you care for your tires? Would you change your oil? Would you drive carefully? Would you look for the best deals on tires and oil changes and car-washes? Or would you just go to town, knowing that your “insurance” was going to pay for everything no matter what you did? What do you think would happen to the prices for tires? For oil changes? For car-washes?
Those costs would go up astronomically, because the price becomes whatever the market will bear. When the one making the choices isn’t the one paying the bills, the market will bear a whole lot of exorbitant prices, which can be demonstrated by our current “health”-care spending. We spend a whole lot to get not-a-lot of actual health in return.
Primary Care, the care that we get for our everyday problems like rashes, and colds, sprains and even chronic diseases like diabetes is like car maintenance. Everybody will need to do some medical care for themselves sometime. Everybody needs health maintenance, someone to discuss exercising, quitting smoking, improved diets and their social needs. It shouldn’t be paid for with insurance. It should be paid for with cold-hard-cash, that we control, so we know what we’re getting for our money.
On the other hand, there is catastrophic care, the kinds of things that can’t be planned for, like car-accidents, cancer and premature birth. Or things that are beyond the capacity of a normal person to afford, like organ-transplants, ICU care for sepsis or a child with sickle-cell anemia. These things can be covered by insurance, and should be available to all. Should there be no cost-sharing? No, I don’t think so. I think that people make better decisions about their care when they know they are on the hook for a part of it. Nor should we leave poor people to “fend for themselves” when it comes to medical care, or the working class to have to spend themselves down to bankruptcy to get covered for these catastrophic expenses.
The ideal system, one that combines elements of the Swiss system and the Singapore system, is one where everyone is required to have both catastrophic insurance AND to have a Health-Savings-Account. The Health-Savings-Account is for the everyday expenses, with the insurance actually doing what insurance is supposed to do, take care of the unexpected. The government can subsidize the HSA for those who cannot afford to make full contributions so that everyone, regardless of income level, can get good care.
Even chronic, expensive, diseases like sickle-cell-anemia and asthma from prematurity can be better and less expensively cared for in a healthy primary-care environment. Excellent primary care has been shown repeatedly to lower emergency department visits and hospitalizations for a range of conditions, to include diabetes, COPD, asthma and chronic kidney disease.[iv]
All of this is why I recommend to my new patients who don’t have insurance, or have expensive and more-or-less useless HMO plans that they start on Liberty HealthShare. Liberty HealthShare is an expense-sharing organization where members band together to take responsibility for their own health, but also reach out to help those in need. Members pay for the basics themselves, but are backed by a large group of like-minded citizens who want to help and similarly be helped in return should they need it. It’s not perfect. They don’t cover pre-existing conditions immediately, but they do offer affordable assistance in a cost-effective way. They also avoid the third-party pitfall of taking the payer out of the decision-making process. It puts you, the patient, back in control of your care and your health.
And that is what “Health” care should be all about.