Health Care in America: real problems, real fixes
I was discussing the recent health care bill (now signed into law) with betacandy over at her blog, and she invited me to share my thoughts. I've actually been meaning to do this for the better part of a year, but have been extraordinarily lazy about updating my LJ. But a good prod was all I needed. :)
Much of the following rant was both informed and prompted by articles by Maggie Mahar (you can read some of her pieces here and here) and by John Silviera (you can read his rant here).
How the fuck to solve the medical crisis in America.
First, we need to identify the problems with medical care in America. Obama and the dems have identified ONE problem with health care, and that is that too many Americans don't have access to it. They have attempted to address this with the current law, and to some extent have probably succeeded. However, I rank this law a failure for the following reasons:
1.) It addresses a symptom, not an underlying problem.
2.) It does so by radically affecting every American, some much more than others.
3.) It is tremendously expensive. I've heard numerous claims about it actually reducing the deficit, blah blah, but that is a shell game. That's like me buying a new TV on my Mastercard (which already has a high balance), then robbing a liquor store to pay down some of the debt and claiming that the new TV purchase was what helped reduce it.
No, the real problem is not health insurance. At all. The insurance model as a whole is a pretty crappy way of achieving the underlying goal, which is to get Americans health care. And the real reason so many do without it is because it is expensive. America spends more (WAY more) per capita on health care than any other country. THAT is the elephant in the room we need to address.
Why is it so expensive? Lots of reasons....I'll list some here.
1.) Too few doctors to treat too many patients. You'd think we'd have tons of doctors, right? It's a lucrative profession...we all know doctors are rich. And it's a morally wealth profession, too...doctors save lives, they're universally respected, right? Well, not quite.
First of all, there aren't as many doctors as there are people who want to be doctors...and who could actually qualify to be doctors. This is because the AMA limits the number of slots available in medical schools, and thus, who can learn to be a doctor. Even if you have the grades, drive, and so forth, you might never get a chance to be a doctor. In economic terms, we call this an artificial limitation on supply...and it has a corresponding effect on demand.
Second, many people who could be good doctors don't even apply...because a medical degree is enormously expensive, a huge investment of time and money.
Third, of those who DO become doctors, too many become specialists and not enough become primary care physicians. Because specialists make the big bucks, and if you're going to work your ass off and get a ton of debt, you want the big money, right?
Finally, not only does the AMA artificially limit the supply of doctors, it eliminates competition for doctors through overly restrictive licensing. This prevents alternative care providers (like chiropractors, midwives, and others) from competing...and thereby, from actually helping patients and easing some of the workload.
So...how to fix this? Well, it starts be re-examining the status quo, after realizing that the current system is bound to produce expensive health care.
Mahar, in talking about medical schools, misses an important point. She seems to think that a deeper, broader applicant pool would help the AMA pick only "the best and brightest" to become each years new batch of doctors. But I say...why not let them ALL be doctors, if they can do the work? Why limit how many people can train, be it by limiting slots at schools or (for that matter) not having enough schools? I would rather have 200 competent doctors than 100 superlative doctors...not least because, the more doctors you have, the more the burden is eased for doctors. Many doctors in America are horrendously overworked, and that contributes to medical complications and mistakes more (IMO) than having someone who is perhaps not quite as brilliant.
If there's a guy out there who can learn to remove my appendix without killing me, I want him practicing...if for no other reason than that he does a job that a brilliant doctor doesn't have to do...that guy can go spend his time curing cancer and shit.
Along with getting more doctors into circulation, we need to be opening up the medical field to NON-doctor medical professionals. More Nurse Practicioners, more midwives, more ancupuncturists for God's sake. Overlicensing is complete bullshit, and while it is claimed to be for "consumer protection", what it most often does is serve as a form of industry protection, and an artifical barrier to entry into the market. Perhaps you haven't heard the bullshit story about how a successful hair-braiding company was shut down by the cosmetologist lobby (if not, you should), but there is no reason that, for instance, the AMA should be allowed to require a master's degree to deliver babies in some places. Look, I'm all for competent doctors, but in a lot of cases delivering a baby is not exactly rocket science. People do it in their own homes in a kiddy pool, with no assistance at all (I'm not kidding).
Now, clearly some deliveries are easier or harder than others; my wife, for instance, had all 4 of ours by c-section, and that's clearly not something I'm going to try at home. But come on...telling midwives they're not competent to deliver babies is just bullshit.
2.) Medical Malpractice. I'm actually going to skip the rant on this one, I'm sure most of you have heard it before. Long story short...our horrorshow of a legal system ruins everything. I do not have a quick fix for this problem, but there needs to be one.
