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Health Care Reform: A Possible Approach to Figure Out What to Do

Updated on July 13, 2017
Teddi DiCanio profile image

Writer, voice teacher, and storyteller, Teddi DiCanio, often blends music and story. Her taste in subject matter is eclectic.

What might an effective healthcare act look like? After the first Republican healthcare bill tanked in the House, news sources reported that legislators were assailed by calls and emails from constituents showing little or no support for what the Republicans had proposed. But it wasn’t because all the callers were enthusiastic about the existing Affordable Care Act. Many supported it, but many also hated it. However, all hated the new proposal even more.

Other developed countries pay less, per person, for health care than does the United States, and, for the most part, obtain better results. Life expectancy is a little longer in other countries while infant mortality rates are lower. Nor are there millions of people with no access to health care at all.

Statistics from the Organization for Economic Co-operation and Development (OCED), consistently report the US spends a far bigger proportion of its gross domestic product than any other country. For 2016, the US spent 16.91%. The closest any other country came was in the 11% range. Most were 7% to 10 %. The latest statistics from our own Institutes of Health report the amount has risen to past 17%. What can be done about this?

Will Congress’s next attempt to amend—abolish—replace—Obamacare as it’s called, be any more successful than was the first attempt? House members are feeling the wrath of angry constituents over the bill that did pass in the House. Many Republican senators seem lukewarm about the House bill. The senate bill that has come out of committee, after having been drawn up behind closed doors, has been applauded, but only in certain quarters. Some senators dislike what they see, for varying reasons, and they are not just Democrats. Already any kind of vote has been delayed.

A few Republican senators want out and out repeal of the Affordable Care Act. Others are critical of measures that, in the long run, are more draconian than those of the House bill particularly in regards to Medicaid. A number of primarily Republican states desperately need those Medicaid funds. Governors of both parties are opposed. And now the president says to just repeal the Affordable Care Act and worry later about concocting a new scheme to replace it.

Of course, the senators are hoping for compromises palatable to all. But nothing proposed, particularly draconian measures like cutting Medicaid funds, get at the question: “What causes American health care to be so much more expensive than that of other developed countries?” Until Congress finds the answer—or rather answers—to that question, and then devises remedies for the causes, no bill will be worth passing.

Do any of us believe our present legislators know enough about our health care system—which is often referred to, charitably, as Byzantine—to write an effective bill? Do We, the People, know enough? We occasionally hear a little thoughtful analysis from a few legislators, but mostly we hear the same catchphrases. There may be a way to remedy our woeful ignorance, but let us first recall a couple of items, born of what brought about passage of the ACA, now fueling resistance to present proposals.

A Few Problems

There is enormous incentive to fight ferociously to keep the ACA in place. The ACA allows millions of people previously unable to obtain health insurance, whether precluded by an existing condition or without enough funds to afford full price, access to insurance and, thus, medical care. Opponents to repeal might be open to improvements, but only if they are convinced of their efficacy, such as those that might reduce costs.

Since the ACA was passed, there have been spikes in premiums for some and locales where insurance companies have opted out of the exchanges. However, much of that, particularly companies not offering insurance, has come about recently in response to the uncertainty engendered by the Trump administration and the actions of the present Congress. A side benefit of more insured is that the number of bankruptcies, arising out of medical problems, has dropped. The single largest cause of bankruptcies in the US, by far, comes out of medical bills that can’t be paid.

The idea of cost containment is popular, but difficult to achieve. One reason is that our ‘system’ and the methods by which it is paid for are excessively fragmented. Each step is set in its own little category, and paid for by separate fees. Related services are not bundled together in one paid-for package in which unneeded steps, repeating what may already have been done, are eliminated. And that’s just one of many reasons.

This lack of co-ordination also shows up in our record keeping. Our use of technology lags. US electronic record keeping is uneven, thus doctors, if they cannot quickly obtain records of tests that have already been performed in another facility, often re-order tests. That contributes to the fact that administrative costs in the United States run as much as triple that of some other countries.

