Is healthcare a right or a privilege?

Healthcare is probably the single biggest issue in our country right now, as republicans try to dismantle our current system and progressives push for single payer healthcare. Indeed, more Americans than ever are interested in single payer healthcare: 33% say we should adopt such an approach to healthcare (up 14% from 2014), and 60% say that the federal government has a responsibility to ensure its citizens have healthcare coverage (whether that be public or private).

This stands in stark contrast to the current republican government’s approach to healthcare, which, judging by the legislation they’ve written, is that you should only get healthcare if you can pay for it. Naturally, republican politicians have taken to all forms of media to speak out against single payer healthcare.

But really, there isn’t much of a data-driven argument against single payer healthcare. We know that it’s significantly cheaper. We know that the health outcomes for people tend to be the same, if not better. No, people in Canada and Sweden aren’t dying in the streets because of “rationed care.”

The main objection to single payer healthcare, as far as I can tell, is completely philosophical and boils down to one simple question:

Is healthcare a right or a privilege? 

Ask most conservatives and they’ll probably tell you it’s a privilege, not a right. I’ve had numerous conversations about that with people lately, and I’d like to closely examine this argument.

There’s an underlying assumption in this conservative argument that healthcare is a privilege, namely that there is some finite amount of rights in existence, and everything else is just a privilege. The conservative argument that healthcare is a privilege seems predicted on treating rights as if they’re matter or energy–they can be neither created nor destroyed.

To that end, many conservatives use the constitution as the end-all-be-all of rights. If it isn’t in the constitution, it isn’t a right and therefore must be a privilege. This meme perfectly illustrates this line of thinking:

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This is a particularly bizarre argument given that the founding fathers purposely created a constitution that can be changed, amended. And indeed it has been, 27 times. 100 years ago this meme could have said, “Trying to find in the constitution where it says women have the right to vote.” Or you could have run this meme in 1859 to say, “Trying to find in the constitution where it says black people aren’t personal property.” It’s just a foolish argument.

But the point is that rights aren’t some static, finite thing. You’re given new ones all the time. The 26th amendment gave 18 year olds the right to vote. The 17th amendment gave you the right to vote for your own state senators. Prior to those amendments being written, those rights did not exist.

Similarly, rights can be taken away. The 18th amendment took away your right to manufacture or sell alcohol. That one was repealed, thankfully.

The ultimate point here is that rights aren’t written in stone. We give ourselves new rights all the time, as the previous examples showed. So why couldn’t healthcare become a new right?

It almost was. FDR was on the verge of introducing a second bill of rights in the 40’s, shortly before the end of WWII.

Unfortunately, FDR didn’t live long enough to see this enacted, and it became a mere footnote in American history. I’m sure though, that many conservatives would argue that FDR was some kind of communist for this proposal. Ironic, given that in this short speech he seems intent on protecting free markets.

So then, what would be the argument that healthcare is indeed a right? Well, if you’re having a conversation with someone who wants to use to constitution as an argument that it’s a privilege, try giving them this line:

“We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”

It’s right there in the preamble. “Promote the general welfare.” What’s the argument that single payer doesn’t fulfill this part of the constitution? Or, conversely, how does a “you can have it only if you can pay for it” model promote the general welfare?

But, one might argue, even if healthcare were a right, that doesn’t mean that government run healthcare is. Perhaps it’s simply a matter of the government ensuring that you have access to affordable care. On the surface, this seems like a valid argument.

Well, this is where I would point out that single payer healthcare is vastly cheaper than the alternative. But even ignoring that point we could still make an argument for it. If we were to argue that “promote the general welfare” means that the government is obligated to look after the health of its citizens, that doesn’t necessarily follow that you need to use it. If you want to buy your own private insurance, you should be free to do so. And indeed, in many countries with single payer healthcare, citizens have every right to buy their own supplemental or private coverage. Just because the government offers a single payer option to its citizens doesn’t mean your right to choice vanishes. Indeed, perhaps a little competition between the government and private industry would be a good thing.

If nothing else, we could look at this issue through an ethical lens. If your neighbor was dying and could be saved, but he doesn’t have the means to save himself and you do, are you ethically or morally obligated to help him? What would you want if you were the dying neighbor?

Ultimately, I think I can walk away from this post to leave you with a couple of ideas. First, in reality, there is very little difference between a right and privilege. Indeed, I might argue that a right is simply a legally protected privilege. Which means, as we’ve seen throughout history, we are capable of being granted new rights if we demand them, if there’s a referendum on them. Second, if a government has an obligation to look after the welfare of its citizens, there is no reason why this should stop at healthcare. We’ll subsidize your education, your protection, your infrastructure–the line drawn at healthcare seems completely arbitrary.