In the end, the only solution to the health care crisis is to fix the root causes of overexpensive healthcare. Finding a way to pay for overexpensive health care for everyone is a stopgap at best, and not likely to work very well...because despite what some democrats like to believe, you cannot simply pull money out of your asshole. It has to come from somewhere...which means that at the end of the day, people are still overpaying for a broken system.
We cannot plug this dike, okay? We need to build a new fucking dike before this one breaks and floods the lowlands.
Now...along with lowering the actual costs, if we want to continue the insurance model (and I'm sure many do)...we need a public option.
I'm sorry to my conservative brethren who decry this as "socialized medicine"; history has shown us that for-profit health insurance companies are simply NOT going to help a lot of people who desperately need care. If the choice is "give them something" or "leave them with nothing", I think the former is a gimme.
Now here come the conservatives to tell me how a public health care plan will destroy free market medicine and insurance. And my response is: Bullshit. What are you right-wingers afraid of?
"The government doesn't need to profit, so they'll run private insurers out of business!" But WAIT...doesn't that conflict with your OTHER favorite claim...
"Government care is always cruddy and rationed and it will suck!"
So let me get this straight...it will suck...and private insurers can't compete with suck? If that's the case, I don't want them around.
I will be frank: if the government option can provide care just as good as private insurers, at a lower cost...what the fuck do we want private insurers around for? The whole point of private insurers is that they can do a BETTER job than the government, but they want to turn a buck so it costs the user more. And that's FINE.
What are conservatives so afraid of? That public health care might *gasp* actually WORK?
I am no fan of big government, okay? And I will freely state that any public option needs to be as cost-effective as possible (no bloated waste or massive deficits) and as competetition friendly as possible (not heavy-handed government monopoly throwing up roadblocks to the private sector through legislation). But for God's sake, let them try. It's seriously that bad, okay? Big government is an idiot asshole a lot of times, but big business is a heartless greedy asshole, and right now that's worse. When a government solution is the lesser of two evils, you are in dire fucking straits.
Now if this is going to work, the liberals out there are going to need to choke something down too: the public option does NOT need to be perfect, does NOT need to be 100% free, and does NOT need to cover everything. I want it to make primary care affordable for lower to middle-class people. I would like the premiums to be income-based, so that anyone can afford it regardless of income level, but where people are paying what they can afford. I want it to provide good care for most things, but not heroic efforts or necessarily "top line" or "cutting edge" treatments. I do want anyone to be able to get it, regardless of medical history. And yes, this means that rich people can afford to use private care or insurance, and they probably will. That's GOOD, IMO...it leaves more resources in the public system for people who need it.
Now here come the bleeding hearts to yell at me about "tiered care". Yes, yes it is. So what? EVERYTHING is tiered in this country. We have tiered food (food banks and shitty McDonalds vs. filet mignon), we have tiered transportation (buses and beaters and coach vs. limousines and cadillacs and chartered jets), we have tiered self-defense (cheap hi-point automatics vs. custom-built Kimber 1911A1s), hell, we even have tiered police services (911 vs. private bodyguards and security firms). I don't really have a problem with tiering. You cannot have a free and capitalist society (which I want) without rich people being able to afford more than poor people. That's what being rich means. The only thing that SHOULDN'T be tiered in this country is the damn legal and political system, and frankly that's something not enough people are fighting for.
This may sound harsh, but in the words of Bricktop: "If I throw a dog a bone, I don't wanna fucking know if it tastes good". Yes, you may not be getting quite the same level of care as a millionaire. It's STILL better than the care you WEREN'T getting before! Something IS better than nothing, especially if you're getting it on the cheap. And I'm very sorry: we cannot afford to give everyone in the country cadillacs. And we can't afford to give everyone first-tier medical care.
That doesn't mean we need to give poor people ghetto care. It should still be good, solid, quality care. But we can have it be the "Wal-Mart" version. Generic medicines. Cheaper buildings, furniture, supplies. Poorer quality food (though with hospital food, I think we're already there). And...you'll probably need to make do with competent health care professionals who are not necessarily "best in their field" or expert specialists.
Does this mean that using public health care will be less likely to save your life if you have a serious illness? Sadly, yes. Again: that is already the situation, and not just with health care. Being rich insulates you against many of the problems that come with poverty, and health care is just one example. In the words of another dude "that's why it's called poor and not awesome". In a perfect world, the poor would have everything just as good as the rich (for that matter, there wouldn't be any poor). This is NOT a perfect world, and trying to devise a health care system for a perfect world is a waste of time and money.
