etee's Blog

There is a saying that goes something like this:

If you are assigned the task of boiling the ocean, the only way to accomplish it is to boil one cup at a time.

Or something like that, anyway.

"Boiling the ocean" (and its kin "eating an elephant" and "solving world hunger") refer to an effort which is gargantuan in scope. These Herculean efforts often become this way because of something called (in project lingo) "scope creep", uncontrolled changes in the products or features that are to be delivered by a project. This is most assuredly not a good thing in projects (though it is actually quite common.)

So, what does this have to do with "health care"? Lots. Health care has become a (some might call it the) hot button social issue of our time. It is a real hydra, with heads firmly planted in the political, social, and economic fields of society. And, thanks to a change in the political climate reflected in the election results of the past November, activities at the state level, and a mention in the recent State of the Union address, it has wormed its way back onto the radar screen of the nation's collective conscience.

Unfortunately, the term "health care" itself is misleading. In many ways, the state of health care in this country reflects the paradox Charles Dickens describes in A Tale of Two Cities: simultaneously being "the best of times, the worst of times." We have a delivery system that people from other countries (where health care is provided as a benefit by the government) come here to seek out. We have technology and treatments in place that would seem magical to our ancestors. At the same time, the system by which we pay for this care is a real mess, to the point that many people in this country are unable to obtain proper care in a timely manner at a price they can afford. Why is this?

As I see it, the problem really started when labor unions negotiated employer-paid health insurance. Starting out as 'major medical' (also known as "catastrophic medical") insurance, the idea was to spread the risk of catastrophic medical bills out across a large enough population that the workers wouldn't face bankruptcy if they or someone in their family got seriously ill. However, over time this 'insurance' evolved into something quite different, resembling to an extent the socialized health care systems in place in many countries in Europe (and elsewhere.) And, the introduction of a third party (the insurance company) into the health care equation changed the dymanics significantly, and skewed the system to the point that we are now in what is perceived to be a crisis.

How did things change? When I was young, if I was sick my parents took me to the doctor. I was examined, and a course of treatment was prescribed that the doctor and my parents agreed upon (as a child, of course, I had no say in the matter.) If the treatment suggested by the doctor was too pricy for the family budget, negotiations took place until a mutually-acceptable solution was found. The same was true for the dentist, by the way (and I see dental care as the "next big thing" in the ongoing health care crisis.) My parents then paid the bill. Now, of course, if I am sick I see the doctor, the doctor prescribes a treatment from a list that is approved by the FDA and the paying insurance company, and I am responsible for my part of the bill, or 'co-payment'. It is sort of like when I was a child, but with the insurance company taking over the role of my parents.

Now, the role of the insurance company is to handle the negotiation on behalf of a large group of people - the "members". Actually, they work for (represent) the one paying the bills, which in this country is normally the employer. And, their job is to keep costs down. So, when I go see the doctor, the doctor is not really working for me, since I am not the one paying the bill: he is working for the insurance company! Given that it is very difficult to serve two masters, this makes for one Mell of a hess...

To make things even worse (can they get any worse?), when the insurance companies got involved, they brought lots of money - and that brought in lots of lawyers. Given that the insurance companies operate under formulas for assigning risk (loss) and tables of data reflecting large populations (actuarial tables), adding the additional risk of large PI lawsuit payouts upset the apple cart in a big way (the problem with these large payouts is that it is very difficult to accurately plan ahead for them, thus the insurance companies must keep some pretty hefty reserves in order to deal with them, which raises the cost for everyone, which adds more money into the system, which drives the lawyers into an even greater feeding frenzy, which requires the insurance companies to boost their reserves...)

Oh yes, it is a hydra with many, many heads.

Now, back to the changes in the delivery system. Acting on the principle of "an ounce of prevention is better than a pound of cure", we saw the rise of the HMO (Health Maintenance Organization), which in some cases was outright owned by the insurance company. Promising lower outlays though keeping people healthy, employers flocked to these plans, dragging the employees with them (and oftentimes forcing the employees to sever long-standing relationships with their family physician.) As costs didn't really drop (the HMO concept encouraged people to see the doctor for trivial illnesses, which in my younger days were handled by a phone call, or directly by the parents - which of course increased the cost of operation), the employers would change out plans every couple of years - leading to more physician changes. This inability to have a stable long-term doctor-patient relationship impacted the quality of health care, as the doctor now had to operate assembly-line fashion (great for manufacturing widgets, not so great when dealing with sick people.)