 

Why the GOP can walk all over its voters–and get away with it

The GOP finally got their bill to repeal and replace the ACA out the house. It’ll now go to the senate, where it’s pretty much doomed. If it doesn’t collapse altogether, it’ll be sent back as a much different bill. Regardless, pundits and experts are predicting that the AHCA has shown the republican hand, namely that they care more about tax cuts for the rich and not at all about your health.

That’s certainly true.

The bill sees hundreds of millions of dollars cut from medicaid and a corresponding tax break for the wealthy. It also allows insurers to drop you if you become ill or have a pre-existing condition. It’ll raise premiums for the elderly. It’s just an awful, awful bill. Which is why pundits are predicting a major backlash against the party come 2018.

I don’t think we’re going to see that.

Ultimately, a few red districts in blue states may flip, but it won’t be enough to shift the balance of power. Because I don’t think that this will perturb republican voters. History has shown, time after time, that they’ll vote against their own self-interest and I don’t think that this moment in history is an exception. Many of the deep red states have had republican governors, legislatures, and courts for 30+ years. And yet things keep getting worse for those states. If republican voters were ever going to finally wake up to the fact that they’re voting against their own interests, it would have happened by now. In fact, it’s probably never going to happen.

Here, take a look at this:

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Every single one of those states is solid red, and every single one voted for Trump. And every single one of those voters with a pre-existing condition will see their insurance either disappear or skyrocket in price. But I’m willing to wager that come 2018 they’ll still vote for the very same congressman who voted to strip them of healthcare. Why? Because many republicans are single issue voters. And what is that issue, you ask?

Abortion.

As long the GOP continues to be the party that opposes abortion and wants to overturn Row v. Wade they can pretty much do whatever they want to voters and still get re-elected.

59% of republican voters think abortion should always be illegal. Even among moderate or ‘liberal’ republicans, 41% think it should always be illegal. And that number has shifted up from where it stood in 1995; 20 years go, republicans were split almost evenly, 49%/48%. In the last two decades, republican voters have only become more conservative on this issue. In 2015, 21 percent of Americans said they would only vote for a candidate who shared their abortion views, up from 13 percent in 2008.

Particularly ironic, given that the AHCA isn’t friendly to pregnant women or babies and children. But I digress.

Economically, many conservatives align with progressive values. 52% of republicans with family incomes <$30,000 say the government has a responsibility to provide healthcare coverage for everyone, up from 31% just last year. And in a recent Gallup poll, 45% of republicans said they think the wealthy don’t pay their fair share in taxes. They hate those free trade deals that sent their jobs overseas–something Bernie Sanders talked about extensively during the election.  In other words, conservative voters know that they’re getting screwed over economically. As time goes on, they seem to be getting more progressive economically.

And yet…when it’s time to step into that voting booth, they always pull the red lever. And what does it get them? Healthcare? Gone. Overtime pay? Gone.  Clean water and air? Gone, too. Taxes? More income redistributed from the middle and lower classes to the donor class.

But hey, abortion, right?

The new GOP “healthcare” plan

In case you missed it, republicans are back with a re-vamped version of their failed ACA repeal. The new American Healthcare Act (AHCA) is somehow even worse than before after a new amendment was added by Representative Tom MacArthur (R-NJ). The problem with the last bill was that it apparently didn’t screw enough people over, so the “freedom caucus” (hint: the freedom they want is the freedom for you to die destitute) lifted their noses in disgust and said no. The new amendment by MacArthur aims to bring those ultra-conservative members of the freedom caucus over to their side. How does this amendment do this, you ask?

I am so glad you asked. Here’s a copy of the actual amendment to the bill. The proposed changes are many, but I’d like to focus on one specific part which I think illustrates why this bill isn’t really a healthcare bill at all. One of the main focuses of this amendment is eliminating the mandate that insurance plans offer certain “essential health benefits” as outlined by the ACA. Here’s the actual text of the amendment:

(B) In the case of plan years beginning 2 on or after January 1, 2020, for health insurance coverage offered in the individual or small  group market in such State, to apply, subject to paragraph (5), instead of the essential health benefits specified under subsection (b) of section 1302 of the Patient Protection and Affordable Care Act, essential health benefits as specified by the State.

“Essential health benefits” are things that, by law, insurance is currently REQUIRED to cover. So, what kind of things did the ACA define as “essential” to your heathcare plan?