Fear that the government will ‘regulate prices’ poses another impediment to a path to co-ordination in health care. The American fear of such regulation verges on paranoia akin to treating it like devil worship. The idea is that this is counter to an economy where the ebb and flow of the free market regulates prices. But the free market is a societal construction. It does not work like the laws of gravity. The laws of physics work on their own with no interference from the human race. We tinker with that ‘free market’ all the time.

On both the state and federal levels, the government will grant a tax break to this or that industry. Or, will create laws or regulations that greatly favor a particular segment of the business world. For example, when, in the 19th century, railroads were allowed to take domain of strips of government owned land, they were often granted the mineral rights to said land instead of those being retained by the government. Because we needed railroads, granting advantages to help them be built, was logical and justified. But why should the railroad companies have the mineral rights? That’s a giveaway. Our legislative history is littered with nonsense like that.

Certain segments of the health care industry profit from our present system as is. For example, we in the United States pay far more for drugs—the same drugs—than do other countries. Medicare, the nation’s largest purchaser of drugs, cannot, by law, negotiate purchase prices. That’s not free market. That’s the result of industry lobbying for an unconscionable advantage. If Washington is willing to agree to such a flagrant giveaway, then where is the will to seriously take on health care problems?

Percentage Shifts in Types of Health Insurance Coverage, from National Center for Health Statistics (NCHS)

Year
Private through workplace
Medicaid
Uninsured
Children under 18
 
 
 
1978
67.6
11.3
12.0
1990
60.9
12.7
17.1
1995
60.4
21.5
13.4
2000
63.0
19.6
12.6
2005
58.6
27.2
9.2
2010
50.7
36.4
7.8
2015
59.6
39.9
4.5
2016, Jan.-Sept.
49.2
39.2
5.0
 
 
 
 
Adults, age 18-64
 
 
 
1978
71.4
4.4
11.9
1990
68.8
4.7
17.2
1995
67.6
7.1
17.3
2000
68.8
5.2
18.9
2005
65.7
7.2
19.3
2010
58.9
9.2
22.3
2015
60.4
13.2
13.0
2016, Jan.-Sept.
60.9
14.1
12.3
In the middle of the twentieth century, health insurance was a benefit many businesses could offer workers at a reasonable cost to the company, but no more. The price of health insurance premiums has increased dramatically over the decades with busin

History of a Different Problem and the Solution Created

Given other countries seem to have better results while having a firmer grip on expenses, would it not behoove us to study how they do it? Then we could seriously examine what we do--and don't do--and create something new that might work better. There may be those who insist that other countries are not America. We have a different kind of society. What others do is not applicable to our circumstances. However, the United States Constitution was, to a great extent, born of studying the history and governmental structures of other countries going back for millennia. The person we have most to thank for this is James Madison.

By the late 1780s, we desperately needed some change from our Articles of Confederation. The thirteen states were acting like querulous nations, unwilling to collaborate. Commerce suffered as states printed their own money, charged tariffs on goods coming from neighboring states, and states with minimal access to the sea were at the mercy of those that had large, extensive ports. Gouging, not mercy, was the rule. There was no central, recognized authority to force co-operation.

For months preceding what would become the Constitutional Convention of 1787, Madison studied everything he could find on the art of government and the histories of republics and democracies. How had they fared? At his request, Thomas Jefferson sent Madison hundreds of books to add to every scrap he himself had gathered.

His studies led him to a conclusion at odds with what had always been the popular view of democracies, which was that, to survive and thrive, a democratic society needed to be relatively small with a relatively homogeneous population. However, a major weakness in this type of society had always been recognized. Should there be a major division—two competing ethnic groups, two religious groups, or a major ideological difference arise—this could bring about a tyranny of a majority over the minority, with no recourse or relief.

