Cheap Medicine, Part Two
Written with guest writer LRM
Say, did you hear the one about the man from Wisconsin who had to wait nine months for a hip replacement so he went to Canada to get it done?… Neither did I! (Borrowed from a letter to the Wall Street Journal)
It’s no secret that countries with single payer systems, like Canada, often have long waits for certain procedures. What’s less well known, however, are other features that many might find to be even more problematic: denial of treatments such as dialysis, chemotherapy, cancer treatment, joint replacement and other crucial interventions, primarily on the basis of age. It’s a fact that single payor systems invariably implement RATIONING to keep costs down. Although rationing of some sort may be inevitable because there’s not enough money in the entire GDP to go all out on every medical condition for every patient (Personally I would start by cutting out sex change operations for prisoners and multiple liver transplants for repeat drug abusers), we be very wary of insurance practices that are simply inhumane. Denying dialysis or hip replacements or chemotherapy for individuals solely on the basis of age is something I don’t think any of us would find acceptable. Unfortunately, with a single payor system, patients in such predicaments will have absolutely no recourse. (Bernie Sanders, for example, would make it ILLEGAL for doctors to contract with patients for treatments that his plan doesn’t cover!)
And, in addition to restricted access, health care reform advocates aim to make deep cuts in medical expenditures by eliminating so called “inefficiencies”. Ladies and gentlemen, it is NOT a truism to point out that Medical care is expensive. Although the fact that health care is inherently expensive should be obvious to any thinking person, bureaucrats and reform advocates just don’t seem to “get it”. Health care is both labor intensive and technology intensive. It employs large numbers of highly skilled and extensively trained people, and those people deserve to be paid fairly for the huge investment of time and money that they’ve made in their education and training. And, the extremely advanced technologies that are necessary to provide state of the art care are also very costly. So, while there may be some waste and inefficiency in the system, there’s not as much as non-medical people think. And, ask yourself this: when has government intervention ever made ANYTHING more efficient. The terms “Government” and “efficiency“— simply don’t go together!
Now, aside from cost, there’s another facet of medical care that the reformers and policy makers understand poorly. And, again, it’s NOT a truism to say this: medicine is complicated. People are genetically diverse and a treatment that works for one person may not work for another. And, in disease states, many pathological processes may come in to play, so what works therapeutically in one circumstance may not work in another. Simple diagnostic and therapeutic algorithms, advocated by reform proponents, don’t, unfortunately, always work. No matter how hard we try, we can’t MAKE medicine simple and easy and cheap, simply because it ISN’T any of those things. And, the so called “best practices” guidelines that are also advocated as a panacea for medicine’s complexities, are often overly simplistic, frequently out of date, and, sometimes just plain wrong.
Now, back to costs. There’s a fact about medical reimbursement that many people find surprising: Medicare and Medicaid consistently pay less than the actual cost of providing the care. Hospitals get reimbursed by Medicare at about 80%-90% of their actual cost. Doctors may get only 20-25%. Both hospitals and doctors partially make up for this shortfall by treating privately insured patients which, effectively, pay higher rates. And Medicaid (Medicare for the indigent), by the way, is even WORSE (When I was practicing Anesthesiology, Medicaid paid us 6 cents for every dollar we billed). Imagine what would happen if Medicare or Medicaid were the ONLY payors out there. Most doctors (and some hospitals) will go out of business. Private practice medicine will simply disappear. The doctor/patient relationship that Americans have cherished for so many years will vanish. And, it will be extremely unlikely that institutional doctors will work the horrendous hours which are the norm in private practice. Even with “physician extenders” (physician assistants, nurse practitioners, nurse clinicians) a doctor shortage will be inevitable. And, consider also, that radical reductions in medical salaries may “scare away” the “best and the brightest” talent, ultimately resulting in diminished quality of care.
Eighty percent of Americans are insured either through their employers, Medicare or through the military (Source: Phillip Rotner, The Bulwark, April 25, 2019). Studies show that 80% of these insured rate the quality of their health care as excellent or good. Likewise, 70% rate their insurance as excellent or good (Source: Gallup Polling, 2019). In other words, our system of health care is actually working very well. In this age of “pie in the sky” politics, America should be VERY cautious about tampering with it. As explained above, “Medicare for all” will result in the total elimination of private practice medicine. And, unfortunately, it’s replacement will NOT be just a minor modification of what we have now. It’s replacement will soon, quite likely, become unrecognizable. If Bernie Sanders and Kamala Harris think that America can switch to a radically different health care system (one with NO co-pays, NO premiums, NO deductibles and NO paperwork), and still deliver the same standard of care that we now enjoy, they must have been smoking some of the “weed” that they’re so anxious to legalize!