  1. Ambulatory services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services
  6. Prescription drugs
  7. Rehabilitative services
  8. Laboratory services
  9. Preventive services and chronic disease management
  10. Pediatric care, including oral and vision screening

Right off the bat, we can see some major hypocrisy here. I find it truly insulting that the party that claims to be about “family values” and touts how “pro-life” it is says you don’t need newborn care, maternity care, and screw your children’s pediatric care. They don’t give a fuck if your child’s teeth rot out or he can’t get glasses.

Second, whenever the issue of gun control comes up, republicans are the first people to shout, “It’s not a gun problem, it’s a mental health problem!” So naturally their healthcare plan would allow insurance companies to drop mental health coverage.

Third, and also just as disgusting: Trump campaigned on the opiate epidemic. Remember that? He talked about how it’s a tragedy and he feels their pain. So of course now they can just take the whole substance abuse treatment part out of your plan.

So how does this save you money? Well, let’s say your insurance company says, “Sure, we can provide all ten of those benefits for $500/month. But what if we lobbied the state, and now your plan looks like this…”

  1. Ambulatory services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services
  6. Prescription drugs
  7. Rehabilitative services
  8. Laboratory services
  9. Preventive services and chronic disease management
  10. Pediatric care, including oral and vision screening

“There. We’ll just provide you with those 4 benefits. You won’t need to visit the hospital, right? And you didn’t want drug coverage, did you? And forget preventive care–you don’t need to waste your money on avoiding illness. If we take all of those things out, we can give you a plan for $50/month.”

The problem with this amendment is that it allows states and insurance companies to decide what’s essential, and let’s them pare down the plans they offer to the point that you aren’t even really receiving healthcare anymore. Of course healthcare will be cheaper if nobody is actually offering you healthcare.

It saves you money in the same way that selling a car without windows, doors,  mirrors, seat belts, airbags, a back seat, and brakes would save you money on a vehicle.

Of course none of this is an issue if you’re rich. If you’re wealthy, you can afford everything that’s essential. But if you’re poor? Screw you, you have to pick and choose from bare-minimum plans that don’t cover everything necessary to keep you healthy.

If you’re middle or lower class, here’s your GOP healthcare plan:

libertarian-healthcare-plan-i-part-1-of-3-accepting-your-19537818

In defense of socialized medicine

Socialized or government run healthcare is often derided by its capitalist critics here in America. But does it really deserve all of the hate and mistrust that it gets from us? So many times I’ve heard people claim that such systems are inefficient, even tyrannical because they limit choices. More recently, I’ve heard and read many people talking about how even people in the Scandinavian countries are turning their backs on socialist principles.

However, much of these claims remain to be proven. Strangely, nobody ever offers evidence that increased choice leads to better health outcomes. As for inefficiency, most people who demonize socialized medicine cry about increased wait times for procedures. And what about citizens themselves turning their backs on socialized medicine? I’m willing to bet that the majority of the people who make this claim have never been to any of these other countries and have never bothered to ask its citizens what they actually think–they’re simply parroting economic and political rhetoric and propaganda.

In reality, it’s actually pretty easy to take a magnifying glass to socialized medicine and hold it up to scrutiny. There are a lot of data one can analyze and compare to determine whether socialized medicine is really the evil and inefficient scourge that people claim. There’s even a way to find out what the people in places like Sweden actually think about their healthcare: by–shockingly–asking them point blank and not relying on American politicians and conservative economists to spoon feed you their own biases.

There are two primary resources that we’re going to be looking at in this post. The first is here. That link will take you to the complete 2014 International Profiles of Health Care Systems released by The Commonwealth Fund. The majority of the information I will be providing comes directly from the report. It’s an excellent read, albeit a long one. The report compares the healthcare systems of Australia, Canada, Denmark, England, France, Germany, Italy, Japan, The Netherlands, New Zealand, Norway, Singapore, Sweden, Switzerland, and the US. That’s a pretty broad base to compare, and I feel it’s an adequate sample to really show genuine reflections in outcomes and costs.

First, it’s worth noting exactly how all of these systems work in terms of how they cover healthcare. Australia, Canada, Denmark, England, Italy, New Zealand, Norway, Singapore, and Sweden all have national health systems that cover all citizens, run by the government, and funded through taxpayers. France, Germany, and Switzerland have a statutory insurance mandate, similar to Obamacare, wherein all citizens are required to purchase insurance; funding largely comes from employee/employer contributions. And finally the US, where 56% of people have private insurance, 13% are uninsured, and the remaining 31% are covered under government run programs (Medicare, Medicaid).

Now, the first thing we can do is look at cost, since that’s currently what we are bemoaning here in the US. Per capita, here is what healthcare spending looks like in each of those countries. I will highlight the highest and lowest numbers.

