Why It’s So Hard to Reform Canadian Health Care
by Danielle Martin - NYT - March 23, 2018
TORONTO — Too many Canadians and Americans are negatively fixated on each other’s health systems — and the distortions that accompany so many conversations about health reform make it harder to improve care on both sides of the border.
Canadians staunchly support our universal health care system, according to polls over many years. We live longer, healthier lives than Americans, and our survival rates for cancer and other diseases are comparable. The father of universal health coverage in Canada, Tommy Douglas, is considered a national hero.
Like much of Europe, Canada considers access to health care a right on par with the right to food and shelter. In a country where medical bankruptcy is almost unheard of, we are reminded of our privilege every time we read about the shortcomings of the American health care system.
And yet Canadians are forced to defend our health system every day in the American media. American politicians grossly distort reality, proclaiming as fact the myth that Canadians die waiting for treatment. Perhaps that’s why many Canadians and some Americans cheered when I took on such claims at a United States Senate subcommittee a few years ago.
What Americans may not realize is that most Canadians are just as terrified of your system as you may be of ours (which, in fact, are several province-level systems). But sometimes that mix of pride, defensiveness and terror of American-style health care makes it hard for us to admit where Canada falls short.
In a paper recently published in The Lancet, my co-authors and I analyze the Canadian systems’ strengths and weaknesses, and we explore the obstacles to change. The weaknesses exist not because our systems are universal and centrally coordinated; rather it’s because they are often not universal or coordinated enough.
For example: Most provinces don’t cover prescription drugs for most people. Many people live in remote, sparsely populated areas where specialized care is hard to get. Indigenous peoples and many new immigrants and refugees face complex barriers to health care access.
And long waits for non-urgent services like hip replacements or M.R.I. scans for back pain are a genuine problem in many parts of our country. More than a third of Canadians wait more than two months to see a specialist, and 18 percent of Canadians wait at least four months for elective surgery.
But it’s important to recognize that long waits are not an inherent feature of all universal health care systems — many countries in Europe and elsewhere with strong universal systems don’t experience these problems. What’s different is that in Canada, doctors and hospitals have a high degree of autonomy, and don’t always participate in efforts to reduce waits. At times they have opposed attempts to have other professionals care for patients or to shift resources into needy communities.
And we have been slow to adopt virtual care, group-based care, and other models that would reduce waits. The solutions to delays in Canada lie in changing how we deliver health care services, not how we pay for them.
More robust dialogue is needed to really tackle these important problems — but the long American shadow chills our discussions. Fear of an American-style market-based system inhibits a national conversation about how to expand the breadth of coverage and increase the timeliness of services. Instead of talking about how to make our system better, we’re talking about how much worse things are in the United States.
And such behavior is evident on both sides of the border: Instead of closing their insurance coverage gaps, many Americans are busy pointing fingers at our difficulties. It’s an absurd habit that needs to end so that both countries can engage in more meaningful debate about how to fix our systems.
In truth, neither country performs as well as it should aspire to do. For our part, Canadians must tackle a culture of incrementalism that stops us from expanding services and improving how they’re delivered.
I know many doctors in the United States who would say the same about your system. The opportunities and challenges of rapid technological advances and an aging population don’t respect international borders. It would help us all if both countries stopped making each other a boogeyman to excuse their own paralysis.
B.C. vows to reduce surgical wait times for hip and knee replacements
The Vancouver Sun - March 21, 2018
VANCOUVER — British Columbia will address long wait lists for hip and knee replacements, allowing an extra 4,000 people to have the surgeries in the coming year, the premier says.
John Horgan said a $75-million investment this year is expected to increase to as much as $100 million in 2018-19 with the opening of new programs focusing on system improvements, such as operating room efficiencies.
Health Minister Adrian Dix said advocates for improved care have long argued that lessons learned from a former hip and knee project in Richmond be applied more broadly.
“When it comes to surgeries, I think it’s fair to say people have been waiting too long to get back to their normal lives,” Dix said Wednesday.
Dr. Bassam Masri, head of orthopedics for Vancouver Coastal Health, said he’s seen wait lists of up to two years during his 23 years of performing the surgeries.