Piling yet another straw on the camel's back, many of the treatment decisions now required approval by an 'agent' at the insurance company. Oftentimes, these were people who had medical experience (as an LVN or RN), but again their assignment was to keep the cost down - not to ensure that the treatment was appropriate. They would always push for shorter hospital stays (a day in the hospital being very expensive), or even out-patient care when it was available.

The next straw: the negotiated rates with the insurance companies were followed by the 'negotiated' rates from Medicare (which were not really negotiated at all, but promulgated by decree.) So, now the doctors are being squeezed between the insurance companies and Medicare on one hand, while their premiums they had to pay for malpractice insurance went up like a moon rocket. This resulted in a shortage of practicioners in some specialties, leading to a true 'health care crisis'.

But, I digress. For, at the core, the issue with our health care system is how it is funded, and who is responsible for paying for it. Because the primary benefiaries (the patients, you and I for example) are pretty much out of the loop as far as responsibility for payment goes, and as we also have a limited role in determining the course of treatment, there is no incentive for us to practice self-discipline when seeking care. In addition, the physicians and other practicioners have a strong incentive (protection against lawsuits) to practice aggressively defensive medicine, with lots of tests and therapies designed to show that they did the best they could in the event the patient fails to get better. All this puts upward pressure on the system costs, which combined with the cost-containment practices of the insurance companies, leaves those who don't have 'health insurance' (a misnomer if there ever was one) holding the bag.

And, there are more and more people in that category, as employers are finding the increase in health care costs eating away at their bottom line. As the employers bailed, the government stepped in. We had the 'universal health care plan' mockingly called Hillary care, which had a number of flaws (not the least of which was that the proposal reportedly had more instances of the word "felony" then it did "physician".) More recently, the states have tackled the issue. These efforts have spanned the spectrum, from the so-called "Wal-Mart health care reform" (aimed at curbing the practice by a particular retailer of steering its employees to government assistance in lieu of employer-paid health benefits), to recent proposals from Massachusetts and California, which are aimed at ensuring that all residents of the state have some kind of health coverage. These measures may be a start, but currently they run afoul of Federal laws concerning health care, and local blogger Polimom has written an excellent article on the subject.

So, it is apparent that we are indeed in one "Mell of a hess" as I noted above.

The question is, what do we do about it? The answer to that is a very complex one, as it involves rethinking a system that has served us well in certain aspects, and failed us miserably in others. We need to understand exactly where it is broken, so that we don't end up (metaphorically speaking) throwing the baby out with the bathwater. This is one of the most notable flaws in the Clinton proposal (the afore-mentioned Hillary care), as it attempted to re-engineer the entire system, putting the Federal government in the role of "Cat What's in Charge" of everything from education to payment to delivery to diagnosis and treatment.

However, we need to start taking some steps. Remember, the way to boil the ocean is one cup at a time. And, the first step we can take is to put the patient back in the loop. Simply requiring they have health coverage (as MA and CA are doing) isn't enough. The patient must have a financial stake in their care, and the authority to participate in the decision making related to their care. Along with this is the requirement that they have the knowledge to make good decisions. For example, the doctor suggests you take your child who has a low-grade fever to the ER: but, that would cost let's say $1,000, while you could treat him at home using such time-honored remedies as aspirin (or a substitute recommended by the doctor), chicken soup, and close parental monitoring - and leave the ER for those whose conditions are life-threatening. Or, you can take very expensive prescription drugs to combat the effects of your being mildly overweight: on the other hand, you can adjust your diet and exercise levels, which just might produce the same result. It is certainly easier to take the pills (don't I know that!), but in the long run the latter course of treatment may in fact be the more cost-effective. Insurance for catastrophic events (and I would include things like diabetes in that category) is all well and good: but, it makes more sense to take the external payer out of the loop for routine medical care. Let the patient pay for the 'ounce of prevention', and maybe we won't need as many pounds of cure.