A teenager I know lives an area replete with doctors and highly rated hospitals. Last Sunday he whacked his ankle while playing a pickup game of basketball. It immediately swelled to the size of a baseball, causing pretty intense pain.
His mother decided against taking him to the ER, because the last time she did something like that, her health insurance company refused to pay. She’s still fighting them months later.
So she waited until Monday, called their primary doctor, and was referred to an orthopedic practice. Those people first said her insurance would cover the visit, then, when she asked for the name of the person okaying it in case her insurance company balked, she was told the visit wasn’t covered.
Eventually, she found another doctor to look at her son.
To be sure, this isn’t a story of someone dying in the street, as happens to third world countries (not to mention third world areas of this country). But it is a common middle-class occurrence in this country, where the biggest cause of bankruptcy is medical bills.
So how does that happen?
More important, why do doctors and hospitals advertise for patients even as sick people go untreated? Why are doctors retiring early? Why are medical bills the biggest causes of bankruptcy in the country?
The answer: a fundamental conflict between democracy and capitalism.
Democracy is a political system in which the majority rules. Our form of it is “representative democracy,” meaning we elect people to work the corridors of power for us.
It is, as Churchill famously said, “the worst form of government, except for all the rest.” Why? Because in democracies individuals have more control over who leads them than any other form of government.
Which is messy, time consuming and highly inefficient.
Capitalism is an economic system, not a political one. It is based on competition and efficiency – you win the competition by combining the highest profit with the lowest cost. The less mess the better the outcome. Employees and customers can have a say but the CEO rules.
The two systems have different goals and processes: one gives power to people in a bottom-up process; the other takes power from people in a top-down process. They’re in conflict by definition. Carnegie, Rockefeller and others were dictators of monopolies that were broken up by majority-elected lawmakers.
Which brings us to health insurance companies.
Health insurance started in the US nearly a hundred years ago as a way to manage healthcare costs, just as a hundred or so years earlier fire insurance began to manage fire damage costs. In the last 50 years health insurance companies took efficiencies to new heights. They effectively stole all the patients from doctors and hospitals.
As a result, medical professional are now controlled by a handful of insurance companies. Doctors no longer decide treatment; insurance companies do. Rationing has been introduced by insurance through the process of refusing or inordinately delaying payments. Hospitals have closed and doctors are retiring even as the number of patients is growing. Insurance and healthcare companies have consolidated across the country.
Competition, the engine of capitalism that drives innovation, efficiency and profit, has reduced from a supercharged V-8 to a two-stoke lawnmower.
Thus a drop-in quality of -and access to – healthcare.
To solve that, the government has added a new layer: Obamacare, a system including Medicaid, cobbled together by Congress and 50 states, to make insurance companies fairer.
(I pause here for laughs).
This merging of democracy and capitalism has produced a health system that is, according to data from the Organization for Economic Cooperation and Development, the World Health Organization and others, ranked lowest out of 11 first-world countries in “efficiency, equity, and outcomes” and highest in cost.
What to do? Here are four ideas.
First, get rid of the health insurance companies. They’re profit centers, not medical centers.
Second, replace them with a single-payer system providing efficiencies through reduction of redundancy.
Third, manage them with medical professionals, not politicians and reward managers based on patient outcome, not fee for service. The better the outcomes, the more money for the managers.
Fourth, oversee management with elected officials just as elected officials supervise our military. If they do a lousy job, they can be thrown out. That way, the patients will have more say in the whole process.
Will this bring the next teenager treatment on a par with the 10 other first world countries? Maybe, maybe not.
One thing is for sure; doing nothing will guarantee more pain – to patients and the entire medical system.
Date: January 28, 2015