“The target is that we can get almost everybody done in 26 weeks to alleviate the pain and suffering,” he said of a benchmark set in 2005 by health ministers in all provinces.
Masri said primary-care doctors will send patients to specific clinics where physiotherapists and nurses will determine whether they should be referred to orthopedic surgeons.
“That way, you’re reducing the overall wait time,” he said.
The latest figures from the Canadian Institute for Health Information show British Columbia was third from the bottom of all provinces in 2016, with only 61 per cent of patients getting hip replacements within 26 weeks.
Nova Scotia was in last place, with 56 per cent of patients getting the surgery within that benchmark, followed by New Brunswick at 60 per cent. The best outcomes were in Ontario.
British Columbia fared second worst in Canada when it came to patients needing knee replacements, with 47 per cent having the surgery within the benchmark, while Nova Scotia was at the bottom, at 38 per cent.
Jenn D’Silva, manager of emerging issues at the institute, said the number of surgeries in B.C. and elsewhere has increased since the benchmarks were set, but wait times have also risen.
In 2012, 80 per cent of people were being treated for hip replacements within the benchmark in B.C., and in 2016 it was 61 per cent, she said.
However, D’Silva said wait times are measured starting when the decision for surgery is made, not when patients first see their family doctor.
The recommended maximum wait time for hip-fracture surgery is 48 hours, and B.C. meets that benchmark 86 per cent of the time, which is the average time across Canada, the institute says.
But there are regional differences in all the provinces. In British Columbia, patients on Vancouver Island have the longest wait times for hip and knee surgery, at 45 per cent receiving care within the recommended time frame, compared with 77 per cent of patients in the Vancouver Coastal area.
Dr. Brian Day, a longtime proponent of private clinics, has been fighting a battle in B.C. Supreme Court since September 2016, arguing patients have a constitutional right to pay for speedier surgery.
He said 26 weeks is an unacceptably long time for patients needing surgery, and provinces are being “dishonest” in not using actual wait times.
The Canadian Orthopaedic Association’s maximum time for joint replacement is three months, said Day, a former president of the Canadian Medical Association and Doctors of BC.
Day said he routinely operates on patients who injured themselves at work as part of their WorkSafeBC claims, as well as RCMP officers and prisoners.
“I’m pushing for the medicare system to become efficient,” he said. “There’s no monopoly that’s good for consumers. If there’s no competition then how can you compare your performance?”
Critics Say Susan Collins’ Bill To Stabilize Insurance Market Would Restrict Abortion Coverage
by Patty Wight - Maine Public - March 20, 2018
U.S. Sen. Susan Collins of Maine has joined with Republican colleagues to introduce a bill that they say aims to stabilize health insurance premiums in the individual market.
Some elements of the legislation have the backing of national insurance, physician and hospital groups. But one major sticking point is a provision that critics say would effectively eliminate abortion coverage, even in private plans.
The major components of the bill include some that may sound familiar, such as funding for cost-sharing reduction subsidies. Those are payments insurance companies get to lower co-pays and deductibles for lower-income individuals. President Donald Trump ended those payments last year — Collins’ bill would reinstate funding for three years.
Her bill would also provide $30 billion in funding over three years so states can establish high-risk pools, which help cover high medical costs for some patients.
Those provisions have the backing of the Maine Medical Association, says spokesman Gordon Smith.
“This is very important in Maine to stabilize the insurance marketplace, and it’s a shame that it’s being held hostage to other issues,” he says.
The “other” issues Smith is talking about are restrictions to abortion coverage. A federal law called the Hyde amendment prohibits the use of federal funds to cover abortions. Language in Collins’ bill, Smith says, goes a step further by barring the use of cost-sharing reductions and reinsurance payments for plans that simply offer abortion coverage.
“That really does expand the Hyde amendment, it seems to me, into the commercial area where it has not been previously,” he says.
The Planned Parenthood Federation of America issued a statement condemning the bill, and warning that blocking those payments to insurance companies that offer abortion coverage will force insurers to drop that coverage altogether.
