America's health care system is neither healthy, caring, nor a system.
Walter Cronkite
This isn’t going to be pretty.
I apologize in advance to anyone I might insult here, but I am very angry and what I’m angry about is an issue of some import to all of us. I also apologize for the length of this.
What follows are just opinions. I make no claims to extraordinary prescience. I have tried to do my research, so hopefully these opinions are more than just the product of bile.
They are also informed by personal experience.
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On a nice spring Saturday morning in 2004 I was doing some housecleaning. As part of the effort, I flipped the mattress over. As I pulled it up to my chest there was an audible POP in my upper left arm followed by a blast of pain in my bicep that left me laying across the mattress on my stomach, literally seeing stars.
On Monday I was at my doctor’s office. He examined the injured area and noted that the bicep might very well be partially detached. He said I needed an MRI to properly diagnose it. Imagine my (and his) surprise when my insurance company (then Blue Shield, now Highmark/Blue Shield) denied the claim, and instead suggested physical therapy. My doctor called them and appealed the decision, but they blew him off.
So I went to physical therapy for a month. Twice a week, the therapist massaged the deep tissue with ultrasound and with her fingers, and then had me perform a series of exercises and stretches. She, like the doctor, thought I had probably detached the muscle and didn’t think the therapy would do anything. It didn’t. My insurance paid for all eight sessions to the tune of several thousand dollars.
After the one month delay, they agreed to pay for the MRI, which diagnosed a detached bicep. A surgery was scheduled, which they also paid for. When I was awakened after the surgery, the doctor informed me that the muscle had retracted during the over one month delay before the operation, and he was unable to tug it back down and reattach it.
The injury is permanent, and I have lost much of the strength and stability I once had in my left arm.
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The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes.
The Commonwealth Fund “Mirror, Mirror On The Wall — 2014 Update”
By most empirical measures, America sucks at health care. We do have some great doctors, and we are innovative in developing treatments and medications, but those are about the only areas in which we excel. We spend more, die sooner, and are less healthy than all other comparable countries.
In 2014 the Commonwealth Fund looked at many aspects of health care in eleven of the world’s wealthiest countries and we rank damn near dead last in almost all of them.
http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
The Institute of Medicine, one of the National Academies, agrees with this assessment.
http://iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health/Report-Brief010913
And even lefty publications like the Business Insider don’t have much good to say about the status quo.
http://www.businessinsider.com/us-health-lags-the-developed-world-2013-1
While the effects of the Affordable Care Act/Obamacare have at least led to more insured people, the cost of health care in America remains inordinately high, and all the other problems remain. Further, since so many of the newly available plans have high deductibles, for middle class and poor folks getting sick in America remains an excellent way to go into debt or at least to get poorer.
None of this is news. I just wanted to repeat it because people who live in an economy the size of ours ought to be absolutely enraged by it. There are people and companies in America who have become fabulously wealthy by trading on human misery and sickness, and among the victims have been our elderly, our children, the poor, the mentally ill, and the disabled.
It’s the sort of thing that puts people in the streets in other countries.
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Since my family doctor was out of town the second week of May in 2009, I was examined by a nurse-practitioner who carefully manipulated the red, hot and angry lump in my right calf. She looked worried.
“I think you have a DVT, a blood clot. You might have cellulitis as well. You need to have a venous Doppler examination right away, and you probably should be hospitalized.”
As this sank in, I asked her if she could call to have me admitted to the hospital and she explained that she couldn’t.
“I don’t have admitting privileges at any area hospitals. You’ll have to go to the emergency room.”
My first stop was the downtown city hospital emergency room, which had a line that literally extended out the door. I left for a suburban hospital. While the line was shorter, it was still a full house. So I gave them my name, described my symptoms, and took a seat. This was at roughly 5:30 PM.
I spent the evening watching the blue collar and poor of my community wait patiently and otherwise for their basic health care. Since none of these poor folks had coverage, their only recourse for a child’s earache, sore knees, a bad cold, etc. was the emergency room. A man with a janitor’s uniform sat across from me with his wife, a sick little boy and all the child’s siblings (child care, like health insurance being prohibitively expensive or simply unavailable). A waitress with the flu sat curled up in a plastic chair in the corner. A Serbian immigrant had brought his aged mother shaking with fever. We all waited, looked at magazines, and tried not to make eye contact.
By 11:00 PM I had a raging fever and my leg was throbbing and red above the knee. At 11:30 I was taken back into the EM. I had been there six hours. Had I stayed downtown it would have been worse. The EM itself was staffed by good and dedicated people, but it was chaotic almost beyond description. It had been a bad night, as it frequently is in many American hospitals. All the small cubicles were occupied and a few patients were on beds in a hallway. Some badly injured and/or gravely ill people had come in by ambulance, and some like me had walked in, and there were just too many sick people. I was given an IV of saline, administered an oral antibiotic, given an injection of a blood thinner, and since no beds were available in the hospital and I had not been ejected from a demolished car nor suffered a heart attack, at 2:30AM, I was discharged.
