A few thoughts on Health Care
1. Health Care is not a right.
The reason it's not a right is because someone has to provide it. Free speech is a right -- it doesn't cost anyone anything to let you speak (though it does tend to cost money and effort to stop people from speaking). Freedom of religion is a right -- because again, it doesn't require any effort or expense from a 3rd party for you to believe what you believe, but there are costs associated with forcing you to believe a particular way. Or at least follow the forms of a particular religion, what you think while you're at your devotions is very hard to police.
Health care on the other hand requires the work and knowledge of skilled and educated people. You can't just wander out into the forest and pick up a pair of free-range knee replacements and install them yourself. The technology required to make them, the skill required to install them, and the post-op nursing and physical therapy all require a good deal of training (which has to be paid for) and hard work. Three hours in surgery with a surgeon, assistant, anaesthetist, Scrub nurse, anaesthetic tech, and a couple of other nurses is a lot of time invested by a lot of skilled people. Four days of round the clock post-op nursing: again more hardworking skilled people.
All these people have bills to pay, families to feed and clothe. They pay taxes, need the services of hairdressers, cab drivers, doctors and dentists, have hobbies they like to pursue. Just like you and me.
Even if we'd worked it all out, had a remedy for every possible illness, could cure everybody all the time, health care would still carry a substantial overhead in staffing costs, as well as the cost of equipment, medication, dressings and bandages, laundry, utilities, etc. ad nauseam.
All that has to be paid for somehow.
2. In a system where the patient is not directly responsible for the cost of his/her treatment, costs will continue to rise.
2a. In a system where the patient is not directly responsible for the cost of his/her treatment, demand for services will continue to rise.
Every time an expense comes along, you make decisions about how much to spend, what to buy, where to buy it, when you'll get it fixed, and who'll do the fixing. Unless you're in government, you make those decisions based on what you can afford and what you need. Government seems to care a lot less about whether they can pay for it or not. Obviously, if you've just broken your leg, or are exsanguinating all over the carpet, then you are more likely to spend money and get it fixed, than if you've got a chronic condition like arthritis, hypothyroidism or hemorrhoids. In the same way, you'll shop round for the best way to replace an inadequate heating system, but will pay the 24-hour emergency plumbing charges when your water heater bursts at 3:00am.
Medicine's a bit like that too.
Because you have to pay for your home improvements, you probably live with some features of your home that you'd really like to change. But until they can be squeezed into the budget, you live with them. If you could write out a cheque on someone else's bank account, without fear of reprisal, you'd have the central air, hot tub, granite countertops, home theatre, or landscaped yard of your dreams.
The same happens when someone else pays for your health care -- things that you wouldn't get fixed because they're not that big a deal and you can live with them, you get done because you're not footing the bill.
Not having to pay for treatment directly encourages doctors to recommend more aggressive treatment, earlier intervention, and very often more expensive surgical cures. You'd be surprised how many things that could well clear up on their own, or be dealt with quite effectively with conservative treatment, end up getting radical (and expensive) surgery because the patient doesn't have any responsibility for the bill so doesn't inquire about alternatives.
3. In order to "control costs" regulation gets put in place. This drives costs up.
We're seeing a lot of this in the current HMO world where the bean counters at the insurance companies, or the various government regulatory bodies, come up with a "quality measure" or a "best practices protocol" and pay the doctors more for following these guidelines. In theory it's a good idea, in practice it stinks. For one thing it relies on a very mechanical model of the human body and while we're a lot of things, identical machines is not one of them. Sometimes the result of a best practices protocol means that a patient is seen more frequently than they need to be. Sometimes they're not seen often enough.
Expensive tests are often ordered routinely, without consideration as to the value of the test in the individual case, or the potential long-term damage to the patient of multiple testing. MRIs and CAT scans are one of the biggies here. Current best practices protocols in emergency rooms mean that anyone presenting with any symptoms that could be a stroke, gets a CAT scan. That's a lot of radiation. It's hugely important to know, in the case of a stroke, where the problem lies and which areas of the brain it's affecting. But if the patient has Bell's Palsy a CAT scan adds nothing to the diagnosis, but does add a large dose of radiation to the patient's cumulative lifetime exposure.
And guess what: Clinical diagnosis of both stroke and Bell's Palsy was possible before the CAT scan was invented. Not only that, but it was possible for a clinician to make an accurate differential diagnosis on the basis of clinical observation alone. With backup from a second clinician if there was any doubt.
Once you've got regulations in place, you need to police them. There have to be people who make sure everyone knows and complies with the regulations, and inspectors who come round to make sure that the trained monkeys staff are complying. All those people have to be trained and paid. Some by the hospitals and doctors offices, some by the government, some by the health insurance companies. Ultimately, you pay -- either through taxes, fees, or higher premiums.