Collins spokeswoman Annie Clark says the legislation merely follows federal law. In a written statement, Clark says Collins’ bill retains the exact same protections that block federal funding from being used for abortions that have been in place for more than 30 years.
“We’d just like to see them pass something and get things done,” says Jeff Austin of the Maine Hospital Association.
Austin says the organization doesn’t have a position on the abortion language in the bill. But he says it’s critical to stabilize the insurance market.
If Collins’ bill were enacted, the health consulting firm Oliver Wyman projects that it would lower premiums by 40 percent and increase the number of people with insurance by about 3 million over the next few years. A Congressional Budget Office analysis projected a smaller premium reduction of 20 percent.
Whether the bill can garner enough support from both Republicans and Democrats is uncertain. On Wednesday morning, Collins and other Republicans will hold a press conference to push for the stabilization proposal to be included in the omnibus spending bill that Congress will take up this week.
Getting Sick Can Be Really Expensive, Even for the Insured
by Margot Sanger-Katz - NYT - March 21, 2018
When you get really sick, the medical bills may not be your biggest financial shock.
New research shows that for a substantial fraction of Americans, a trip to the hospital can mean a permanent reduction in income. Some people bounce right back, but many never work as much again. On average, people in their 50s who are admitted to the hospital will experience a 20 percent drop in income that persists for years. Over all, income losses dwarfed the direct costs of medical care.
The pattern and impact are comparable to what happens to workers at a mill when it closes.
The authors of the paper, published in The American Economic Review, were surprised by how often an illness or injury could upend the finances of Americans with health insurance.
“I had sort of assumed that if they had health insurance, then they had economic protections against health shocks,” said Amy Finkelstein, an economist at M.I.T. and an author of the paper. “I hadn’t thought about the idea that even with the best gold-plated, fancy health insurance, you could still have a lot of economic risk.”
The researchers focused on hospitalization because it’s one of the easiest ways to pinpoint when a person’s health declines substantially. They looked at people who had heart attacks, strokes or knee replacements, as well as those who contracted pneumonia or were hit by cars. The only cause of hospitalization they excluded was childbirth.
Hospitalization can cost thousands (or tens of thousands) of dollars, which is why health insurance has been shown in study after study — including a seminal one of Oregon patients in which Ms. Finkelstein was a co-author — to greatly improve the financial security of people who experience illness or injury.
Obamacare brought new insurance coverage to some 20 million Americans, and that coverage has seemed to make them more financially secure. Low-income people in states that expanded Medicaid appear to have fewer medical debts and bills in collections. Fewer of them are avoiding medical care because of the cost.
But the costs of illness are not always limited to medical bills. Being sick can make it hard to work. Though people who had insurance were better protected from hospital bills than people who were uninsured, both groups faced a substantial risk that they would lose income, and a substantially increased chance that they would declare bankruptcy after leaving the hospital.
On average, uninsured people in the study owed the hospital $6,000, compared with only $300 for those with insurance. But the average decline in income for both groups was much larger — an average earnings hit of $11,000 by the third year. Much of that average — around 60 percent — came from people who never returned to work at all.
Other research supports the notion that serious medical problems are associated with work interruptions. A 2015 survey conducted by The Upshot and the Kaiser Family Foundation found that, among people struggling to pay medical bills, 29 percent said their illness or injury had led to a drop in household income. In general, the United States doesn’t provide much sick leave, disability or wage insurance to protect people from those kinds of costs.
Yolanda Carrero, who got a diagnosis of breast cancer in 2014, loved her job in the infant room at a day care. She was fortunate to have health insurance from the day care, where she had worked for 14 years, and short-term disability insurance. She thought she’d need only a few weeks off to recover from a mastectomy. But an infection led to two more operations, and she missed three months of work.
Then, when she returned, she couldn’t lift the infants or sit on the floor with them anymore. Her employer supported her, moving her to another assignment and allowing her to scale back to part-time hours, but the shift was a big financial hit. Her adult son was living with her and helped pick up the slack. “I couldn’t even afford the rent,” said Ms. Carrero, who lives in Holladay, Utah. “That was a rough few years.”