  • Australia: $3,997
  • Canada: $4,602
  • Denmark: $4,698
  • France: $4,288
  • Germany: $4,811
  • Italy: $3,209
  • Japan: $3,649
  • Netherlands: $5,219
  • New Zealand: $3,172
  • Norway: $6,140
  • Singapore: $2,881
  • Sweden:$4,106
  • Switzerland: $6,080
  • UK: $3,289
  • US:$8,745

The US pays the most, almost double the average of $4592. Now, what about spending as a part of GDP?

  • Australia: 9.1%
  • Canada: 10.90%
  • Denmark: 11.00%
  • France: 11.60%
  • Germany: 11.30%
  • Italy: 9.2%
  • Japan: 10.30%
  • Netherlands: 12.1%
  • New Zealand: 10.00%
  • Norway: 9.30%
  • Singapore: 4.7%
  • Sweden: 9.6%
  • Switzerland: 11.40%
  • UK: 9.3%
  • US: 16.90%

Again, the US spends the most. We get an average here of around 11%, and the US is a good 50% higher than that.

So we spend the most of all of those countries. Surely, then, we get better outcomes for that, right? Well, let’s look at some healthcare quality indicators listed in the survey. The first one is: “Diabetes lower extremity amputation rates per 100,000.”

  • Australia: 4.6
  • Canada: 10
  • France: 7.1
  • Germany: 18.4
  • Netherlands: 13.5
  • New Zealand: 6.7
  • Norway: 8.7
  • Sweden: 3.3
  • Switzerland: 7.1
  • UK: 5.1
  • US: 17.1

Hey, look! The US wasn’t #1! That honor goes to Germany. But just barely, we’re a close second. It’s still worth pointing out that we’re still nearly double the average rate (9.2). So I don’t really know if I would qualify that as a victory.

What about lifespan?

  • Australia: 82.8
  • Canada: 82.2
  • Denmark: 80.6
  • France: 82.4
  • Germany: 81.0
  • Italy: 82.7
  • Japan: 83.7
  • Netherlands: 81.9
  • New Zealand: 81.6
  • Norway: 81.8
  • Singapore: 83.1
  • Sweden: 82.4
  • Switzerland: 83.4
  • UK: 81.2
  • US: 79.3

(Data from the WHO).

We don’t seem to live the longest, which is odd considering how much we pay compared to everyone else. Okay, well what about deaths due to the healthcare system? In other words, how many avoidable deaths in the healthcare system were there (per 100,000)?

  • Australia: 57
  • Canada: n/a
  • France: 55
  • Germany: 76
  • Netherlands: 66
  • New Zealand:79
  • Norway: 64
  • Sweden:61
  • Switzerland: n/a
  • UK: 83
  • US: 96

Yikes. Looks like our healthcare system kills more people.

Now it wasn’t all bad news for the US. We had the highest 5 year breast cancer survival rate (barely) and we were somewhere in the middle of the pack when it came to mortality after admission to a hospital for a heart attack. And that seemed to be the general trend, that the US was either the worst offender or somewhere in the middle.

Okay, what about the long waits and rationing? There were several markers here. The first was “Able to get same or next day appointment when sick.”

  • Australia: 58%
  • Canada:41%
  • France: 57%
  • Germany: 76%
  • Netherlands: 63%
  • New Zealand: 72%
  • Norway: 52%
  • Sweden: 58%
  • Switzerland:n/a
  • UK: 52%
  • US: 48%

Everywhere else but Canada it’s easier to get a same/next day appointment. The next measure was “Very or somewhat easy getting care after hours.”

  • Australia: 46%
  • Canada: 38%
  • France: 36%
  • Germany: 56%
  • Netherlands: 56%
  • New Zealand: 54%
  • Norway: 58%
  • Sweden: 35%
  • Switzerland: 49%
  • UK: 69%
  • US: 39%

Again, the US isn’t the worst, but it’s far below the average (48.7%). Okay, now the one I’m sure you’ve all been waiting for: “Waited 2 months or more for a specialist appointment.”

  • Australia: 18%
  • Canada: 29%
  • France: 18%
  • Germany: 10%
  • Netherlands: 3%
  • New Zealand: 19%
  • Norway: 26%
  • Sweden: 17%
  • Switzerland: 3%
  • UK: 7%
  • US: 6%

Well, well, well. While it’s true that other people have to wait longer to see a specialist, we weren’t necessarily the fastest. And it isn’t as if people those other countries are dying in the streets because they can’t see a doctor. Indeed, it would seem as if this whole issue is really a nonissue–clearly it doesn’t affect mortality, as every other country on the list had a higher average lifespan than America. Also, “waiting” depends on what we’re talking about: we might get people into specialists faster, but other countries do primary care faster than we do. However, there’s one more piece of this issue to look at: “Experienced access barrier because of cost in the past year.”

