healthcare (1)

Since the collapse of GM and Chrysler an d, of course as a result of the Obama campaign, "healthcare for all" and especially its allegedly high cost has been much in the news. Now that the O. Admin. has made its budget public and a "down payment" on its cost is proposed to be funded by revoking the tax relief on the very rich, opposition voices (mostly Republican) are becoming louder than ever. The parts of the Obama plan are gradually revealed, and what is known is not very encouraging as it is an extension of the hodgepodge already practiced for those who have insurance, i.e. employers are still the ones to provide the insurance which is in the hands of private insurance companies. Govt subsidies will be available and for the poor a govt system will be created (an extension of Medicaid?).

From my Dutch perspective the problem with US healthcare was that there has not been a national system (except for the Medicaid and Medicare programs aimed at specific groups of the population). The prevailing view of healthcare is that it is a matter for individual citizens and where it is "collective" it has been achieved by the various Unions. A new start has been made with the Children's healthcare system.

Opponents to universal healthcare make use of several arguments, all of them either spurious or just plain false; they mainly center on 1) increases in taxation, 2) the inability to pick one's own physician as well as on 3) problems with the care provided in countries that do have a national system.

1) About 80% of US citizens have some form of health insurance, mostly through an arrangement with their employers. This is actually paid for by anyone who buys a product of that employer, for ex. an American-made car, or an education. Among this 80% are also govt employees of the many govt institutions, their insurance is paid for by their gov.t institution as in the case of Congress (with members paying a supplemental that annually amounts to 12-2400 dollars) or through their salaries that are financed from local, state and Federal taxes paid by all who have taxable income, incl. those who may themselves not have health insurance. Because govt employees form large pools (and insurers want to have the goodwill of the government), insurance premiums may be lower and benefits higher than that of smaller groups and certainly of individuals. The most popular Congressional plan is a Blue Cross/Shield Preferred Provider Org. at $152/ind. or $357/family per month. The providers are PREFERRED by Blue Cross/Shield, but coverage is near complete, for ex. for out- and in patient mental-health care (which appears not always effective or so I deduce when listening to C-Span or Fox).

It is clear that citizens with income may in fact pay for the healthcare of others several times over. My own insurance was paid for by my College; it covered all costs (for the last 10 years even up to $1,000/year for dental care). The College still covers my medical and prescription costs. The College also covers my (still working) partner's costs, but under a new program she has a co-pay arrangement and when she retires she'll have to find her own supplemental insurance (for which a small fund is being accumulated in her name by the College). For a long time the insurance was through a Blue Cross/Shield system (as mine still is) but hers is now through other companies that have been changed several times. I found an old statement detailing my salary and the cost of all benefits which then, on a salary of 68.000 came to an additional 18.000 for the College, all of which was paid for through tuition charges, annual giving, etc. I noticed that the State and the County are now taxing those benefits as salary and her W-2 shows a federal withholding salary and a higher one that includes the benefits for Local and State withholding purposes. Obviously some fiction is involved in this arrangement. The annual givers, etc. deduct the gifts from their taxes but much of these gifts is taxed in turn as faculty salaries etc. Also, when I began teaching, I paid 5% into a retirement program and so did the College. In competition for faculty the C. (like most others) began to pay the entire contribution as well as an ever better medical insurance. I pay a Medicare contribution that is withheld from my Soc. Sec. payments. Thus models for universal withholding programs exist.

In the recent debates surrounding the near collapse of the Detroit auto makers, the fact that the companies have to pay for all sort of benefits, incl. health care for the workers is always cited as one of the causes of GM and Chrysler's (near) collapse as these benefits raise the price of the cars. Cars made in other countries, where these benefits are provided by governments out of general revenue from several earmarked withholding programs, or Japanese cars made in the US that have no benefit costs built into their price, can thus be cheaper, etc. (Incidentally, when employers are facing financial problems they are apt to use their employee retirement and healthcare funds, which may therefore not be available for their purpose and employees may in fact become uninsured on retirement, etc. or, as seems likely, when the companies go into bankruptcy).