Madison believed the circumstances rising out of having a large population, with numerous distinct groups, none having dominant power, could force the groups to negotiate with one another in the political arena. He thought the solutions they created to deal with their problems were likely to be more practical, more acceptable to a cross-section of the population, and perhaps more just. Yes, there was enormous diversity in the thirteen states, but there was no unifying, effective governmental instrument by which to create E Pluribus Unum—Out of the Many, One.

Madison’s studies led him to create a plan before he ever set foot in Philadelphia. His plan was not the end product. It was the start and the core. His studies, coupled with the studies and experience of men, themselves well read, who: created a new governmental institution, the Continental Congress, that started a revolution; wrote eleven new state constitutions as they fought the revolution; created a confederation which, just barely, kept them afloat as they learned what worked, and didn’t work,; did then spark a summer of debates that gave birth to our federalist system, a new system that had never been seen before, and which is still here two hundred plus years later. That system has suffered its moribund periods—plus a civil war—but has always come out of such periods. However, there must be the will to do so.

What is the True Relation of Cost to Profits?

May 2017, AARP Bulletin:  "9 out of 10 big pharmaceutical companies spend more on marketing than on research. Morningstar: S&P 500 net profits. 10%; drug companies, 15-40%. Veterans Health Administration pays up to 80% less for a drug than Medicare.
May 2017, AARP Bulletin: "9 out of 10 big pharmaceutical companies spend more on marketing than on research. Morningstar: S&P 500 net profits. 10%; drug companies, 15-40%. Veterans Health Administration pays up to 80% less for a drug than Medicare. | Source

Healthcare

If our forefathers created the fundamental political structure of our country by studying others, why can’t we do it for health care? Congress could invite medical personnel and administrators, plus government officials to appear before them to describe what they did for their individual countries and, most importantly, why. Why this arrangement? Why that rule? Remember, each nation has a different system and for all the pundits like to scream ‘socialized medicine,’ many countries have private systems with private insurance companies.

If they could walk us through their reasoning, how their specific systems work, the decisions they made due to how their societies are structured, and what they’ve had to change, our legislators should then be knowledgeable enough to intelligently study what we have and then create a new system that could work for this country. One would think that they have studied the issues over the years, but the bill that never made it to the floor of the House was thrown together. The second bill seems equally slap-dash. Such an approach has more to do with mindless hurling of ideological slogans than it does to do with study and thoughtful analysis. Moreover, if hearings were broadcast, maybe We, the People would learn more, too.

In the Preamble to the Constitution, one of the stated purposes of ‘We, the People’ in creating this Constitution was to ‘promote the general welfare.’ A health care system that threatens to bankrupt the country while still leaving millions out in the cold in no way accomplishes that.

Bibliography

Bowen, Catherine Drinker. Miracle at Philadelphia: the story of the Constitutional Convention, May to September, 1787. Little, Brown, and Co. 1966.

Cheney, Lynne. James Madison: a life reconsidered. Viking. New York, New York. 2014.

Calsyn, Maura and Emily Oshima Lee. “Alternatives to Fee-for-service Payments in Health Care Moving from Volume to Value.” Center for American Progress. September 18, 2012. www.americanprogress.org

Editors of AARP. “Why Drugs Cost so Much.” AARP Bulletin. May 2017.

Fram, Alan. Associated Press. “Senate Republicans quietly work on their version of a health overhaul bill.” PBS NewsHour Rundown. May 22, 2017.

https://www.cdc.gov/nchs/fastats/Default.htm

https://dataoced.org

Kane, Jason. Associated Press. “Health Care Costs: How the U.S. Compares with Other Countries.” PBS NewsHour Rundown. October 22, 2012.

Murphy, Rom. Associated Press. “Insurers continue to hike prices, abandon ACA markets.” PBS NewsHour Rundown. May 25, 2017.

PBS NewsHour. “Where does Congress go next on health care?” March 24, 2017.

Stein, Harry and Alex Rowell. “New Data Deliver Good News for Health Care and Bad News for Speaker Ryan’s Tax Reform Plan.” Center for American Progress. March 30. 2017. www.americanprogress.org.

www.worldbank.org

© 2017 Teddi DiCanio

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