So that's how I feel about the current fix. In some ways it does too much, and in other ways it doesn't do enough...but most importantly, it doesn't do the right stuff. At all. When all four of the Goodenbery brothers (two conservative, two liberal, all different) can agree that this was a bad bill...it was a bad bill.
Much of the following rant was both informed and prompted by articles by Maggie Mahar (you can read some of her pieces here and here) and by John Silviera (you can read his rant here).
How the fuck to solve the medical crisis in America.
First, we need to identify the problems with medical care in America. Obama and the dems have identified ONE problem with health care, and that is that too many Americans don't have access to it. They have attempted to address this with the current law, and to some extent have probably succeeded. However, I rank this law a failure for the following reasons:
1.) It addresses a symptom, not an underlying problem.
2.) It does so by radically affecting every American, some much more than others.
3.) It is tremendously expensive. I've heard numerous claims about it actually reducing the deficit, blah blah, but that is a shell game. That's like me buying a new TV on my Mastercard (which already has a high balance), then robbing a liquor store to pay down some of the debt and claiming that the new TV purchase was what helped reduce it.
No, the real problem is not health insurance. At all. The insurance model as a whole is a pretty crappy way of achieving the underlying goal, which is to get Americans health care. And the real reason so many do without it is because it is expensive. America spends more (WAY more) per capita on health care than any other country. THAT is the elephant in the room we need to address.
Why is it so expensive? Lots of reasons....I'll list some here.
1.) Too few doctors to treat too many patients. You'd think we'd have tons of doctors, right? It's a lucrative profession...we all know doctors are rich. And it's a morally wealth profession, too...doctors save lives, they're universally respected, right? Well, not quite.
First of all, there aren't as many doctors as there are people who want to be doctors...and who could actually qualify to be doctors. This is because the AMA limits the number of slots available in medical schools, and thus, who can learn to be a doctor. Even if you have the grades, drive, and so forth, you might never get a chance to be a doctor. In economic terms, we call this an artificial limitation on supply...and it has a corresponding effect on demand.
Second, many people who could be good doctors don't even apply...because a medical degree is enormously expensive, a huge investment of time and money.
Third, of those who DO become doctors, too many become specialists and not enough become primary care physicians. Because specialists make the big bucks, and if you're going to work your ass off and get a ton of debt, you want the big money, right?
Finally, not only does the AMA artificially limit the supply of doctors, it eliminates competition for doctors through overly restrictive licensing. This prevents alternative care providers (like chiropractors, midwives, and others) from competing...and thereby, from actually helping patients and easing some of the workload.
So...how to fix this? Well, it starts be re-examining the status quo, after realizing that the current system is bound to produce expensive health care.
Mahar, in talking about medical schools, misses an important point. She seems to think that a deeper, broader applicant pool would help the AMA pick only "the best and brightest" to become each years new batch of doctors. But I say...why not let them ALL be doctors, if they can do the work? Why limit how many people can train, be it by limiting slots at schools or (for that matter) not having enough schools? I would rather have 200 competent doctors than 100 superlative doctors...not least because, the more doctors you have, the more the burden is eased for doctors. Many doctors in America are horrendously overworked, and that contributes to medical complications and mistakes more (IMO) than having someone who is perhaps not quite as brilliant.
If there's a guy out there who can learn to remove my appendix without killing me, I want him practicing...if for no other reason than that he does a job that a brilliant doctor doesn't have to do...that guy can go spend his time curing cancer and shit.
Along with getting more doctors into circulation, we need to be opening up the medical field to NON-doctor medical professionals. More Nurse Practicioners, more midwives, more ancupuncturists for God's sake. Overlicensing is complete bullshit, and while it is claimed to be for "consumer protection", what it most often does is serve as a form of industry protection, and an artifical barrier to entry into the market. Perhaps you haven't heard the bullshit story about how a successful hair-braiding company was shut down by the cosmetologist lobby (if not, you should), but there is no reason that, for instance, the AMA should be allowed to require a master's degree to deliver babies in some places. Look, I'm all for competent doctors, but in a lot of cases delivering a baby is not exactly rocket science. People do it in their own homes in a kiddy pool, with no assistance at all (I'm not kidding).
Now, clearly some deliveries are easier or harder than others; my wife, for instance, had all 4 of ours by c-section, and that's clearly not something I'm going to try at home. But come on...telling midwives they're not competent to deliver babies is just bullshit.
2.) Medical Malpractice. I'm actually going to skip the rant on this one, I'm sure most of you have heard it before. Long story short...our horrorshow of a legal system ruins everything. I do not have a quick fix for this problem, but there needs to be one.