4. Cover Your Ass Medicine, brought about by malpractice suits, doesn't improve the quality of medical care
What it does do is improve the ability of doctors and nurses to conceal their mistakes. Iatrogenic illness and death harm a massive number of people every day. And the numbers Dr. Lucian L. Leape reported in his 1994 JAMA paper, "Error in Medicine." don't include the hundreds of thousands whose health is impaired by the assorted treatment protocols that are the result of erroneous disease hypotheses -- the cholesterol-heart disease hypothesis for one, current treatment of type II diabetes for another, and the immunize against everything hypothesis for infants. These people aren't counted as having been sickened by medicine because very few of them realise that their condition was caused or worsened by the medicine they're taking.
Gods alone know how much is spent on unnecessary medication and treatment that doesn't actually do any damage (except to our purses and the GNP).
5. The older you get, the worse it gets
Despite papers demonstrating that cholesterol reduction in the elderly doesn't reduce the rate of heart attack or stroke, the protocol, endorsed by Medicare, is for the prescription of statins. The same for hypertension -- reducing moderate hypertension in the elderly has almost no effect on their rate of heart disease. But most of them are on two, three or more medications for hypertension. It used to be that it was expected that one's blood pressure rose as one aged. Now a 90-yo is expected to have the same BP as a 20-yo. Flu shots do not reduce the incidence or severity of flu in the elderly (or any one else for that matter) but side effects from vaccination are harmful.
By the time you're in your 50s and 60s, if you're an average American, you're taking 4 - 6 medications a day: something for your blood pressure, something for your cholesterol, maybe a second anti-hypertensive because the first isn't getting the right results, something for that perpetual acid reflux, and probably an over the counter allergy pill or two, and some tylenol for those age-related aches and pains -- the list goes on.
How the hell did any one live to old age before modern medicine?
When the statistics say that 1/3 of the population has hypertension, or that 30% of Americans are obese, you gotta wonder -- who's doing the measuring and what are they actually measuring.
The old height and weight charts were actuarial charts -- created by life insurance statisticians and based on the height and weight of those who lived longest. In my lifetime these charts have been revised downwards at least twice that I know of. Add in the change to using BMI as a measure of obesity, which obscures the issue some more (and is a lousy way of measuring obesity) and the whole thing is meaningless.
Thirty years ago, normal total cholesterol was 240 - 280mg/dl. Now that's high and the new normal is below 200mg/dl. People haven't changed. The rate was changed by various government bodies (NIH - I'm looking at you) who were influenced by physicians who were in receipt of research grants and other monies from the pharmaceutical companies which stood to make a lot of money by putting people on statins.
6. Linking health insurance coverage to employment was the worst move that could have been made
Initially health insurance was a perk for high-level executives -- the people who were too important to the company to get sick. (It also made a nice pair of golden handcuffs.) The rest of us poor suckers, either went to charitable institutes or paid the doctor for what we needed. Or we just got sick and died. Not an ideal situation, but pretty much par for the course worldwide at the time.
Then Europe started all those socialist plans to provide health care for everyone.
America, prided itself on its non-socialist system and ignored the rest of the world. But needless to say, there was benefit inflation, and what used to be a perk for upper management, became something middle management wanted. The unions weren't going to be left out either, and so we ended up with a system where medicine became a for-profit industry. This really started to go bad in the 1970s when the old supported-by-charities hospitals found themselves up against the wall with inflation and started hiring smart young men with MBAs to "improve efficiency". It didn't work all that well, because they weren't doctors or nurses so medical protocols (like handwashing) which were seen as "old-fashioned" or "inefficient" were given the boot. The handwashing one -- it takes too long to wash hands between patients, disposable gloves provide as much protection and save time -- has come back to bite us. When a doctor or nurse puts his unwashed hands in a box of gloves, he contaminates the whole box. When the next one does the same, it just gets worse. So we've got a situation now where poor hand hygiene coupled with improper use of antibiotics has created those nasty resistant super-bugs that have taken over many hospitals.
What needs to happen is the following:
There's probably more but it's late and I'm tired.
The reason it's not a right is because someone has to provide it. Free speech is a right -- it doesn't cost anyone anything to let you speak (though it does tend to cost money and effort to stop people from speaking). Freedom of religion is a right -- because again, it doesn't require any effort or expense from a 3rd party for you to believe what you believe, but there are costs associated with forcing you to believe a particular way. Or at least follow the forms of a particular religion, what you think while you're at your devotions is very hard to police.
