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Commentary
Health care in the US is too expensive. There are 3 ways to fix it
Boston's doctors and nurses saved my life, twice, 10 months apart. In 2015, they detected and operated on my prostate cancer. Then, after I heedlessly ignored a don’t-walk signal and was hit by a Toyota pickup, they repaired my concussed, bleeding brain, partially collapsed lung and bone fractures. Fortunately, I had more insurance than smarts. I needed it.
The United States outspends the world on medical care, and the bill for my pedestrian accident opened a window to that distinction for me: $20,000-plus for three days in the hospital, almost $1,300 for the radiologist and $230 for the ambulance. In partial redress, Massachusetts, which ranks second among states for health care costs, is weighing limits on what Bay Staters pay for prescription drugs as well as hospital stays and long-term care.
These well-intentioned efforts would be the proverbial Band-Aid on a gunshot wound.
Sure, targeted remedies might do targeted good. The Massachusetts Senate, for example, would cap patients’ out-of-pocket spending on drugs at $25 for 30-day supplies of certain name-brand medications, while making generics free. But “these proposals are fairly described as incremental,” Matthew Fiedler, senior fellow with the Brookings Institution’s Schaeffer Initiative on Health Policy, told me. They “might save some money, but none will radically change the Massachusetts health care system.”
The truth is that built-in budget-busters riddle health care financing as fat marbles steak. Even Obamacare (AKA the Affordable Care Act), while bolstering the ranks of insured Americans, hasn’t bent the cost curve meaningfully. Our nation’s medical talent laps the competition. But the way we pay for it stinks. Only three root-to-stem solutions will fix that. No presidential candidate endorses these changes. Yet no nation has made private health insurance and medicine affordable without them, as journalist T. R. Reid documented in his bestseller on global health systems, The Healing of America.
Universal coverage. Requiring everybody to have insurance expands those who are covered beyond a smaller, sicker and therefore costlier-to-insure clientele. It treats health problems preventively before they explode into expensive, acute illnesses. Massachusetts takes the blue ribbon here, boasting the lowest percentage of uninsured residents among the states, at 2.4%. (Nationwide, it’s 8%.)
Countries that spend less than we do on health care require all citizens to be insured. That’s a necessary first step, but insufficient on its own.
Nonprofit insurance. Those who overdosed on Bernie Sanders rallies may not know it, but single-payer health care — Medicare for All — is not the only route to affordable, universal coverage. Germany, Switzerland and the Netherlands cover all citizens through private insurance. But it’s nonprofit insurance, so premiums aren’t raised to pay dividends to insurance company shareholders. (Massachusetts’s insurance mix includes both for-profit and nonprofit firms.)
“It may be possible to finance fair and cost-efficient health care for all through profit-making health insurance,” Reid wrote. “It may be possible, but no country has ever made it work. For-profit health insurance clearly hasn’t worked in the United States, which spends more than any other country and still leaves millions without coverage. And no other developed country wants to try it.”
A unified bureaucracy. We don’t have a “health care system;” we have multiple, needlessly expensive systems. Most workers get coverage from a private plan chosen by our employers; the elderly get Medicare or private, competing Medicare Advantage plans; the poor, Medicaid; military vets, the U.S. Department of Veterans Affairs or VA; Native Americans, the Indian Health Service (IHS). Obamacare didn’t end our spending orgy because it retained these redundancies. A unified bureaucracy is our best bet for controlling costs.
Countries that spend less than we do on health care require all citizens to be insured. That’s a necessary first step, but insufficient on its own.
“All the other developed countries have decided to use one system of health care that applies to everybody,” Reid explains. “Young or old, employed or unemployed, military or civilian, sick or well, aboriginal or immigrant, private citizen or prime minister, newborn or about-to-die — everybody is included in the same system and covered by a single set of rules. … [A] single system is much easier to administer, with one set of forms to fill out, one book of rules, and one price list.”
“In principle,” Fiedler says, “there’s nothing keeping a state from implementing a single-payer system or a system of harmonized private coverage.” The catch: It would be expensive. A state would need federal permission to use all the money Uncle Sam spends on health coverage, from Medicare and Medicaid to tax subsidies, he notes.
No state that’s tried has enacted single-payer, a pipedream in a country with staggering public debt and a wariness of Big Brother since King George. Alternatively, Fiedler argues, “aggressive regulation” by states of hospital and physician payment rates “could save a lot of money.” But that’s a massive lift politically, which may be why Beacon Hill merely nibbles at the edges of reform.
Yet going small, on either the state or federal level, spins our wheels in time-wasting mud. Experience is the best teacher, and planet-wide experience confirms that our sick system of health care financing needs more than Band-Aids.