  • Australia: 16%
  • Canada: 13%
  • France: 18%
  • Germany: 15%
  • Netherlands: 22%
  • New Zealand: 21%
  • Norway: 10%
  • Sweden:6%
  • Switzerland: 13%
  • UK:4%
  • US: 37%

While it’s true we do get people seen faster in some instances, we certainly make them pay through the nose for it. So much so that some people can’t or don’t access healthcare at all. I wrote awhile back about stress in America and the role that Americans said money played: 20% said they put off medical appoints because of cost. That’s worth noting.

Also worth noting before we move on is how much people pay for drugs per capita in each country:

  • Australia: $588
  • Canada: $771
  • Denmark: $295
  • France: $651
  • Germany: $668
  • Italy: $514
  • Japan: $718
  • Netherlands: $450
  • New Zealand: $297
  • Norway: $414
  • Singapore: n/a
  • Sweden: $478
  • Switzerland: $562
  • UK: n/a
  • US: $1,010

Look at that, ours is the only number with a comma in it.

Okay. So we’ve looked at efficiency and outcomes. But what about popularity? You often hear that criticism. “Well yeah, it’s cheaper in Sweden, but the people over there hate it!” Is that really true? Well, luckily for us, we have some sources.

Public views of the health system: “Works well, minor changes needed.”

  • Australia: 48%
  • Canada: 42%
  • France:  40%
  • Germany:42%
  • Netherlands: 51%
  • New Zealand: 47%
  • Norway: 46%
  • Sweden: 44%
  • Switzerland: 54%
  • UK: 63%
  • US: 25%

You can ask the converse, too: “Needs to be completely rebuilt.”

  • Australia: 9%
  • Canada: 8%
  • France: 11%
  • Germany: 10%
  • Netherlands: 5%
  • New Zealand: 8%
  • Norway: 12%
  • Sweden: 10%
  • Switzerland: 7%
  • UK: 4%
  • US: 27%

Well it looks to me like socialized medicine is pretty popular. Meanwhile, a much higher percentage of people don’t like the American healthcare system. In fact, very few people in countries with socialized medicine feel it needs to be completely abandoned. That’s not exactly a stinging rebuke of socialism. As an example, I find it interesting that Canada, the nation with the worst scores when it came to access, had numbers in the single digits with regard to completely scrapping their system. And we can look at other sources, as well.

Eurobarometer conducts public polling in the EU. When asked about the overall safety and quality of their healthcare, almost 3/4 of EU citizens responded that it’s good (71%).

While it’s true that in many other countries people can purchase private or supplemental insurance, those numbers are generally low, with some exceptions. In England, only 11% of people buy supplemental coverage. That number plummets to 7% and 5% in Norway and Sweden. Again, hardly a shunning or abandonment of socialist principles. And where those numbers are much higher (between 50-70% of people) that coverage mostly allows for things like private hospital rooms, elective surgery, optometry, etc–it doesn’t necessarily buy access to better basic care (although in some cases it certainly can buy you access to faster private hospitals and doctors).

Alright, so what can we conclude from all of this? Well, for one, we can say that when politicians call US healthcare the greatest on earth, they’re talking out their asses. It’s not. The data clearly demonstrate that it isn’t. It doesn’t manage to make us live longer, and it puts us in the middle of the pack when it comes to industrialized nations as far as most other health outcomes. We pay the highest prices for mediocre results, basically.

At this point, I don’t really know how anyone can completely bash socialized medicine. It produces better outcomes for less money. That isn’t up for debate, that’s what the numbers indicate. There are some aspects that don’t measure up to the needs of some Americans, like the amount of time one waits to see a specialist. Although, that might be one reason why they pay so much less than we do: they don’t refer people to specialists at the drop of a hat. That probably saves a lot of money in the long run.

These data also seem to speak against the idea that “When the government gets involved everything goes wrong.” On the contrary, we see that the countries where the government is most involved have the lowest costs, the best outcomes, and the highest rate of approval among their citizens.

And as far as the “they’re all fleeing socialism to embrace the free market” lines go, that’s a bunch of baloney. By and large, people are satisfied with socialized medicine, and people are turning to private industry mostly for niche care. And even if more people are embracing some aspects of the free market, they aren’t doing so while abandoning socialism: it seems most countries agree that basic healthcare is a human right, and all citizens should have access to it.