Health care on the other hand requires the work and knowledge of skilled and educated people. You can't just wander out into the forest and pick up a pair of free-range knee replacements and install them yourself. The technology required to make them, the skill required to install them, and the post-op nursing and physical therapy all require a good deal of training (which has to be paid for) and hard work. Three hours in surgery with a surgeon, assistant, anaesthetist, Scrub nurse, anaesthetic tech, and a couple of other nurses is a lot of time invested by a lot of skilled people. Four days of round the clock post-op nursing: again more hardworking skilled people.
All these people have bills to pay, families to feed and clothe. They pay taxes, need the services of hairdressers, cab drivers, doctors and dentists, have hobbies they like to pursue. Just like you and me.
Even if we'd worked it all out, had a remedy for every possible illness, could cure everybody all the time, health care would still carry a substantial overhead in staffing costs, as well as the cost of equipment, medication, dressings and bandages, laundry, utilities, etc. ad nauseam.
All that has to be paid for somehow.
2. In a system where the patient is not directly responsible for the cost of his/her treatment, costs will continue to rise.
2a. In a system where the patient is not directly responsible for the cost of his/her treatment, demand for services will continue to rise.
Every time an expense comes along, you make decisions about how much to spend, what to buy, where to buy it, when you'll get it fixed, and who'll do the fixing. Unless you're in government, you make those decisions based on what you can afford and what you need. Government seems to care a lot less about whether they can pay for it or not. Obviously, if you've just broken your leg, or are exsanguinating all over the carpet, then you are more likely to spend money and get it fixed, than if you've got a chronic condition like arthritis, hypothyroidism or hemorrhoids. In the same way, you'll shop round for the best way to replace an inadequate heating system, but will pay the 24-hour emergency plumbing charges when your water heater bursts at 3:00am.
Medicine's a bit like that too.
Because you have to pay for your home improvements, you probably live with some features of your home that you'd really like to change. But until they can be squeezed into the budget, you live with them. If you could write out a cheque on someone else's bank account, without fear of reprisal, you'd have the central air, hot tub, granite countertops, home theatre, or landscaped yard of your dreams.
The same happens when someone else pays for your health care -- things that you wouldn't get fixed because they're not that big a deal and you can live with them, you get done because you're not footing the bill.
Not having to pay for treatment directly encourages doctors to recommend more aggressive treatment, earlier intervention, and very often more expensive surgical cures. You'd be surprised how many things that could well clear up on their own, or be dealt with quite effectively with conservative treatment, end up getting radical (and expensive) surgery because the patient doesn't have any responsibility for the bill so doesn't inquire about alternatives.
3. In order to "control costs" regulation gets put in place. This drives costs up.
We're seeing a lot of this in the current HMO world where the bean counters at the insurance companies, or the various government regulatory bodies, come up with a "quality measure" or a "best practices protocol" and pay the doctors more for following these guidelines. In theory it's a good idea, in practice it stinks. For one thing it relies on a very mechanical model of the human body and while we're a lot of things, identical machines is not one of them. Sometimes the result of a best practices protocol means that a patient is seen more frequently than they need to be. Sometimes they're not seen often enough.
Expensive tests are often ordered routinely, without consideration as to the value of the test in the individual case, or the potential long-term damage to the patient of multiple testing. MRIs and CAT scans are one of the biggies here. Current best practices protocols in emergency rooms mean that anyone presenting with any symptoms that could be a stroke, gets a CAT scan. That's a lot of radiation. It's hugely important to know, in the case of a stroke, where the problem lies and which areas of the brain it's affecting. But if the patient has Bell's Palsy a CAT scan adds nothing to the diagnosis, but does add a large dose of radiation to the patient's cumulative lifetime exposure.
And guess what: Clinical diagnosis of both stroke and Bell's Palsy was possible before the CAT scan was invented. Not only that, but it was possible for a clinician to make an accurate differential diagnosis on the basis of clinical observation alone. With backup from a second clinician if there was any doubt.
Once you've got regulations in place, you need to police them. There have to be people who make sure everyone knows and complies with the regulations, and inspectors who come round to make sure that the trained monkeys staff are complying. All those people have to be trained and paid. Some by the hospitals and doctors offices, some by the government, some by the health insurance companies. Ultimately, you pay -- either through taxes, fees, or higher premiums.
4. Cover Your Ass Medicine, brought about by malpractice suits, doesn't improve the quality of medical care
What it does do is improve the ability of doctors and nurses to conceal their mistakes. Iatrogenic illness and death harm a massive number of people every day. And the numbers Dr. Lucian L. Leape reported in his 1994 JAMA paper, "Error in Medicine." don't include the hundreds of thousands whose health is impaired by the assorted treatment protocols that are the result of erroneous disease hypotheses -- the cholesterol-heart disease hypothesis for one, current treatment of type II diabetes for another, and the immunize against everything hypothesis for infants. These people aren't counted as having been sickened by medicine because very few of them realise that their condition was caused or worsened by the medicine they're taking.