As to the argument that universal healthcare would require more taxes, these taxes may be offset to a great extent as employers no longer have to include the cost of health care for their employees in the price of their product and when the insurance is no longer provided by for profit private companies. One argument in favor of privatizing all sorts of things is that the govt will not be responsible for the cost of the retired employees. But employees of private companies will have to be paid enough so that they can retire with health benefits and thus the cost will remain and perhaps be higher as the private company raises the cost of doing business, etc.

The cost of health care could also be reduced by limits on reimbursement to care givers as is now already done by most insurers and is shown on the forms sent to the insured which includes the statement: your provider has agreed to accept this amount (or some such phrase). This is sort of like the outlawing of smoking, if it is forbidden in every bar, bar goers will not be able to go to a 'smoking permitted" competitor, etc.

But perhaps the best argument, selfish though it sounds, is the fact that the uninsured are very likely a risk to all who come in regular contact with them. Additionally the cost of lost production through illness that could have been prevented or shortened if all people were insured, is born by the entire citizenry. (There is a sort of disconnect between medical journalists and reality as in the case of differences in age when heart problems arise in blacks and white men. Treatment of high blood pressure in a twenty year old is advisable and "they should consult their doctor." This would be good advice if these young blacks were insured and therefore could afford to have regular check ups, rather than have to rely on emergency room situations.

BUT TO CALL WITHHOLDING FOR HEALTHCARE TAXATION IS A POLITICAL PLOY, FOR THE PAYMENT IS IN FACT THE PREMIUM THE CITIZEN WOULD OTHERWISE PAY TO AN INSURANCE COMPANY.

2) The choice of one's primary care physician in the USA isn't all that free, even in cities where there could be a choice. Most of the uninsured end up in emergency rooms (not always available as hospitals have abolished them to save costs) where the care is given by the first available physician (sometimes an intern). I ended up there several times and in spite of my excellent insurance, once had to wait 2 and 1/2 hours. My son who had an appendicitis had to wait until a surgeon could be located (one was found in a clubhouse on the golf course, the still very visible scar - after some 30 years - in the form of a "z" provoked the ire of several subsequent doctors. Even in non-emergency cases an insured patient may not be able to pick the physician, for supplementary insurers have lists ( a network) of approved doctors and in other cases pay only part of the charges. Moreover I found that some medical groups refuse to participate in an insurer's system because they consider the reimbursement fees too low. I found in discussion with my longstanding physician who charges the insurance about half of what my ear specialist does, that the fee-for-service, tends to inflate the fee if the insurer pays a percentage of the fee.

One morning when I had an appointment for an ear check up and later for a dental cleaning, I spent the time in the waiting room (I was early in both cases) going though the available mags. The Time of 3/16/09 had a lengthy Cover-story by its medical reporter entitled "So you think you're insured? (Think again.") about the misery experienced by her brother because of the insurance company's unwillingness to accept his medical expenses. And he had the benefit of his sister's expertise in finding the people who could go to bat for him. Actually that day (April 1) was a bad day for medical insurers as the NYT had a long exposee on insurers in New York State who employed retired doctors (ostensibly to root out fraudulent claims) to "examine" patients so that the insurer could routinely deny reimbursements.

While there, I also checked the fine print in drug adverts that Pharmaceutical Companies began to resort to "to fave an informed public" (and avoid legal action, just in case). Obviously, modern medicine has come a long way in helping patients since the thalomidide scandal, but it seems that (like "Wallstreet") they just don't get it. Drugs still have to be taken off the market and some of that fine print I read was very disturbing, not in the least as some of the side effects were introduced by phrases like "In a few cases. . ." or "3 in 100. . ." But 3 in 100 is the same as 3% of 1 million or 30,000, which is a staggering number. The possible side effect of an asthma remedy: "in rare cases the asthma may get worse." Anti-depressants may cause "suicidal thoughts."In each of these adverts the advice (as on the t.v. adds) is "tell your doctor" or "immediately alert your physician." Great advice if you can get hold of your doctor, most of them are protected from their patients by telephone systems that are confusing even to me and undoubtedly an obstacle course for any patient not speaking English (or Spanish). This reading reminded me of the fake sponsor of some of St. Colbert's segments: ". . . Prescott Pharmaceuticals. We have medicines for any illness caused by our previous medicines." (While I was there a second time I found the Consumer Reports of May 2009 which has an article on heath insurance policies for individuals, the fine print of which must be read, it is as disquieting as the fine print of pharmaceutical products).

