Thinking It Through for American Health Care

Due to a large project I have not posted here for a long time. The project has underscored the importance of being able to not only think things through, but do so with a good understanding of the context.

Let’s look at that in terms of a current hot topic. Let’s be brave about how big a topic we tackle—the American health care system comes to mind.

Medicare and Medicaid are single payer health care systems. Medicare is for the elderly. Medicaid is for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Some states also provide Medicaid for all low-income adults below a certain income ceiling.

There are some problems with Medicare and Medicaid. Many doctors will not accept patients who are covered by those programs, saying the amounts they would be paid for their services are lower than their costs to provide the services. But on the whole, these programs are very efficient. This has made single payer a rallying cry for some on the left in American politics.

These systems are also targets for abuse, which some on the right use as part of their argument for wiping out the single payer portion of the health care, but they are not targets in the way that political campaigns may tell you.

Through a personal connection that I can’t discuss, I’ve had a view into what kind of target for theft Medicare & Medicaid are. Some politicians occasionally claim there is rampant fraud by individuals. It makes for good sound bites but it isn’t true. Individuals attempting to defraud Medicare and Medicaid are a miniscule issue. Not that many try it, not many succeed, and when they do the amounts are a drop in the bucket.

But fraud by organized groups is an entirely different matter and they aren’t always from the Mafia. At one point a huge batch of corrupt officials in a large state were taken down by Federal investigators for bilking the system. They lined their pockets by billing Medicare for non-existent wheelchairs etc. A couple of years later the same state had regrown the whole corruption ring with another batch of officials.

Some of the organized fraud schemes would curl your hair. Can you imagine methodically finding elderly people who have no close family to advocate for them and institutionalizing them against their will until you’ve billed the maximum Medicare will pay, then kicking them out, then doing it again as soon as the system would be willing to pay again? Such things are done. They usually only get into the newspaper locally, and only after months or years of case-building by Federal agents result in arrests.

Each organized fraud scheme diverts large sums of taxpayer money from the system. Medicare and Medicaid are efficient despite these schemes thanks not only to a well run system, but also thanks to constant investigatory and prosecutorial efforts by Federal law enforcement.

Now that we have added that element of context to our thinking, does it have implications for what we should do to make good health care accessible to everyone in the United States?

It does. As focused one-umbrella systems that don’t require a PhD to navigate, Medicare and Medicaid are well suited for the elderly and people with special challenges such as disabilities or poverty. We’ve done well at protecting them from organized fraud so it makes sense to keep them for the people who use them now. But making the entire USA health care system single payer would magnify the value of the pot of gold tempting criminal minds. I can hardly imagine how hard criminals would work to siphon money out of it and how hard it would be to protect it.

What if we nationalize the health care system? Would it all be rosy then?

For the past decade I’ve been living in England. The UK is struggling with what happens to a national health system that goes off track. It may be okay for a while. For decades, the NHS made health care available to all where it had been inaccessible for many before. But now that it has taken a wrong turn, wrestling it back on track is a Herculean task. The people who actually do the work in the NHS (including my spouse) face crushing workloads and shrinking resources. People relying on the NHS for care face longer waiting times and cutbacks in services. In headlines and in ordinary conversations, people are talking about the crisis in the NHS. So far nobody has come up with a way to set it right.

The USA has five times the population of the UK. If we go to a national health service, it will be that much larger a beast than the UK’s NHS. It will be that much harder to pull it back on track whenever it goes astray.

Last but for many people not least, going completely single payer or nationalizing the health care system would radically restructure about one sixth of the entire American economy, practically overnight. That would cause a lot of pain for a lot of people who work in the current system.

What the USA has right now is Medicare or Medicaid for a slice of the population, and privately insured health care coverage for everyone else under the Affordable Care Act (ACA). What’s the story with the ACA?

The ACA is very close to the Swiss model. One of my close friends lives in Geneva and has a complex life threatening chronic illness. Another friend is a doctor there, with a special interest in medical ethics. They have given me a clear view into the Swiss system. Health care in Switzerland is widely regarded as the best in the world, and the lowest ranking anybody gives it is top tier.

Everyone has to buy health insurance. People who don’t have the means to do so are helped by the government to get it. There are rules that all the players in the system must abide by, and incentives are aligned. Health care providers want to provide the best care they can so patients will choose them. They also want to keep costs under control so their reimbursement from insurers will be enough to keep them going. Insurers can’t cherry-pick which people they will cover. Insurers want to provide good coverage at a good price, because if they don’t, policyholders will jump to a competitor. Not being able to cherry-pick makes them care about long term results for patients, so they are inclined to pay for preventive care that keeps people healthier for longer (not needing the most expensive care for avoidable health crises). The system provides universal access to health care, good quality, affordability, and keeps escalation of costs well below what the USA experiences.

Why isn’t the ACA doing all of that for Americans?

Because some members of Congress recognized that it was no longer politically feasible to block passage of the ACA, but it didn’t suit their ideology. They insisted on removing a few key features of the Swiss model from the ACA before they would provide the crucial last few votes needed to pass the bill. The lack of those key features is biting now. Most notably, it is allowing insurers to opt out of the system and it is allowing premiums to rise faster than they would if the ACA had passed fully intact.

Now that we’ve added so much context, how does the situation look?

Thinking it through, we’ve seen that Medicare and Medicaid have some problems, but grappling with those problems is within the country’s means. We can keep that as it is.

For Americans who are not covered by Medicare or Medicaid, the cleanest route to universal health care is to fix the flaws in the ACA. The flaws aren’t as large as their effects make them appear. A functional government (which admittedly we don’t have) could make those changes easily—it should be a promise that would be relatively easy to deliver.

Plug those holes and the USA will have single payer for the most vulnerable, and will be fully on the Swiss model for everyone else. As a bonus, that is much harder to corrupt, steal from, or knock off track than a pure single payer or nationalized system would be.

If we look at this issue without enough context, we can box ourselves into a corner. It’s important to think things through, and to remember that context matters.