Ms. Carrero, 49, fared better than many people in the study. After a few years, she left the day care and moved to an advertising agency. She says she misses the children, but the new job is less physically taxing and pays more.
The researchers looked at two major sources of data to understand the financial consequences of a big health shock. One was a large government survey of people in their 50s and 60s. That survey followed people over time, and asked them whether they’d been hospitalized, whether they were working, and how much they were earning. The survey produced the results about the specific income changes that came after a hospitalization. (The income drops might be smaller for younger people, who are further from retirement.)
The team also looked at a big California database of everyone over 24 who was admitted to the hospital, data it was able to match with individual credit reports (names were hidden). The credit report data showed that people’s overall spending tended to go down and stay down for years after a hospitalization, suggesting a drop in income. It also showed large increases in the risk of bankruptcy among people who were hospitalized.
Some people who go to the hospital probably end up with disabilities that make it hard or impossible for them to work. Others may just get knocked off their career trajectories if they must leave a job temporarily while recovering from illness. Other research in economics shows that career hitches, like taking a break to have a childor graduating from college during a recession, can have long-term consequences for people’s earnings, just like plant closings. A health shock may follow that pattern.
“It makes me wonder: What exactly does insurance insure against, and is that the thing that we really want it to insure against?” said Benedic Ippolito, a health economist at the American Enterprise Institute, who has studied medical debt.
To the authors, the lesson of the paper is that standard health insurance isn’t enough — policymakers need to think about ways to better protect people against the income risks that accompany illness. In Denmark, for example, similar reductions in income have been found after hospitalizations, but government programs help replace some of the losses, lessening people’s financial burden. Such programs, to expand wage insurance, sick leave or disability insurance, would require new resources from the government or employers.
“We just don’t have as robust of a system that protects people against large changes in their household income,” said Matt Notowidigdo, an economist at Northwestern University, and another co-author of the paper.
In their study of California patients, the researchers found that hospitalized older Americans, who typically earn Social Security income and tend to be retired, didn’t have the same heightened risk of bankruptcy as their younger peers. It was another indication that what we often think about as medical bankruptcy may be more about how sickness affects work than the cost of medical bills.
David Himmelstein, a professor of public health at Hunter College, was the co-author of a much-cited paper estimating that medical problems were responsible for a large proportion of American bankruptcies. (Another co-author was the Harvard Law professor Elizabeth Warren, now a Massachusetts senator.) Dr. Himmelstein said, based on his research and his experience as a physician, that he wasn’t surprised to see how lost work was contributing to the financial travails of the sick. His original paper called not just for health insurance, but also for disability insurance.
“It’s why when we wrote about this we titled our paper ‘illness and injury’ as a cause of bankruptcy, not ‘medical expenses’ as a cause of bankruptcy,” he said.
Elizabeth Warren Has A Plan To Make Health Care Coverage Cheaper And More Reliable
by Daniel Marans - The Huffington Post - March 21, 2018
Sen. Elizabeth Warren (D-Mass.) introduced a bill Wednesday aimed at dramatically increasing the affordability and reliability of health insurance plans available on the Affordable Care Act marketplaces.
The legislation, called the Consumer Health Insurance Protection Act, would offer people buying health insurance on their own more financial assistance ― and allow more people to qualify for that assistance. Nobody would have to pay more than 8.5 percent of income on premiums.
Warren does not envision this new plan as an alternative to more ambitious proposals. She remains a co-sponsor of the single-payer legislation introduced by Sen. Bernie Sanders (I-Vt.).
But as Warren made clear in a January speech before the consumer group Families USA, she understands that enacting a single-payer plan would be difficult ― and that, as a result, private insurance probably won’t disappear overnight. And so she also wants to focus on what can be done right away to subject the industry to the type of stringent consumer protections she has already successfully championed in the financial sector.
“So long as private health insurance exists, we should require these companies to provide coverage that is at least as good and priced as reasonably as the coverage offered by our public health care programs,” Warren said in January.