I suspect that the American fear and hatred of socialized medicine is due to several factors. One, for many generations we’ve simply been taught by our government that socialism and communism are dire enemies. Two, here in American we’re used to a corrupt and inefficient government, so we naturally don’t see how centrally planned healthcare can work. But just because our government is inept doesn’t mean that all others are; indeed, it would seem that every other government has found a way to produce better outcomes with less money, which doesn’t exactly prove the “government is inept” theory. Admittedly, socialized medicine wouldn’t work in the current American government. Mostly because the government is bought and paid for in America, where overseas that isn’t the case (or at least not to the same extent as here). Which brings us to three: healthcare, to most of the world, is a human right, while in the United States it remains mostly a privilege.

Most countries see the health of their citizens as something that shouldn’t be considered a for profit venture. We can’t really say the same for the US. We provide healthcare for the elderly, but even that’s questionable now that republicans control all three branches of the government here. There’s a very real possibility that Medicare will be dismantled and replaced with a voucher system where our seniors will purchase private insurance. The problem with that is that insurance companies are in it to make money, and if a senior can’t afford what the insurance companies are charging, tough luck. I guess grandma doesn’t get healthcare.

In reality, having the government run everything allows them to stand up to the pharmaceutical companies and insurance companies (where applicable) and set price ceilings and negotiate. In our American system, we pretty much let private companies write the laws, literally. And now we have a group of people in power who want less government involved, because for some reason the same people who were going to drop you like a brick when you got sick are magically going to have a change of heart once Uncle Sam isn’t looking.

In summation: socialized medicine works. It’s cheaper and it’s more effective. It’s nothing to be afraid of, unless you own stock in an insurance or pharmaceutical company. Anyone who tells you different just isn’t living in a world of facts (or ethics, if you ask me).

I leave you with a meme.

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The real problem with American healthcare

There’s a healthcare crisis in America. This is at least one fact that both sides of the aisle can agree upon here. Of course, each side thinks that the crisis is happening for different reasons, and they both have their own solutions. I have a feeling, though, that both of their solutions are going to incompletely solve the problem, because they don’t address the root cause of the problem.

Let’s delve into the specifics.

Costs associated with healthcare are out of control in America. We spend more than every other country in the world on healthcare, and our results are middling at best. How much more do we spend?

per-capita-total-current-health-care-expenditures-us-and-selected-countries-2010-healthcosts

We spend twice as much as many of the countries on that list. Healthcare costs in America run into the trillions of dollars every year. A lot of people point to the high price of drugs. Yes, that does indeed play a role in the high price of healthcare in the US, and it does need to be addressed. Other countries on that list are able to directly negotiate prices with pharmaceutical companies because the government is the insurance provider. Here in the US, pharmaceutical lobbies spend tons of money to get lax standards passed in congress, and private insurance companies are more than happy to charge you higher prices because it makes them more money too. To be sure, it’s an awful system, but it’s only one factor among many that contributes to the overall failure of our healthcare system.

Still some say that there’s too much bureaucracy involved in our healthcare. To some extent that’s certainly true. There are way too many cogs in the healthcare machine, so to speak, and frequently you get situations where the right hand doesn’t talk to the left hand because the system is so convoluted and bloated. There’s redundancy and waste. That’s obviously a contributing factor and should be addressed.

People also argue that we should either reign in or do away with insurance companies altogether, and go back to a simple fee-for- service model that’s left to the providers. This model makes the most sense, but it still has plenty of flaws. Unless you reign in drug prices, this kind of model isn’t really going to save you money at the pharmacy. It also doesn’t address the fact that there are plenty of treatments out there that cost more than the average person can pay (more on this later). Even if you got all of the insurance and government mumbo jumbo out of the way, open heart surgery is still going to be expensive because it’s complicated and risky with a long recovery period. Cancer treatment is still going to expensive. There’s no getting around that. But a model without insurance companies might work for simple primary care visits, and could serve as a patch or a bridge within the system.

All of these problems skirt around the real issue here, the real reason why the price of healthcare continues to skyrocket in this country: the burden of disease is high and keeps getting higher. In short, Americans pay more for healthcare because we’re sicker than almost everyone else. In my state we have an insurer, Moda, that’s in financial trouble because once the ACA went into effect, they very quickly realized that people were much sicker than anyone realized.

And that’s why the ACA is struggling a bit. The very people that the ACA brought into the healthcare fold were the sickest among us—the people who previously had no or sporadic access to healthcare and the people living in poverty. But that’s not exclusive to the lower socioeconomic groups. Americans in general are unhealthier than ever, and that’s an upward trend. What are the most common causes of death here?