Gods alone know how much is spent on unnecessary medication and treatment that doesn't actually do any damage (except to our purses and the GNP).
5. The older you get, the worse it gets
Despite papers demonstrating that cholesterol reduction in the elderly doesn't reduce the rate of heart attack or stroke, the protocol, endorsed by Medicare, is for the prescription of statins. The same for hypertension -- reducing moderate hypertension in the elderly has almost no effect on their rate of heart disease. But most of them are on two, three or more medications for hypertension. It used to be that it was expected that one's blood pressure rose as one aged. Now a 90-yo is expected to have the same BP as a 20-yo. Flu shots do not reduce the incidence or severity of flu in the elderly (or any one else for that matter) but side effects from vaccination are harmful.
By the time you're in your 50s and 60s, if you're an average American, you're taking 4 - 6 medications a day: something for your blood pressure, something for your cholesterol, maybe a second anti-hypertensive because the first isn't getting the right results, something for that perpetual acid reflux, and probably an over the counter allergy pill or two, and some tylenol for those age-related aches and pains -- the list goes on.
How the hell did any one live to old age before modern medicine?
When the statistics say that 1/3 of the population has hypertension, or that 30% of Americans are obese, you gotta wonder -- who's doing the measuring and what are they actually measuring.
The old height and weight charts were actuarial charts -- created by life insurance statisticians and based on the height and weight of those who lived longest. In my lifetime these charts have been revised downwards at least twice that I know of. Add in the change to using BMI as a measure of obesity, which obscures the issue some more (and is a lousy way of measuring obesity) and the whole thing is meaningless.
Thirty years ago, normal total cholesterol was 240 - 280mg/dl. Now that's high and the new normal is below 200mg/dl. People haven't changed. The rate was changed by various government bodies (NIH - I'm looking at you) who were influenced by physicians who were in receipt of research grants and other monies from the pharmaceutical companies which stood to make a lot of money by putting people on statins.
6. Linking health insurance coverage to employment was the worst move that could have been made
Initially health insurance was a perk for high-level executives -- the people who were too important to the company to get sick. (It also made a nice pair of golden handcuffs.) The rest of us poor suckers, either went to charitable institutes or paid the doctor for what we needed. Or we just got sick and died. Not an ideal situation, but pretty much par for the course worldwide at the time.
Then Europe started all those socialist plans to provide health care for everyone.
America, prided itself on its non-socialist system and ignored the rest of the world. But needless to say, there was benefit inflation, and what used to be a perk for upper management, became something middle management wanted. The unions weren't going to be left out either, and so we ended up with a system where medicine became a for-profit industry. This really started to go bad in the 1970s when the old supported-by-charities hospitals found themselves up against the wall with inflation and started hiring smart young men with MBAs to "improve efficiency". It didn't work all that well, because they weren't doctors or nurses so medical protocols (like handwashing) which were seen as "old-fashioned" or "inefficient" were given the boot. The handwashing one -- it takes too long to wash hands between patients, disposable gloves provide as much protection and save time -- has come back to bite us. When a doctor or nurse puts his unwashed hands in a box of gloves, he contaminates the whole box. When the next one does the same, it just gets worse. So we've got a situation now where poor hand hygiene coupled with improper use of antibiotics has created those nasty resistant super-bugs that have taken over many hospitals.
What needs to happen is the following:
- Disconnect payment for health care from employment status.
- Get the for profit companies out of medical care. A hospital, doctor's office or drug company has to cover its costs, pay its employees and maintain a reasonable surplus for unplanned expenses. Making a huge profit so shareholders benefit and corporate officers get rich is not appropriate for anyone in health care.
- Put management of care back in the hands of the physicians, instead of anonymous bureaucrats at insurance companies and government agencies.
- Clean up the food supply. That means
- treating animals in a humane fashion so that they don't end up diseased and maltreated
- Getting rid of GMO crops
- Ending monoculture which destroys the soil and going back to crop rotation
- Use of sustainable farming methods
- Dismantling the factory farms
- Stop growing corn
- Go back to realistic measurements of height and weight, cholesterol, blood pressure and anything else that's been dicked with in the past 20 - 30 years
- Change our expectation of what "health" means. We're not the same at 50 as we are at 20. Learn to age gracefully and realise that a state of health is a physical, mental, emotional and spiritual state -- not just an absence of disease.
There's probably more but it's late and I'm tired.