Sanders is actually a co-sponsor of the Warren bill, as are Democratic Sens. Kamala Harris (Calif.), Maggie Hassan (N.H.), Kirsten Gillibrand (N.Y.) and Tammy Baldwin (Wis.).
Baldwin’s presence is particularly noteworthy as she faces a tough re-election battlethis November in a state that Donald Trump won.
The consumer advocacy organizations Families USA, Public Citizen, Consumers Union and Community Catalyst have also endorsed Warren’s bill.
“So long as private health insurance exists, we should require these companies to provide coverage that is at least as good and priced as reasonably as the coverage offered by our public health care programs.” Sen. Elizabeth Warren (D-Mass.), in January.
The legislation consists of policies that try to achieve four major goals: increase insurance affordability; provide consumers with new protections; safeguard the ACA from Trump administration attempts to unravel it; and ensure private insurers’ participation in the ACA marketplaces. Some of the provisions apply to all private insurance plans, including employer-sponsored coverage, while others fall on ACA plans alone.
In the affordability category, which features the biggest changes to the health care system, Warren would increase the subsidies available to Americans buying health insurance plans on the ACA’s marketplaces. Currently, low- and middle-income individuals buying ACA plans for themselves and their families are entitled to subsidies offsetting their premiums that are based on the cost of the “silver,” or second-least expensive plans.
The subsidies get steadily smaller as a person’s household income approaches 400 percent of the federal poverty level. Above that income threshold, which is $48,560 for an individual and $100,400 for a family of four, ACA marketplace consumers are not entitled to any federal help.
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As a result, some middle-class consumers buying their coverage on the ACA marketplaces have taken a major financial hit from rising monthly premiums in the ACA plans.
By switching to a system where premiums are capped as a percentage of income, Warren would insure that no household is without protection from premium increases. Basing the subsidies on the cost of the more expensive “gold” plans would also allow families to buy more generous coverage at the same cost or stick with a less generous plan and pocket the savings.
Another feature of Warren’s bill aimed at enhancing affordability is a provision capping out-of-pocket costs on prescription drugs at $250 per month that would apply to all private plans. Since the clause targets a small subset of consumers with exceptionally high drug costs, and ACA consumers are already protected with an annual cap on out-of-pocket spending, the number of people who would save money from the provision is likely minor but still significant.
The legislation would also introduce new rules designed to protect consumers from insurance plans that prove unreliable and inadequate. All private insurance plans would be required to spend 85 percent of their premium dollars on paying out insurance claims ― subjecting them to a tighter standard than the one that already applies to ACA plans. They would also be barred from changing the kinds of drugs that they cover in the middle of the year, as well as how much of those drugs’ costs are born by consumers.
Consumers would also be shielded from the effects of an insurer dropping a plan during their course of treatment. And insurers would have to notify consumers if a plan no longer covered a particular doctor.
The bill’s provisions protecting the ACA from Trump administration sabotage include increased funding for outreach and education about enrollment in ACA plans, and tightening rules requiring coverage of “essential” health benefits, which the administration is trying to water down. Like other legislation under serious consideration in Congress, Warren’s bill would also reinstate the federal government’s cost-sharing reduction payments to insurers, which subsidize limitations on out-of-pocket costs for low- and middle-income consumers. (Trump discontinued them in October.)
Finally, Warren would “call [the insurers’] bluff” by requiring insurance companies that bid on Medicare Advantage and Medicaid contracts to offer plans on the ACA marketplaces in parts of the country with limited insurance industry competition. New York already has a similar regulation in place.
Since Warren’s bill has not yet been scored by the Congressional Budget Office, it is not clear how much it would cost. The most expensive part of the legislation is the component increasing subsidies for ACA marketplace plans.
A 2015 Urban Institute study that assessed the cost of a plan with several similar features, including switching to a gold plan benchmark for subsidies, found that it would cost $221 billion over a 10-year period.
