Health Care Reform: What Do Americans Want? (Or Think They Want?)

On the surface, it seems that American voters have made their will clear. Poll after poll shows that they are calling for a major overhaul of our health care system. But when you look closer, their responses bristle with contradictions and discrepancies that I think the reform-minded presidential candidates will have to consider when deciding how to approach health care reform.

In a poll reported in Health Affairs at the end of last year, sixty-nine percent of respondents rated the US system as “fair” or “poor.” Yet in the same survey, when asked about their own experience with receiving medical services or with their own physician, 80 percent who had received care in the last year ranked their care as “excellent” or ”good.”

Other polls reveal the same pattern.

According to a survey released by Greenberg Quinlan Rosner in July, voters express doubts about the quality of the American health care system (with 49 percent dissatisfied), while 74 percent were dissatisfied with the cost. Yet, “at another, more personal level,” the pollsters note, “a slightly different picture emerges. Fully eight in ten (82 percent) describe themselves as satisfied with the quality of the health care they receive personally. This number jumps to 90 percent among seniors (64 percent very satisfied), but includes impressive majorities of nearly all groups…”

Nevertheless, when the pollsters asked the same group about health care reform, three-quarters called for “major changes” or “completely rebuilding” the system.

If they are satisfied with the care they are receiving, why would they want radical change? Because they don’t feel secure that they will be able to keep what they have: “There’s a precariousness to Americans’ contentment with their own health insurance coverage,” the Kaiser Family Foundation reported after looking at a number of polls at the end of last year. “Among the insured, six in ten are at least somewhat worried about being able to afford the cost of their health insurance over the next few years, and nearly as many (56 percent) said they worry that by losing a job, they or their family might be left without coverage.”

This, then, is why so many Americans want universal health care: it would guarantee that they and their families would always be covered.

Read a little more of the Greenberg Quinlan Rosner report and you find that the ambivalence deepens. On the one hand, many Americans believe the system is broken–or at least badly damaged. “There is a deep and powerful belief that costs are out of control and real ambivalence about the quality of the system overall,” the pollsters explain. “But people’s personal experience is better, particularly among the middle class and affluent, which potentially tempers broad demands for reform…”

How can so many Americans question the quality of the system as a whole, but believe that the care they are getting is more than satisfactory? For the same reason that many American believe that most politicians are corrupt, but that their own Congressman is honest. This is the magical thinking that leads the majority of Americans to distrust most doctors—but to put great faith in their personal physician. As I’ve argued on this blog, we trust our doctors because we must. Who would go under the knife, or submit to any painful or invasive procedure if he didn’t trust the doctor? For the transaction to go forward, the patient must believe in his doctor’s competence and his professionalism.

Reform-minded presidential candidates understand that many Americans like the health care they have—or at least they think they like what have. (Since most Americans are not seriously ill, they haven’t had a chance to find out whether what they believe about their coverage and their doctor is true.) Nevertheless, what voters believe is most important. This is why none of the leading Democratic candidates has proposed a single-payer system. All three have designed proposals that let insured Americans keep the private-sector insurance that makes them feel safe—at least for the moment. (Meanwhile, they are offering a public sector alternative so that, over time, Americans will have a chance to see how the public sector insurance stacks up against for-profit insurance.)

But what many reformers haven’t quite faced up to is this: Not only do most Americans want to keep what they have—they believe that, under reform, what they have should cost them less, even though they also believe that “the government” should spend more on health care.

As a study published in the Winter 2007 issue of the The American Heart Hospital Journal points out: “When Americans complain about [the cost of ] health care, it is generally not about the overall system but rather about personal outlays and the burden their health care bill places on the family budget. In 2006, 65 percent of Americans surveyed thought the average citizen spent too much on health care and that ‘the government’ should spend more. This is what it means when Americans consistently list ‘cost’ as the most important health care problem appropriate for governmental action, but it may be more accurate to think of it in terms of personal affordability rather than overall costs, despite the fact that the two are clearly linked.”

Here, it’s worth pausing to ask: when Americans say that “the government” should pay more, who exactly do they have in mind? Presumably most understand that “the government” equals taxpayers, and so it seems safe to assume that they are saying that other, wealthier taxpayers should pick up a larger share of the tab. If you earn $80,000 a year, you believe that those earning over $100,000 should show a little more generosity. If you bring home $100,000, on the other hand…(Does anyone remember Russell B. Long’s definition of tax reform: “Don’t tax you. Don’t tax me. Tax that fellow behind the tree”?)