In the end, the only solution to the health care crisis is to fix the root causes of overexpensive healthcare. Finding a way to pay for overexpensive health care for everyone is a stopgap at best, and not likely to work very well...because despite what some democrats like to believe, you cannot simply pull money out of your asshole. It has to come from somewhere...which means that at the end of the day, people are still overpaying for a broken system.
We cannot plug this dike, okay? We need to build a new fucking dike before this one breaks and floods the lowlands.
Now...along with lowering the actual costs, if we want to continue the insurance model (and I'm sure many do)...we need a public option.
I'm sorry to my conservative brethren who decry this as "socialized medicine"; history has shown us that for-profit health insurance companies are simply NOT going to help a lot of people who desperately need care. If the choice is "give them something" or "leave them with nothing", I think the former is a gimme.
Now here come the conservatives to tell me how a public health care plan will destroy free market medicine and insurance. And my response is: Bullshit. What are you right-wingers afraid of?
"The government doesn't need to profit, so they'll run private insurers out of business!" But WAIT...doesn't that conflict with your OTHER favorite claim...
"Government care is always cruddy and rationed and it will suck!"
So let me get this straight...it will suck...and private insurers can't compete with suck? If that's the case, I don't want them around.
I will be frank: if the government option can provide care just as good as private insurers, at a lower cost...what the fuck do we want private insurers around for? The whole point of private insurers is that they can do a BETTER job than the government, but they want to turn a buck so it costs the user more. And that's FINE.
What are conservatives so afraid of? That public health care might *gasp* actually WORK?
I am no fan of big government, okay? And I will freely state that any public option needs to be as cost-effective as possible (no bloated waste or massive deficits) and as competetition friendly as possible (not heavy-handed government monopoly throwing up roadblocks to the private sector through legislation). But for God's sake, let them try. It's seriously that bad, okay? Big government is an idiot asshole a lot of times, but big business is a heartless greedy asshole, and right now that's worse. When a government solution is the lesser of two evils, you are in dire fucking straits.
Now if this is going to work, the liberals out there are going to need to choke something down too: the public option does NOT need to be perfect, does NOT need to be 100% free, and does NOT need to cover everything. I want it to make primary care affordable for lower to middle-class people. I would like the premiums to be income-based, so that anyone can afford it regardless of income level, but where people are paying what they can afford. I want it to provide good care for most things, but not heroic efforts or necessarily "top line" or "cutting edge" treatments. I do want anyone to be able to get it, regardless of medical history. And yes, this means that rich people can afford to use private care or insurance, and they probably will. That's GOOD, IMO...it leaves more resources in the public system for people who need it.
Now here come the bleeding hearts to yell at me about "tiered care". Yes, yes it is. So what? EVERYTHING is tiered in this country. We have tiered food (food banks and shitty McDonalds vs. filet mignon), we have tiered transportation (buses and beaters and coach vs. limousines and cadillacs and chartered jets), we have tiered self-defense (cheap hi-point automatics vs. custom-built Kimber 1911A1s), hell, we even have tiered police services (911 vs. private bodyguards and security firms). I don't really have a problem with tiering. You cannot have a free and capitalist society (which I want) without rich people being able to afford more than poor people. That's what being rich means. The only thing that SHOULDN'T be tiered in this country is the damn legal and political system, and frankly that's something not enough people are fighting for.
This may sound harsh, but in the words of Bricktop: "If I throw a dog a bone, I don't wanna fucking know if it tastes good". Yes, you may not be getting quite the same level of care as a millionaire. It's STILL better than the care you WEREN'T getting before! Something IS better than nothing, especially if you're getting it on the cheap. And I'm very sorry: we cannot afford to give everyone in the country cadillacs. And we can't afford to give everyone first-tier medical care.
That doesn't mean we need to give poor people ghetto care. It should still be good, solid, quality care. But we can have it be the "Wal-Mart" version. Generic medicines. Cheaper buildings, furniture, supplies. Poorer quality food (though with hospital food, I think we're already there). And...you'll probably need to make do with competent health care professionals who are not necessarily "best in their field" or expert specialists.
Does this mean that using public health care will be less likely to save your life if you have a serious illness? Sadly, yes. Again: that is already the situation, and not just with health care. Being rich insulates you against many of the problems that come with poverty, and health care is just one example. In the words of another dude "that's why it's called poor and not awesome". In a perfect world, the poor would have everything just as good as the rich (for that matter, there wouldn't be any poor). This is NOT a perfect world, and trying to devise a health care system for a perfect world is a waste of time and money.
So that's how I feel about the current fix. In some ways it does too much, and in other ways it doesn't do enough...but most importantly, it doesn't do the right stuff. At all. When all four of the Goodenbery brothers (two conservative, two liberal, all different) can agree that this was a bad bill...it was a bad bill.