What’s So Good About Health Care?
by LTE - NYT - March 22, 2018
To the Editor:
Re “Why Is U.S. Health Care So Expensive? Some of the Reasons You’ve Heard Turn Out to Be Myths” (The Upshot, March 13):
It’s true that “analysts are fond of describing the system as wasteful, with too many patients getting too many services.” But those of us on the front lines know that large segments of the population have no real access to quality medical care, and even those with “good insurance” struggle through a maze of barriers and increased costs.
The United States has some of the highest administrative costs in the world because of our fractured, multipayer, profit-based system. Private insurers add zero value but drive up costs through administrative waste and profiteering, and require hospitals and doctors to maintain complex billing and cost-tracking bureaucracies.
While no system is perfect, we have an excellent solution in the form of Medicare. A single-payer plan like H.R. 676, “Medicare for All,” could save an estimated $617 billion a year by slashing administrative waste in the private insurance industry ($504 billion) and bargaining down drug prices ($113 billion), freeing up money for universal coverage without any net increase in health spending.
ERIC SALK, TORRINGTON, CONN.
The writer is medical director of emergency medicine at the Charlotte Hungerford Hospital.
To the Editor:
On a recent Friday night, I was rushed to an emergency room in Taipei, Taiwan, for the worst headache of my life. The wait time was on a par with the United States, but the cost was considerably different. The total cost of my visit, including medication, was roughly $83 because I am not a Taiwanese citizen. Otherwise, it would have been around $20.
Our researchers should be focusing on a nationalized health system to reduce systemic costs instead of being instruments for the health insurance companies.
NICHOLAS RAINS, FREMONT, CALIF.
To the Editor:
Regarding the recent JAMA study concluding that American health care compares favorably with other countries:
What’s rosy about a system that leaves millions of working Americans without insurance or without sufficient coverage; that issues insurance denials to those who pay exorbitant premiums for it; that scares people away from getting medical attention because the deductibles compel them to choose which of their multiple ailments they can treat in a given month?
How Maine seniors can see lower drug prices
by Terry Wilcox - Bangor Daily News - March 23, 2018
Patricia Bernard of Falmouth has unwittingly become the face of American seniors facing high drug costs.
Sen. Susan Collins recently invited Bernard to tell her story before the Senate Aging Committee, which Collins chairs. Diagnosed with rheumatoid arthritis 25 years ago, Bernard worked until age 79 to keep her employer-sponsored health insurance plan that allowed her to purchase the medication she needed for between $10 and $30 a month.
“I felt so much better,” Bernard said of the medication. “It truly gave me my life back. I was no longer aching and in agony. I was finally able to live an ordinary life and I started taking the stairs just because I could.”
But upon retirement she faced a monthly out-of-pocket cost of $3,800 for the same drug. This drug price spike had nothing to do with a change in the underlying cost of the medicine, but everything to do with the insurance design. Medicare would not cover her self-injected medication, but as an alternative, Bernard is being treated for her condition with an infusion medication that Medicare does cover in an outpatient hospital. Despite the inconvenience, it’s affordable.
How can state and federal legislators lower drug prices afflicting Bernard and millions of other seniors like her across the country? One effective way is by scrutinizing the practices of pharmacy benefit managers — as several states are in the process of doing.
Benefit managers are the middlemen between drug companies and insurers, purchasing prescription drugs from the former — at substantially discounted rates — and selling to the latter, taking a cut from both sides. But benefit managers aren’t just traditional middlemen. They keep their prices hidden, so insurers don’t know what benefit managers paid drug companies, and drug companies don’t know what they are charging insurers. Patients, of course, are kept completely in the dark.
This secretive design allows benefit managers to set a minimum price they will accept from insurers and a maximum price they will reimburse pharmacies. This spread between the two prices guarantees a fat profit margin.
“Very little, if any, of that money, goes to the patients whose prescriptions make the rebate revenue happen,” Dr. Robert Goldberg, vice president of the Center for Medicine in the Public Interest, wrote in an OpEd in The Hill. “Moreover, the PBMs and insurers make the sickest patients pay between 30 and 100 percent of the retail (not rebated price) of medicines depending on the drug plan.”