My phone being dead, and it being the middle of the night, I just drove myself home. Had the blood clot moved, or the sepsis not responded to the antibiotic, I wouldn’t be sitting here venting my spleen. The attending physician undoubtedly knew how risky it was to release me, but given the situation at the time, made a rational decision to do so. She simply had no choice in the matter.
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Almost nobody else does this. Almost everywhere else in the developed world, health care is, to one degree or another, paid for by the government. Anyone who tells you this is a perfect system is disingenuous or ill informed. Public sector single payer health care lacks some bells and whistles we are used to and would probably miss. T.R. Reid’s book and films on the issue note that hospitals in other countries are smaller and plainer than American hospitals. Medical equipment isn’t as cutting edge as it can be here, and gets used longer and harder. Testing and procedures that are elective or non emergencies takes longer to get scheduled. Doctors and other health care workers aren’t as well paid, although they still do OK. And of course, while you don’t get a bill from the doctor or hospital, it ain’t free. You pay higher taxes and those taxes pay for your health care. Depending on what data you look at, the Brits cough up more than 3 grand per capita to fund their system, the Canadians more than 4 grand.
All that said, nobody envies us. Whatever other folks pay in increased taxes pales in comparison to what we pay in premiums, co pays and deductibles. We drop more than $8,000 per person per year on healthcare; the highest in the world. For this we get lots of uncovered and insufficiently covered people jammed into emergency rooms, we get private policies with ruinous (i.e. multi-thousands) deductibles, we get health insurance providers that are primarily concerned with making money (including some that are supposed to be non-profits), we get health care CEO’s and Board Chairs who are multi millionaires, we get the world’s most expensive drugs, procedures, and medical devices, we get medical cost statements full of indecipherable gobbledygook and nasty expensive surprises, we get to be sicker and die younger than people in other developed countries.
We get shafted.
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I just wrote a check to a health care provider for 300 bucks. The bill they sent me itemized the many expensive charges Highmark covered when I had a lymph node biopsied back in October of last year, but one charge was not covered. It was for the anesthesia. So I called Highmark and spoke to a pleasant young man.
JB: “So why isn’t the anesthesia covered?”
Highmark: “Well, we don’t cover anesthetics unless they’re administered by an anesthesiologist. Yours was administered by the surgeon who conducted the procedure.”
JB: “I see. So why exactly don’t you cover anesthetics administered by a surgeon?”
Highmark: “Because that’s our written policy Mr Baker.”
JB: “No, I mean, what is the actual medical reason you don’t cover it?”
Highmark: “Oh, I couldn’t tell you Mr Baker, I’m not a doctor.”
The exchange, while at least mildly entertaining, wasn’t terribly enlightening. I called the health care provider next.
JB: “Were you aware this wasn’t covered unless an anesthesiologist administered the drugs?”
Provider: “No sir, but that’s not our responsibility. You signed a paper accepting responsibility for any uncovered medical expenses. Would you like us to FAX you a copy?”
JB: “No thanks, I don’t own a FAX machine. So is there any way I could have avoided this charge?”
Provider: “You could have declined the anesthetic.”
JB: “There was a guy waving a scalpel and a very large-bore needle around in between my legs. No anesthesia sounds like a bad idea.”
Provider: “Well that was your decision sir. If the invoice isn’t paid in 30 days, we’ll send it to a collection agency.”
Medical bills can be catastrophic, so in the big picture 300 bucks doesn’t seem too bad.
So why do I feel like I just got held up at gunpoint?
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In my opinion, we ought to have a single payer option of some kind here in the US, warts and all. I want this because it would be cheaper and simpler, but that’s not the only reason. In my opinion there are a few public concerns that should not be exposed to the ruthless efficiency of the market economy.
Competitive markets exist to make a profit. That’s hardly a bad thing. That’s what our national wealth is based on. My concern with exposing health care to the open market is value-based. I don’t think that turning a profit is always the primary public interest. Speaking for myself, I think the purpose of health care is to promote everyone’s health and to alleviate the suffering of sick people. The purpose of competitive markets is to make a profit. I’m not implying making a profit is immoral, but it frequently is a-moral. Making a profit in health care requires sick people. There is no real market incentive to have lots of healthy people who don’t pay to use the system. There is a real incentive for a publically funded system to promote health: it’s cheaper. It’s also morally defensible: a public policy based on empathy and decency.
Imagine that.
One of my conservative friends pointed out that a public single- payer system would decimate the health insurance, drug, and maybe even care provider industries as we know them. Good private sector jobs would disappear, as would investment income. That’s probably true. My only response is we’ve done that sort of thing in this country before, and we’ve survived it and become a better nation because of it.
Chattel slavery is a highly efficient and lucrative way to practice agriculture. Lots of people made lots of money off it. Sailing off to Africa and stealing people used to be a good job. We don’t do that stuff anymore for moral reasons, and there was great economic privation in parts of the antebellum South as a result. We did it anyway. As public values evolved in this country, holding people in bondage became intolerable, thank God!
