Our Health Care System Needs A Structural Makeover

Doug Watt, Rights & Democracy member from Nashua, on why we need Medicare for All:

Our healthcare system is broken.  ‘ObamaCare’ did not fix it, only delayed a badly needed and painful reckoning, by removing some of the worst abuses by third party insurance, mitigating some of its grossest inequities, and closing some of the holes in its coverage.  Why and how is our system still broken?

First of all, the system is predatory, meaning that in the context of a major illness, it can potentially take your savings, your home, and virtually every dime you have.  Out-of-pocket healthcare expenses – even for those with insurance – are the most common factor in personal bankruptcies in the United States. Out-of-pocket costs are rated as ‘extremely stressful’ by more than one quarter of the population, suggesting that the system does more than just bankrupt the most ill consumers of care.

Second, our system is staggeringly expensive – consuming over $10,000 per man, woman and child per

year, while covering significantly less than everybody, and with coverage holes under its patchwork quilt of coverage.  Despite consuming $3.3 trillion/yr – making our healthcare system all by itself the fifth-largest economy in the world – critical health-related outcomes and biomarkers lag seriously behind those of every single other Western democracy, and all technologically advanced countries in

Asia.  We are a staggering 31st in terms of life expectancy, while infant mortality rates are 45th – double to triple the rates in countries with lowest infant mortality (Japan, Finland, Singapore & Sweden).  We have among the highest rates of obesity & type II diabetes (‘diabesity’), critical risk factors for all the diseases of aging.

How are we getting such poor outcomes for such staggering amounts of money? No single factor explains this.

1. we are the only technological society without some version of universal coverage. The current system of private third party insurance adds an additional 20% (administrative costs for Medicare are ~ 3%, while third party insurance adds a 22-24% as profit/operating costs). Additionally, 3rd party insurance contains an embedded conflict of interest – insurance companies make more money the less they cover in terms of patient care, and the more they can squeeze payments to providers;
2. The current system incentivizes high-technology care, and late-in-the-game (inpatient) interventions, rather than ‘primary prevention.’  Primary prevention involves lifestyle change aimed at preventing or delaying onset of common diseases of aging that are breaking the medical bank (cardiovascular diseases, cancers, Alzheimer’s disease and type II diabetes);
3. Because of the failure of primary prevention, we spend much more as these diseases of aging penetrate and then destroy quality of life, creating disability mandating expensive residential nursing care.  This failure of prevention is particularly penetrant into disadvantaged socioeconomic groups;
4. End-of-life care averages ~$100,000 per person – the baby boomer generation costs will top $6 trillion;
5. We pay highest prices BY FAR among any advanced technological society for drugs, due to our giveaway approach to big Pharma (see #6);
6. As an overarching theme, all of the big players in the healthcare marketplace – Big Insurance, Big Pharm, Big Technology (device manufacturers) and Big Hospital corporations – have well funded lobbies with huge influence on political and regulatory processes setting prices.  Cost escalations, and guaranteed profits for the major players, are baked into this arrangement;
7. There is a staggering degree of waste, fraud, and abuse – probably in toto at least $500 billion worth out of ~$3.3 trillion/year in costs.  Gaming of the system takes place in many ways, from borderline upcoding to outright fraudulent billing, to the steady profit-driven introduction of on-patent agents no more effective than current generic alternatives. Medicare and other payers also compensate for therapies and treatments that have no proven efficacy.

What are possible solutions?  There will be no improvement until we oust the current plutocratic corporate enablers in Washington, who already are fear-mongering against any version of Medicare for all as insidious ‘socialism.’  But without universal coverage, re-prioritizing of primary prevention isn’t possible. Universal coverage is not enough, as costs need to be more rationally structured, and controlled. In just so many protean ways, we must have the healthcare system prioritize the real needs of patients and clinicians providing care instead of big corporations and vested special interests.