Saturday, January 28, 2006

Demanding the Impossible From Our Health Care

Almost everyone agrees that we ought to ``fix the health care system'' -- a completely meaningless phrase despite its popularity with politicians, pundits and ``experts.'' Indeed, it is popular precisely because it is meaningless. The people who proclaim it rarely tell you the discomforting choices it might involve. Instead, they focus on a few specific shortcomings of our $1.9 trillion health-industrial complex and imply that, if we correct these often-serious flaws, we'll have ``fixed'' the system or at least made a good start. This is rarely true, and so most forays into ``health reform'' end with disillusion.

We are about to start the cycle again. By most accounts, President Bush plans to highlight health care in his forthcoming State of the Union address. His proposals may or may not have merit, but they surely won't fix the health system in any fundamental way. The reason is that most Americans don't want to fix the system in that sense. Most are satisfied with their care. Most don't see (or pay directly) most of their costs. Because politicians -- of both parties -- reflect public opinion, they won't do more than tinker. Unfortunately, tinkering isn't enough. As everyone knows, health spending has risen steadily. In 2004, it totaled 16 percent of national income, up from 7.2 percent in 1970. As health insurance becomes more costly, the number of uninsured, now about 46 million, may grow. Worse, health costs may depress wage gains, raise taxes and squeeze other government programs.

Here's the paradox: A health-care system that satisfies most of us as individuals may hurt us as a society. Let me offer myself as an example. All my doctors are in small practices. I like it that way. It seems to make for closer personal connections. But I'm always stunned by how many people they employ for non-medical chores -- appointments, record-keeping, insurance collections. A bigger practice, though more impersonal, might be more efficient. Because insurance covers most of my medical bills, I don't have any stake in switching.

On a grander scale, that's our predicament. Americans generally want their health-care system to do three things: (1) provide needed care to all people, regardless of income; (2) maintain our freedom to pick doctors and their freedom to recommend the best care for us; and (3) control costs. The trouble is that these laudable goals aren't compatible. We can have any two of them, but not all three. Everyone can get care with complete choice -- but costs will explode, because patients and doctors have no reason to control them. We can control costs but only by denying care or limiting choices.

Disliking the inconsistencies, we hide them -- to individuals. We subsidize employer-paid health insurance by excluding it from income taxes (the 2006 cost to government: an estimated $126 billion). Most workers don't see the full costs of their health care. Nor do Medicare recipients, whose costs are paid mainly by other people's payroll taxes. We're living in a fantasy world. Given our inconsistent expectations, no health-care system -- not one completely run by government or one following ``market'' principles -- can satisfy public opinion. Politicians and pundits can score cheap points by emphasizing one goal or another (insure the uninsured, cover drugs for Medicare recipients, expand ``choice'') without facing the harder job: finding a better balance among competing goals.

Every attempt to do so has failed. Consider the ``managed care'' experiment of the 1990s. The idea was simple: herd patients into health maintenance organizations or large physician networks; impose ``best practices'' on doctors and patients as a way to encourage preventive medicine and eliminate wasteful spending; and cut costs through administrative economies. But managed care upset doctors and patients. After a backlash, managed care relaxed cost controls.

Now, some say that because the ``market'' has failed, greater government control is the answer. Private insurance has high overhead costs and generates too much paperwork. True. Still, there's not much evidence that over long periods government controls health spending any better. From 1970 to 2003, Medicare spending rose an average of 9 percent annually. In the same years, private insurance costs rose 10.1 percent annually.

Americans want more health care for less money, and when they don't get it, they indict drug companies, insurers, trial lawyers and bureaucrats. Although these familiar scapegoats may not be blameless, the real problem is us. We demand the impossible. The changes we truly need are political. We need to reconnect people with the public consequences of their private acts. We should curb the subsidization of private insurance. Medicare recipients should pay more of their bills. But these changes won't happen because people don't want to see the costs. We don't have the health-care system we need, but we do have the one we deserve.



More fallout from the closure of emergency services at Caboolture hospital

A fire crew was dispatched to give urgent first aid to a Bribie Island man who had a heart attack because ambulances were busy transporting patients away from the troubled Caboolture Hospital. Fire officers gave oxygen for almost 1 1/2 hours to retired NSW police officer John Kenny, 57, until an ambulance was available. As well as having to wait for an ambulance, Mr Kenny was diverted away from Caboolture Hospital's emergency department which normally would have treated heart attack victims in the area.

A Queensland Ambulance Service spokesman last night confirmed a fire truck had been sent to Mr Kenny because it was "an unusually busy night". He denied ambulance crews had been busy diverting patients from the Caboolture Hospital. "Every available crew in the area were on a code-one emergency response," he said. "It was just an unusually busy period at that stage. "We responded with a firefighting crew who all have advance first-aid and lifesaving equipment on their trucks. "While it doesn't happen very often, we do have a standing agreement with the fire service to do this sort of thing. They are a great back-up. It is better having someone with advanced first-aid and life-saving equipment than no one at all." The spokesman said that at all times ambulance officers were in contact with Mr Kenny and the fire officers treating him.

Mr Kenny said he telephoned for the ambulance at 3am on Saturday and was shocked 10 minutes later to hear a fire engine siren outside and four fire officers walking into his home. "They put me on some oxygen and said there were no ambulances available," Mr Kenny said last night. "I didn't believe it. I thought someone was playing a bad joke on me. It took an ambulance an hour and a half to get there. "In the end an ambulance came from Caboolture station. They said they were spending all their time running people around the place because there is no Caboolture Hospital."

Mr Kenny has been in Brisbane's Prince Charles Hospital waiting for an angiogram since Saturday morning. He said the person he was sharing his room with had been waiting for most of that time for a 10-minute stress test which he was unlikely to get before Friday. "I moved here seven years ago and I remember (Premier) Peter Beattie saying we've got the best hospital system in the world. It's world-class," Mr Kenny said. "It might have been then, but, by God, it's not now. "You can give the firies and the ambos a real wrap. But you can give the people running the place -- the State Government -- the thumbs-down."

A spokeswoman for Mr Beattie said last night the Premier was unable to comment until he had been briefed on the circumstances. Opposition health spokesman Bruce Flegg said the incident showed other emergency services were being drawn into the problems confronting the state's public health system. "Heart attack carries with it a very high risk of sudden death," Dr Flegg said. "Failing to dispatch the properly equipped ambulance and paramedics increases the risk the patient will not survive." He said the failure to send an ambulance was compounded by the fact that the nearest hospital, Caboolture, was not taking patients such as Mr Kenny.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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