Maybe comparing our current health care system to slavery is unfair. I don’t know. If someone wants to explain to me how making a pile of money off illness and misery is morally defensible, I guess I’m all ears.
Of course, given the way we govern ourselves these days, a sea change in public health care is just a pipe dream.
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In late December, not long before Christmas, I damn near died. I had been to my family doctor in November complaining about feeling tired and drifting off to sleep in odd places at odd times. She said “That sounds like sleep apnea. I’m going to schedule a sleep study for you.” A sleep study measures the dissolved oxygen in a patient’s blood and monitors the patient’s breathing while they are asleep. If sleep apnea is diagnosed, it can be readily corrected with a machine that pumps air into the patient’s mouth and nose while they sleep.
I didn’t hear from my Doctor’s office about the referral for a week, and the symptoms were getting worse, so I called. They hadn’t received an approval yet from Highmark for the sleep study. Weeks passed with no word from Highmark. On December 10th, the Doctor’s office called to tell me that Highmark had denied paying for the sleep study. Instead they would pay for a home study, i.e. one I would conduct myself with equipment they would mail me. The home study is much cheaper, apparently. This would be scheduled for December 19th. On December 10th, in the afternoon, I fell asleep at the wheel on the interstate, and wrecked my car, barely escaping with my life. After the wreck, the fatigue problem continued to worsen. I was rushed to the hospital on Sunday, in what turned out to be full pulmonary failure. Thanks to their denial of a diagnostic study, my friends at Highmark came really close to killing me twice in the same week.
I was unconscious Sunday night and Monday. I came to on Tuesday, and was placed on supplemental oxygen and was put on a C-PAP machine to sleep. My dissolved blood oxygen returned to a normal level (in the 90%+ range) from the dangerous levels I experienced (57%) when I arrived. I got out of intensive care on Wednesday. By Thursday morning I felt pretty darned good, good enough to ask the pulmonary specialist when I might be going home.
He chuckled and said “Not any time soon! Maybe Saturday…first we have to do the sleep study.”
I stared at him. “Huh? What sleep study are you talking about?”
“Oh we need to do one tonight so we can demonstrate to your insurer that you have sleep apnea and will require a C-PAP or Bi-PAP machine at your home.”
“But I almost freekin died on Sunday night! Doesn’t that count as proof?”
“Nope.”
“Why the hell not?”
“It’s not empirical.”
“What the fuck are you talking about? It’s empirical to me!”
“But not to Highmark my friend!”
And so that night I was wired up to a few monitors and told to go to sleep without the machine. I was awakened at about 4:00AM with a blinding headache. The nurses said they had collected sufficient data, removed the monitors, and put me back on the C-PAP. I went back to sleep and didn’t open my eyes again until about 11:00 AM. It took me until Saturday morning to recover, and I was finally sent home. My insurance company, having saved themselves a few grand by denying my doctor’s original request for a sleep study, incurred God knows how many thousands in costs for a week in the hospital, every penny of which they paid for. They also paid for my bi-pap machine, which now sits by my bed and keeps me alive.
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Ultimately, whatever changes I’d like to see in healthcare are more or less irrelevant. So are yours. That’s because it would require legislation.
In any deliberative legislative body in our country, or any country, it’s simply not possible to pass legislation that successfully addresses any large scale societal problem without goring somebody’s ox. Single payer health care would create winners and losers and would cost lots of money: money that would come out of somebody’s pockets. That would also be true of legislation that addressed the budget deficit, the Social Security shortfall, public education, pension reform, climate change, tax reform, energy policy, war and peace, poverty and income inequity, infrastructure, or anything else you would care to name. Real solutions require real change, real sacrifice, and real expenditures. Anybody who tells you otherwise is lying or dumb or both.
Our national legislature, all the state legislatures, and the national and state executive branches are all in a state of paralysis induced by money. If any of them profess support for any real solution to any real problem, the interests that might be hurt by the proposed solution go to work. Their money goes to the political opponents of those proposing the solution, and the solution goes nowhere. And that’s that. Our elections have turned into blizzards of cash. Officeholders and candidates spend most of their time raising funds, and the contributors quite sensibly expect something for their money. The result has been the extinction of truly transformative public policy, and that is dangerous.
The best any legislature or any leader can do these days is maybe kick the can down the road for a few years. People are pissed off and dissatisfied. A real plunge into disaster caused by inertia on the big issues could happen to us at any time, and that would create the conditions under which dictators and tyrants thrive. People like Hitler or Putin sell themselves as deliverers who will sweep away the do-nothings and accomplish big things. They wrap themselves in the flag, and identify scapegoats who have caused all the trouble. Desperate people vote for them.
Let’s not become desperate, shall we? The only way to change this short of armed insurrection is to vote for people who promise to get the money out of our elections and out of our legislative processes. Such people do occasionally run for office in all sorts of places. If they wound up in office in sufficient numbers, maybe they would do something about the problem. Last election cycle, about 40% of eligible voters showed up. For the other 60%, I have a suggestion. If you are wondering who is responsible for our cruddy health care system or for the rest of our other big and insoluble national problems, you need look no further than the nearest mirror.
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