Moreover, most Americans do not object to the fact that, as a nation, we are spending well over $2.2 trillion on care—or that at some point, if health care inflation continues to outstrip economic growth, spending on health care will squeeze out outlays for education, the environment, national security, or anything else that we might want to do. Most of those polled see the problem from an individual, rather than from a collective, perspective.

This, then, is the first problem that an incoming, reform-minded president will have to face. While Americans strongly support national health reform, many believe that “reform” will (or at least should) automatically cut their own health care bill without crimping the amount of care that they receive. And while they would like to see universal coverage, the majority may well resist any tax increases.

In fact, as I have argued elsewhere, there is enough money sloshing around in our health care system to provide affordable, high quality care for everyone—but only if we cut back on the waste. This means eliminating the unnecessary tests, unproven procedures and over-priced “bleeding edge” drugs and devices that are spurring health care inflation. In other words, $2.2 trillion is enough to give everyone the health care they need. But what they “need” may not be what they think they want.

The polls show that many Americans like what they have; if there is excess in our system, they embrace it. They find comfort in the idea that, when they consider their medical options, they have a long list of choices, including the newest and the most expensive drugs, devices, tests and procedures. Most subscribe to the American creed that newer is almost always better. And, as the latest ABC News/ Kaiser Family Foundation/ USA Today poll shows, only 30 percent of those surveyed see unnecessary treatments as a problem in our system, while just 28 percent say that the “increased use of expensive new drugs, treatments and medical technology” is driving rising costs, “even though,” the pollsters note, “this is the factor most often named by experts.”

When it comes to public opinion, this is the second major obstacle that a reform-minded president will encounter. The average American doesn’t like to feel that she or her doctor are part of the problem. The polls show that most of us are far more comfortable assuming that people they we already dislike—insurers, malpractice attorneys, or drug-makers—are responsible for excessive costs. We certainly don’t want to entertain the possibility that many of the treatments our own doctors are prescribing for us are, in fact, unnecessary, unproven or simply futile.

Of course, up to a point, the polls are correct: profits made by insurers do add to our health care bill. But if I were elected czarina tomorrow, waved my wand, and eliminated the entire for-profit insurance industry, that would cut the nation’s health care bill by just 4.5 percent (That is the share of our health care dollars that goes to cover insurers’ administrative costs, executive salaries and profits.) And it would be a one-time savings.

As for drug-makers, the problem is not just the blockbuster pricing needed to sustain double-digit earnings; the truth is that doctors are prescribing, and patients are demanding, more and more pills. From 1994 to 2005 the number of prescriptions purchased climbed by 71 percent while the U.S. population grew by only about 9 percent. As a nation, we’re over-medicated.

Over the long run, we can afford high quality, universal coverage—if we just wring the waste out of the system. But that will take time, more research into the “comparative effectiveness” of various products and procedures, and an enormous public relations campaign to convince the public that “more care is not always better care.”

Finally, the polls show that widespread “distrust of government” could block change. As the Greenberg pollsters warn, the last seven years have done little to build public confidence that government is either competent of honest:

“In our accountability research, we noted that voters are pulled between a desire for a more activist government than they are getting and a deep cynicism about whether or not government can function efficiently and effectively,” the pollsters write. “Not surprisingly then, voters identify ‘government run programs are wasteful and inefficient’ as the most pressing concern about health care reform (37 percent). Among independent voters, this concern jumps to 49 percent.”

These are the obstacles that I think presidential candidates should anticipate. I don’t have the answer as to how a president should handle these problems. Much will depend on the economic circumstances at that moment: the temper of the times, the number of seats progressives have won in Congress, and just how many more employers have stopped offering health insurance. But at this point I am convinced that, when it comes down to it, a large share of the public may be more ambivalent about reform than it seems.

In the past, I’ve been keen on the idea of “educating” the public. If a strong leader explains what’s wrong with health care in America, patiently and carefully, I have argued, eventually the public will understand that in our profit-driven system, “over-treatment” can be as much of a problem as “under-treatment.” After all, Al Gore did eventually manage to persuade us that global warming is a serious threat. Though admittedly, it did take years—and people listened only after deep dissatisfaction with the Bush administration turned into a longing for what might have been.