Several states — including California, Nevada, Texas and North Dakota — have introduced legislation to shine a light on benefit managers, potentially exposing their conflicts of interest and demonstrating whether they are passing on cost savings from drug price rebates to insurers and patients.
While state governments work to expose benefit managers, the private sector may also disrupt this inefficient model. The recent announcement that Amazon, JP Morgan and Berkshire Hathaway are venturing into health care sent pharmacy benefit manager stocks plummeting. These companies are big enough to cut out the middleman and negotiate cheaper drug prices for their employees directly with drug companies. Eventually, these discounts may be passed along to all Americans through Amazon.com.
If Amazon can do for prescription drugs what it’s done for the rest of retail, that would not only eliminate Bernard’s trip to the hospital, but also her trip to the pharmacy. Until then, governments must probe the pharmacy benefit manager model to uncover just how much these middlemen are responsible for today’s drug prices.
Terry Wilcox is co-founder and executive director of Patients Rising, a patient advocacy group working to ensure access to vital therapies and medical services for patients with life-threatening and chronic diseases.
It's Surprising How Few Countries Have National, Single Payer, Health Care Systems
by Tim Forstall - Forbes - March 26, 2017
The details of last week's fiasco about American health care are for my colleagues over on that desk to deal with. My purpose here is just to point out that the economic structure of health care in other places just isn't what all too many people think it is. There's a large part of the American political class insisting that this is just obvious. We should have a national, single payer, health care financing system. And the amazing thing about this is that so few countries actually do that. And most of those countries who are thought to have better health care systems than the US don't do that either.
There are indeed national health care systems out there--but they tend not to be single payer. And there are single payer systems out there, or close enough at least--but they tend not to be national. Which is something that we really ought to be thinking about, no?
Take it as read that the US system isn't as good as it could be. And also that we might want to propose something to make it better. So, we're agreeing that something must be done. My point here is just that the economics of what we should do might well not be the same as the economics of that national single payer system we're urged to implement.
This has been sparked by this piece from last weekend in the NYT:
Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it.
OK, let's also take it as read that the Finnish system works. And it does too, it's a pretty good system, as are those in Sweden and Denmark to my certain knowledge. But the bit that concerns me is that nowhere in the piece is a very important qualifier mentioned. So too it's not mentioned in the bulging letters page this weekend.
Those three Nordic systems are not national systems at all, although they are all single payer. It is the municipality which collects the money, the tax, to pay for health care. And it's the municipality which then spends that money too. I maintain that this is rather why those Nordic social democracies work too. The Danish national income tax rate is 3.76%. No, that's 3 point 76%, not 37.6%. The top Danish national income tax rate is 15%. The place the money really gets gouged is at the level of the commune--that can be as small as 10,000 people and is thus a much, much, smaller unit than an American county. That money is raised locally and spent locally and that, I insist, is why people are happy enough that they've got to pay so much in tax.
I've called it the Bjorn's Beer Effect:
Instead they have what I call the Bjorn's Beer Effect. You're in a society of 10,000 people. You know the guy who raises the local tax money and allocates that local tax money. You also know where he has a beer on a Friday night. More importantly Bjorn knows that everyone knows he collects and spends the money: and also where he has a beer on a Friday. That money is going to be rather better spent than if it travels off possibly 3,000 miles into some faceless bureaucracy. I give you as an example Danish social housing or the vertical slums that HUD has built in the past. And if people think their money is being well spent then they're likely to support more of it being spent.In the end, local collection and spending of taxes is likely to lead to people being willing to pay higher taxes.
That's not how anyone is proposing some notional single payer system in the US is going to work, is it? Rather, the vision is of one bureaucracy collecting all the money from 320 million people and then doling it out again on a national basis. And the sums would be eyewatering - $2 trillion sounds about right. 10-12% of GDP is that roughly right number for providing full health care to everyone.
Other systems are mentioned as well:
A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.
Note the very careful indeed wording there. Universal government guided health care--for those systems are not single payer. Holland, Germany and Switzerland all have mandatory insurance systems from private sector insurance companies. Germany has some 130 of them for example.