2014_Leading_Causes_of_Death_stats

 

The striking thing about that list is that many of those things are preventable. Heart disease is the #1 killer of Americans, and it’s also the most preventable. Diabetes is also preventable (at least Type 2 is) or at least manageable. Respiratory diseases and even some cancers can be prevented, too. The common trend here comes down to ONE simple thing: lifestyle factors.

Unlike your genetic predisposition to something like high cholesterol or cancer, lifestyle factors are completely modifiable. And they play an important role in your overall health and the burden of disease within our healthcare system. In fact, there are four things that have tremendous impact on your health:

1) Sleep

2) Exercise

3) Diet

4) Stress

You’ll notice that all of those things can be addressed quickly and, more importantly, basically for free. You don’t need to spend money to go for a walk outside every day. You don’t need to spend money to eat less every day. Sleeping doesn’t cost anything. And you might also have noticed that all of these things have a profound effect on your immune system. Chronic stress will suppress your immune system. Not enough sleep will screw up your immune system and your metabolism. An imbalanced diet will screw up your immune system. And, for our really “with it” readers, you might also have noticed that all of those things affect each other; exercising and eating properly will help you sleep and they reduce stress.

In short, the problem with healthcare in America is this: IT DOESN’T PROMOTE HEALTH.

And because of that,  too many people get fat and stressed and sick and then burn out the healthcare system, which isn’t designed or able to support hundreds of millions of chronically ill people. Just how much of an influence do those four factors have on health? Well, let’s look at them.

Sleep. We all know that you need sleep. That’s when your body heals, replenishes all of its neurotransmitters, grows, etc. You can’t function properly without the proper amount of sleep. How much sleep you need depends on your age and to some extent the individual, but here’s what the facts have to say. A whopping 45% of Americans say they get poor or insufficient sleep. The same report reveals that 67% of people who report getting “poor” sleep also report having poor or “only fair” health.

Exercise. It’s recommended that you move around for at least one hour every day. Yet most Americans lead very sedentary lives. The average American watches 5 hours of TV per day (7 if you’re over 65). In case you were wondering, here’s how our television watching compares to those in other countries:

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If you’re like me, this doesn’t really surprise you. But it does reinforce the fact that Americans are exceptionally sedentary. And what about exercise specifically? The CDC reports that only 20% of Americans over 18 meet the recommendations for aerobic and weight-bearing physical activity; that statistic jumps to just below 50% if you remove the weight-bearing exercise.

Diet. Again, there probably won’t be any surprises here. Take a look at this info from the USDA:

USDAchart1

As you can see, Americans eat too much fat, salt, and sugar and not nearly enough lean meat and vegetables. The average American consumes 3,770 calories per day, which is about 53% more than is recommended. The average American also eats more processed foods than ever before:

dietpiechart-ck

Stress. Stress is hard to quantify, but we can certainly try. Let’s think about some of the things that cause us stress. Work is one thing. We do work more than people in other countries:

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Money or financial things also cause people stress. 63% of Americans have less than $1,000 in their savings accounts. 21% don’t even have a savings account at all. Good luck replacing the refrigerator or repairing the car. This also partially why you’ll never be able to just get rid of insurance companies (as much as we’d all like to). This survey from the American Psychological Association shows that while overall stress levels have decreased since the first survey in 2007, they’re still way above what the survey defines as a healthy amount of stress.What’s more, how Americans manage stress is also horrible: we eat, watch TV, drink, or smoke.

So what does all of this mean? Well, for one thing it means we’re fat. 62% of adults are overweight, and 27% are obese. What does that mean? It means more heart disease. It means more strokes. It means more diabetes. These are all things that happened to be in the top ten causes of death, by the way. It also means things like more arthritis. If you’re diabetic, which about 10 million people in America are, it means chronic wounds, visual problems, kidney failure, etc. That number is expected to jump to 44 million people by 2020, with spending on JUST DIABETES related problems expected to climb to $336 BILLION dollars a year.

And none of this is taking into account all of the effects that hypertension associated with these things have on individuals. Or the fact that 16 million Americans have asthma. And I’ve left out the effects that diet has on oral health, as well. The dental situation in America is out of control, but that’s almost another post. The bottom line is that these things profoundly affect the health of America and the burden on our healthcare system, and they’re all modifiable.

Of course, we don’t do that in this country. For philosophical reasons we let everyone engage in whatever self-destructive and detrimental behavior they want, then we balk at the price tag when the bill comes and can’t understand what went wrong.

But it obviously doesn’t have to be that way. Yes,  waste exists and we should try to eliminate it. But prevent the disease in the first place and you prevent the spending. There are lots of ways this could be done. I personally favor taxes on soda and fast food. I don’t care about “It’s my right to drink 7 Pepsi’s a day,” arguments. We tax alcohol and cigarettes, two other substances that raise the disease burden on the healthcare system. We could do the same thing with soda and fast food.

