Friday, March 29, 2013

Things I'd Like to Know About Healthcare

"Everybody" knows that healthcare is too expensive.  "Everybody" knows we spend far more than other countries, and get worse results.  "Everybody" knows we have to do something.  "We" all know Obamacare is going to kill us. "They" all think Obama is the savior who is going to give us all great healthcare.  Me, I have a bunch of questions I have yet to see addressed on either side, probably because the answers don't help anyone defend his/her political opinion.
  • If you compare dollars spent on typical illnesses in the US, in Canada (universal single-payer system), in Great Britain (universal government-run system complimented with pay for service/insurance for those who can afford it) and in Germany (mandatory, often subsidized insurance based in workplace) what are the differences?  In other words, I'm not looking for percent of GDP overall, I want to know how much it costs to have a baby, get your gallbladder removed or treat stage one breast cancer of a particular variety.  I want to know how much well-baby care costs, how much a knee replacement costs or how much cataract surgery costs.  How much are birth control pills?  Pap smears?  And by cost, I'd like to know both the cost and the amount the typical patient pays out of pocket.  Take some typical patients and follow them through the system.  What happens?  Who decides?  Who pays?  What does it cost?
  • I  want to know what you get for your money in each of those cases.  If you are having a baby, how many ob visits, how many ultrasounds, how long do you spend in the hospital (and in the US, if there is a difference for the insured and the uninsured, I'd like to know that too).  If I get a positive mammogram, what happens here (assuming I'm insured, and assuming I'm not) and when does it happen?  What about there?  What are the survival rates?  What if I have back pain?  What treatment options are available, and how do I go about getting them?
  • I want to know who gets my money (or the patients' money in other countries).  How much do doctors make?  Nurses?  Nurses' Aids?  Hospital administrators? Drug companies?  Insurance companies?  Insurance company employees?  Government employees?
We've all heard that there are lies, damn lies and statistics.  We've all heard how much the US spends on  healthcare and we all groan when we hear how much our premiums are going up next year.  President Obama said his plan would get costs under control yet most insurers are predicting large premium increases next year because of more sick uninsured folks joining the pool while the well ones choose not to.   How are our costs different from other countries?  I've heard that two things we spend a tremendous amount of money on are caring for victims of gunshot and car accidents.  No  healthcare reform is going to "cure" that unless we start refusing to treat them.  Obesity and smoking cause millions of dollars in healthcare expenses yearly, disproportionately among the poor.  Is it fair to ask the overweight and the smokers to pay more for healthcare?  
I personally think we need to define the problem before we can solve it, and right now I don't think it is defined.  Is our problem that Pap smears cost so much that women can't afford to get them without a government subsidy?  If so,why do they cost so much?  Who is making the money?  Do they cost what they do only because they have a steady source of customers willing to pay that amount--in other words, if demand for Paps went down, would the price follow, or would they even go up in price because of economies of scale?  Is our problem that too many women who don't really need Pap smears are getting them , or getting them too often?  Or, are Pap smears something that given their current price, if they weren't covered by insurance, that the average American woman would consider money well spent to have one as often as she currently does?  I said Pap smears just because they are a regular part of healthcare for many women; you can substitute any other medication or procedure and ask the same questions.  

How much of our total healthcare bill is for relatively normal items, and how much for extraordinary things?  In other words, if you spend $1,000 per term healthy baby for hospital care after birth, and $100,000 for care of one premie, (those numbers are just made up, but you get the idea) and the cohort you are studying has 99 normal babies and 1 premie, the total cost for hospital care for newborns is $199,000, or an average of almost $2000 each.  However, no baby cost close to $2,000.  Is our problem that normal doctor visits cost too much, or than treating cancer costs too much, or both?  If so, how do we bring the cost down?


  1. Lots of good questions.... even in Germany some folks pay more to have private insurance. I also know that Theresa's pediatrician (whom we loved) in Germany had to move to another location (mandated by govt) because the doc she was supposed to be replacing decided not to retire.

  2. Oh, Ruth, these are SUCH good questions. And although I've never thought them through that coherently, I've wondered much the same thing. And that's why I have trouble getting terribly excited about this political issue--because everyone's shooting in the dark, at a dark target, with blinders on.

  3. I blame most of it on:

    1. Government involvement in the healthcare.

    2. Insurance for almost everything you do with a doctor takes away the price incentive for the patient.

    1. Christian, I tend to agree with you and wonder how our medical system would have developed had Medicare/Medicaid never existed and had health insurance not become a standard workplace benefit. I know I look for doctors on my insurance company's list, so clearly cost can drive decisions. My mother was on medication for two years that cost over $100,000 per year. Still, she remained a semi-invalid and lived only six months longer than the average life-expectancy for her disease had been before the medication was invented. My dad could have afforded the medication out-of-pocket but he has a generous pension and more than adequate savings However, most people are not in that financial state, they just flat couldn't have afforded to pay what her medical bills (total, not after Medicare and other insurance) were. So, if there was no Medicare, Medicaid or insurance, would that mean that the market would require that treatment to be priced lower, or would the market have kept that treatment from being developed, since few need it and even fewer can afford it?

  4. All of your questions are valid and good.
    I would like to know why it is our country's policy to spend the money on the very beginning and the end- with the middle to fend for themselves. Why is it better to give an 80 year old free cataract surgery and not a 50 year old? Why do we permit a 30 year old with a chronic illness to go bankrupt, but pay for a 20 week premie to be fully covered by the government?

    The word on the street is to save $250,000 per person for your medicare days. I don't think many people are ready fo that.

    1. I'm not saying your questions aren't important, but I think they are a big part of the problem. You aren't asking why premie care is so expensive, or whether it is worth it; you aren't asking why end of life care is so expensive, or whether it is worth it. You aren't asking if the pie is too big, or costs too much, you are simply asking who (or how) we should pay for the pie.

  5. True.
    I think I know why some of the costs are high.
    We simply choose to treat those people rather then let them pass away.
    My grandmother died of "old age"- not fighting cancer or pneumonia. My uncle died of cancer - which he wisely chose not to fight at the age of 86.
    My mother lost her first child- not because he did not have good care- but he was way to young to survive on his own. Her own brother (the same uncle) was born at the same age as my sib- but survived on his own next to a fire in a dresser drawer.
    One of the best advice I ever got was from a priest who worked with the Little Sisters of the Poor. They spoon feed their dying elderly. No machines, just prayer and care.
    We have to die of something.


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