Again, please note I'm not trying to talk about whatever the US should or should not do. I'm making an observation about the economics of systems which seem to work in other places. The exemplars we're all asked to look at are not national, universal and single payer. They tend to be either almost hyper-local in their financing if they're single payer or if they're national then they use insurance companies--they're multi-payer. My assumption would be that both single payer and national is just too inefficient. There's neither local pride nor profit lust keeping the system efficient.
There are indeed national and single payer systems out there, most notably the National Health Service in Britain. That's very fair, very equitable, but performs horribly on "mortality amenable to health care" which is otherwise known as curing people of what ails them. That's not a recommendation.
American Adults Just Keep Getting Fatter
by Matt Richter and Andrew Jacobs - NYT - March 23, 2018
American adults continue to put on the pounds. New data shows that nearly 40 percent of them were obese in 2015 and 2016, a sharp increase from a decade earlier, federal health officials reported Friday.
The prevalence of severe obesity in American adults is also rising, heightening their risks of developing heart disease, diabetes and various cancers. According to the latest data, published Friday in JAMA, 7.7 percent of American adults were severely obese in the same period.
The data — gathered in a large-scale federal survey that is considered the gold standard for health data — measured trends in obesity from 2015 and 2016 back to 2007 and 2008, when 5.7 percent of American adults were severely obese and 33.7 percent were obese. The survey counted people with a body mass index of 30 or more as obese, and those with a B.M.I. of 40 or more as severely obese.
Public health experts said that they were alarmed by the continuing rise in obesity among adults and by the fact that efforts to educate people about the health risks of a poor diet do not seem to be working.
“Most people know that being overweight or obese is unhealthy, and if you eat too much that contributes to being overweight,” said Dr. James Krieger, clinical professor of medicine at the University of Washington and executive director of Healthy Food America, an advocacy group. “But just telling people there’s a problem doesn’t solve it.”
The latest data from the National Health and Nutrition Examination Survey comes at a time when the food industry is pushing back against stronger public health measures aimed at combating obesity.
In recent NAFTA negotiations, the Trump administration has proposed rules favored by major food companies that would limit the ability of the United States, Mexico and Canada to require prominent labels on packaged foods warning about the health risks of foods high in sugar and fat.
While the latest survey data doesn’t explain why Americans continue to get heavier, nutritionists and other experts cite lifestyle, genetics, and, most importantly, a poor diet as factors. Fast food sales in the United States rose 22.7 percent from 2012 to 2017, according to Euromonitor, while packaged food sales rose 8.8 percent.
The latest survey data found that American youth are faring somewhat better than adults. Among Americans ages 2 to 19, 18.5 percent were obese in the 2015 and 2016, while 5.6 percent were severely obese. (A severely obese youth is defined as being 120 percent above the 95th percentile of body-mass-index for age and gender.)
The study found that the percentage of youths who are obese and severely obese rose slightly from the 2007-2008 time frame, but not enough to be statistically significant.
Dr. Craig Hales, co-author of the survey research, said the small increase in childhood obesity “could be due to sampling error,” and that the upshot was “no increasing or decreasing trends over the last 10 years.”
“Something different is happening with adults and youth,” he said, adding that he wasn’t able to explain the reasons.
One group of youths that has seen statistically significant weight gain are the youngest children, ages 2 to 5. Obesity rates in this group rose to 13.9 percent in 2015 and 2016 from 10.1 percent in 2007 and 2008.
Scholars who study childhood obesity disagree about whether childhood obesity has plateaued or is increasing.
“We haven’t turned the tide. If anything, rates are continuing to climb upwards.” said Dr. David Ludwig, a nutrition professor at the Harvard T.H. Chan School of Public Health. The 18.5 percent youth obesity rate in 2015-2016 marked an uptick following earlier years dating back to 2007 and 2008 when it had held steady at about 17 percent.
Dr. William Dietz, director of the Stop Obesity Alliance at George Washington University, said that it is premature to reach any conclusions about the trend in childhood obesity.
“I’m worried about it for sure, but we need two more years of data,” he said. Still, he called the overall report “dismal,” given that the high rates of obesity mean high rates of disease and premature death.
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