I also think we could do a better job providing incentives to people (as if not dying a slow, fat diabetes death isn’t enough in the first place). If you’re classified as overweight or obese, why not grant people tax breaks if they lose weight? Everyone loves saving money. I’d also be a proponent of publicly funded gyms that anyone can access for free. Start a public awareness campaign about diet and exercise. We did the same thing with smoking and teen pregnancy and the rates went down. Perhaps all that “This is your brain on drugs” money would have been better spent on “This is your body on sugar” commercials.

But until the way we conceptualize health and the role of healthcare systems changes, the price tag attached to healthcare won’t change. If we don’t address the root causes of disease we’ll never be able to stem the tide of rising healthcare costs. If we don’t promote and encourage health, we’ll never be healthy.

The gap in mental health

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Yesterday I downloaded a police scanner app for my phone. The nurse in me likes to listen to the fire/EMS channels. So there I was, sitting on our porch swing on a fine summer evening, listening to the goings-on about town. And what I heard was absolutely depressing.

Most people probably have a fairly straightforward conception of what people in law enforcement and EMS do. Firefighters respond to fires, car accidents, and the like. Paramedics respond to the various accidents, traumas, and heart attacks around town. And the police respond to burglars, vandalism, drug activity, and other violent situations.

Wrooooooooong.

You know what the majority of the dispatch calls for both the police and the fire/EMS services were? Suicide threats or attempts.

Let that sink in for a minute.

First of all, this is a gross misuse of these two services. Your tax dollars at work, ladies and gentlemen. Instead of out addressing crime, our police force is dealing with people threatening to take their own lives. Same thing with firefighters and paramedics, amazingly. You’d actually be pretty shocked at how misused fire/EMS services are in general. It’s a huge issue in healthcare in general, not just mental health, because low income people and families have a propensity to use 911 as primary care and a shuttle service instead of going to their local clinic or urgent care. But I digress.

The biggest issue with this is that these people aren’t mental health professionals. At best, these people get cursory training on how to deal with mentally unstable people. They’re a band-aid for a much, much larger issue. And that issue is the unaddressed mental health problem in this country.

I say unaddressed because everyone knows that it exists. It’s just that nobody wants to apparently do anything about it. I don’t know why, considering the rise in violent crime in this country. You’d think that after a few mass shootings by mentally unstable people, everyone would be interested in mental health again. But sadly you’d be wrong.

The current problem with mental health in this country can be linked to deinstitutionalization. A big fancy word, but basically it means that we closed down all the mental health parts of public hospitals and other mental institutions. The act to deinstitutionalize mental health patients started in 1955 and picked up steam in the 1960’s with the civil rights movement. And, like most acts, it started out with the best intentions. Mental health doesn’t exactly have the greatest track record when it comes to having treated people like human beings. Conditions in a lot of these institutions were abysmal, and it was believed that by taking these people out of institutions and placing them into community facilities, they would get better care and more humane treatment.

Obviously that didn’t happen.

So where did everything go wrong? Well, that little tidbit of history I just gave you is from a 2007 report by the Kaiser Commission on Medicaid and the Uninsured. So what does their report say happened? Well, a lot of these deinstitutionalized patients were absorbed by nursing homes–also not exactly equipped for such an influx. Here’s a short list of mistakes in mental health reform from the 60’s to the 80’s according to the commission:

1. While the original plan was to move these patients to nursing homes, single room occupancy buildings, and board and care homes, these places were ill-equipped to handle the shear number of people released into the system. Reagan defunded a lot of public and standardized housing in the 80’s, which made a lot of these people homeless.

2. Essential services were never realized.

3. The federal and state governments did a poor job of communicating terms of community care policy, and therefore a lot of people fell through the cracks.

4. Mental health systems used measures of success like bed-days, instead of quality of care. So instead of saying, “This person got better,” they were essentially qualifying a successful treatment as, “Hey, this person only stayed for three days!” Not the greatest metric for mental health.

5. Money. As usual, everything comes down to the almighty dollar. Multiple funding streams were never coordinated, federal funding never materialized, and state funding was misappropriated.

6. NIMBY. I thought that this one was the most interesting point that the commission made. The “not in my backyard” attitude of our society killed a lot of community mental health services. The stigmas around mental health can be extremely detrimental to treatment and rehabilitation.

I would encourage everyone to read the report themselves, as it makes a fascinating read and gives great information about a crisis facing our healthcare system and our nation.