• CNN – Take another look at health care act

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    My latest piece for CNN.com is up. I was out to dinner over the weekend with friends, and we were discussing the fiscal future of the country. I totally get that people are pessimistic about the future of health care spending, but it’s worth remembering that there’s a law that’s already been passed that reduces the deficit according to the CBO.

    Before you start screaming at me, go read the piece.

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    • Aaron Carroll,

      This is somewhat off topic, but I had a number of questions and concerns about your views on health care. I am not a regular reader, but I am very interested in health policy.

      1.) I have seen you suggest that the claim that single payer health care systems have long waiting times is a “conservative myth”. But, are you not familiar with the wide ranging research showing that people in countries with single payer have to wait far longer than people in the US for specialists and elective surgery. Sure, for primary care doctors, the picture is more complex, but you can’t ignore specialists and elective surgery.

      2.) I am confused to your views about the current state of Medicaid. Once again, my reading the evidence certainly points towards patients with private insurance having FAR better access to higher quality health care than those on Medicaid. The reason for this seems to be that Medicaid underpays providers. Do you disagree with this reading?

      3.) The USA has FAR more MRIs and CT scanners per capita than do other developed countries. In fact, the UK only has 6 MRIs and 9 CT Scanners per million people compared to 32 MRIs and 41 CT scanners per million population in the US. Canada only does a little better than the UK. Wouldn’t this lack of medical technology suggest problems with the single payer systems present in these countries.

      4.) As far as cost growth goes, it is true that the US system costs much more than any other system. However, cost growth over the past decade or so is quite a different story. In fact, from 2000 to 2010, per capital health spending grew 72% in the USA, which is high, but, during the same period, per capita health spending grew by 76% in Canada and by 87% in the UK. If single payer systems are so good at controlling health inflation, this shouldn’t be the case.

      5.) Contrary to what Paul Krugman says, there are examples of free market success stories in health care. It is true that you have to look harder for them, because no country really has free market health care. However, in the developed west, the country that comes closest is probably Switzerland. They have universal care, but with many market mechanisms in place. They rely on competing private insurance companies, and, perhaps more imporantly, they encourage cost sharing. 25% of all health spending is out of pocket in Switzerland, far higher than the 12% in the US (which is about the same as most government controlled systems in the west). And, they do pretty well. Cost growth has been relatively reasonable (64% growth in per capita health spending from 2000 to 2010), health spending as a percentage of GDP is roughly equal to Canada, and they have pretty decent quality as evidenced by the fact that they are close to the US in terms of the amount of CT scanners and MRIs they have per capita (although they are still somewhat lower than the US).

      6.) My final question is why you don’t think that a free market would work in health care?

      This is one question I have never heard advocates of single payer give a real answer too. Typically, the only response is that America’s system doesn’t work that well. Which is true, but it would be hard for anyone to argue that America’s systems looks anything like a free market. Likewise, free market work in pretty much every other major consumer sector of the economy. And, as to the argument that people can’t say “no” to health care, the same is true of food, yet we don’t have government run food companies.

      Alright, well, thank you for your time. I look forward to a response.

    • Excellent article. The AHC act is a start on controlling costs and expanding access to care. Once the furor abates we do need to enact tort reform and add one more piece – dental care has to be brought into the mix, possibly as a separate “Part.” We also need to have an adult ethical discussion about cancer care and end of life care.

    • In the July issue of HEALTH AFFAIRS, there is a report from the Office of the Actuary for CMS. It projects the expense of our nation’s healthcare industry for the next ten years. They healthcare expenses at 17.9% in 2011 and 19.6% in 2021 of our nation’s gross domestic product. Hmm, I don’t see any significant cost-saving.

      I am aware that Henry Aaron at the Bookings Institute has projected a national debt per citizen in ten years that will be same as exists in Greece today. On the back of our nation’s healthcare expense, we will no longer be able to finance our national debt in 10 years.

      Beginning in 1969 and peaking in 2009, our national healthcare industry has undergone a massive paradigm shift. A similarly massive institutional codependency had occurred between the payers of healthcare and the providers of health care for Complex Health Needs. As a result, the providers of health care for Basic Health Needs have not advanced since 1969, i.e., chronically and systematically under-capitalized. Paradigm paralysis has led to a national “maternal mortality rate” that is ranked by a 2010 United Nation’s report as 41st worst among the world’s 43 developed countries. It doubled between 1990 and 2008. A similar report in 2010 by Amnesty International USA described the maternal mortality problem as a reflection of the accessibility issues within our healthcare industry. I would argue that this is the basic issue underlying its total cost problem, as well.

      Universal health insurance (pre-paid healthcare) will not alone improve the character of our nation’s healthcare without an improvement in Primary Health Care that is driven by a locally initiated and nationally coached process of change. The research of Elinor Ostrom is most applicable.