Meanwhile pregnant women, or those that plan to get pregnant or who got pregnant or who are breastfeeding, are excluded from these (all of those I read about) pharmaceutical miracle cures.
One of the latter, used in studies of painkillers for post-delivery pain actually sounds like "oxymoron." Enough said.

3) Usually slick American politicians - like Mayor Giuliani who maintained he could not have had his prostrate operation in another country- cite English examples as their assistants probably know no other language. I don't know much about England, but my Dutch family, like me increasingly old and in need of frequent medical attention, have no complaints and all care is free (and the indigent cannot be refused). My late sister in law spent the last months of her life in a nursing home, and my brother followed her there about 2 years later. He was there, a paralytic, unable to speak etc. for three years and received excellent care. My sister, who lived in an assisted living apartment, was found one morning on the floor, unconscious. She was taken to a hospital and as nothing could be done she ended up in the same nursing home, where she died after 5 months. My remaining brother had a serious fall, received the required care and is still under supervision as an out-patient. My partner's French family also receives excellent care and also without cost or complaints about waiting periods. Her mother, in her eighties had several operations for different problems. She finally died of cancer. While she was at home a visiting nurse came to wash her, etc. and a household help, provided by the city government, came each morning (because of the family's income they paid 40% of her costs). It must be said that my partner's sister in law, herself a healthcare giver for the elderly (in a different district), tended to ride roughshot to smooth out bureaucratic problems which are endemic in France, regardless of which administrative department. During part of the treatment, the mother was in a private hospital or clinique (only part of the cost there was reimbursed by the universal health insurance, the rest was paid for by their private supplementary insurance), but the local hospital was better equipped and that's where she ended up (free of charge).

Each of these patients (Dutch or French) had their own doctor of long standing (who still do home calls!) and specialists were recommended on the basis of the physician's knowledge of his patients, their problems and his knowledge of the specialist. Like the private cliniques some specialists are in private practice and their charges are paid by the universal health system up to the amount approved, the remainder must be paid out of pocket unless the patient has an additional (private) health insurance. When I still worked in Holland everyone paid a health insurance contribution that was withheld from one's pay. In the 1930s my father paid into an insurance fund for the building trades and he did so for my brother who worked with him. In those days we had two M.D.'s in our village and each had consulting hours, where you might have to wait for an hour or so. The wife of our doctor was a pharmacist and dispensed most medicines after the consultation (there was less duplication in those simpler days). We never paid anything by way of co-pay. (I note that of the four sedans in the village, each of the physicians had one and their children, my contemporaries, went to university, which in those years was not free). Of my parents' generation every one lived into their eighties or longer, except an aunt who died of cancer and an uncle who drank. There was no distinction in quality as there were only 4 medical schools with very rigorous requirements (attendance at which - as at all institutions of higher education -is now virtually free). In her later years my own mother was in 3 different hospitals for her operations and post-operative care, according to available space, in Amsterdam, all easily reached by frequent public transportation (Holland is still a small country!)

Recently the Dutch government has come to favor "privatizing" using the "free market competition will lower prices" argument, but in fact as a way to reduce the civil-service payroll and pensions. At the moment, all citizens with income contribute 1,500 euro/year for health insurance; the insurers cannot refuse to provide insurance nor can hospitals refuse care. My youngest niece, a mid-level executive in one insurance company (that used to provide supplemental insurance for private care, etc.) thinks that this privatisation is a step in the wrong direction because in the health industry, competition means duplication and thus extra costs, i.e. rising prices. Already there is developing a certain - she calls it "soft directing" - by insurers of patients to specific physicians that she fears may lead to less freedom of choice. She's also convinced that the personal contribution will increase after the current "transition period" and the for profit insurance companies renegotiate prices with the government. This Dutch experiment is being studied by other Common Market countries.

Question: Didn't St. Paul say: "The love of money is the root of all evil"?