Today, I’m beginning to wonder if we really need a Great Educator: If reformers try to point to the excesses in our system, will people listen? Or will they just feel that much more frightened and insecure? The fact that the three leading Democratic candidates have proposed such similar plans suggests that if you sit down, read the research, and study the problem, there is a fair consensus about what needs to be done. But do most Americans really want to study the problem?

I’m beginning to suspect that “leadership” will be the key to health care reform—leadership combined with a conviction that inspires trust.

Here, I can’t help but recall what Carl Schneider, a Professor of Law and of Internal Medicine at the University of Michigan writes near the end of his exceptional book, “The Practice of Autonomy: Patients, Doctors and Medical Decisions.” Schneider is not convinced that Americans need so many choices. He thinks it may be time to move “away from [the emphasis on] patient choice and toward changing the medical system so that it delivers a better product. To put the point provocatively, it may be time to think about giving patients what we think they want, but have not been able to secure for themselves. We might even consider giving patients what we think they would want if they thought about it.”

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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22 replies »

  1. Yana;
    Actually you should pay for the HPV test and not the pap smear. Recent research indicates that testing for HPV (which is the root cause of most clinically significant changes on the pap smear) is more effective than the pap smear itself. In this case I don’t think they were trying to rip you off.
    As for Maggie’s post concerning the contradictory (and contrary) nature of American attitudes, we have met the enemy and he is us.

  2. Barry, I can’t disagree with you on the reforms you’d like to see and continue to advocate to reduce/control costs, but who is going to force these reforms onto the system without universal/single-pay/gov insurance. The present players, all acting individually, will not do it. Other single pay systems are dealing with the same problems we are, but they are controlling costs more effectively while providing lower cost care and universal access because the final payer, the government, is able to force reforms from the top down by imposing budgets. But don’t get me wrong, the present system of U.S. politics will not make universal coverage/single-pay a success because the power players will simply throw their financial support toward any party/candidate(s) that will game the system in their favor. So until we come up with a reformed political system we won’t have a reformed healthcare delivery system. And I don’t think, under the present system, bringing more payers under a mandate, into a broke system, will lower premiums for everyone, it will just make insurers richer and the mandated angry. Forcing people into an overly expensive system is not the answer. We need to devise a system that will not pit the young and healthy against the old and sick, but given our politics, and our society, that’s what we will get as a campaign slogan – just as Republicans did when trying to privatize social security for their wall street friends. This is a winner TAKE ALL system where winning is the only goal achievable by any means.
    Maggie, don’t think that having health insurance IS insurance against financial ruin ( I think you know). Anyone having a major illness first has to deal with trying to maintain their job to keep the ability to have insurance or pay premiums, then have to struggle to pay deductibles and co-pays which are punishment for getting sick. Yes, I could have an unforseen accident which would eliminate my ability for choice of foreign, less expensive care, but the insurance industry drove me out, even though I was the kind of premium payer they love to get. I eat well, don’t smoke, exercise. I don’t have a family history of heart disease or cancer. I resist seeing a doctor or going to the ER. I avoid taking drugs. I scrutinize my care and don’t take a docs advice on face value. I also try to use alternative (less expensive) care. BCBS lost a hell-of-a-profitable premium payer. I have resources, but most people with marginal resources have figured out that having health insurance will only make them poor anyway, sick or not – so why not keep the $ now and spend it on things that make life enjoyable. At least I’m banking my premiums for future care. And if the proponents are correct, that 10% of the patients are driving 90% of the costs, my odds are pretty good.

  3. This is a very controversial subject and interesting subject that affects many of us. Of all the comments posted I tend to agree more with Barry.

  4. Maggie,
    I think our disagreement over health insurance for young people is little more than semantic. I absolutely agree with you that young people, along with everyone else, should have insurance for the reasons you stated, especially the peace of mind that comes from having coverage if you suffer a catastrophic medical event. Unfortunately, most people (not just the young) don’t seem to place as much value on peace of mind as you and I do. Remember what happened in the late 1980’s when Congress passed, and was later forced to repeal, catastrophic health coverage for Medicare beneficiaries to be financed largely by a tax surcharge on high income Medicare beneficiaries. Then House Ways and Means Committee Chairman, Dan Rostenkowski, had his car stormed by angry seniors in Chicago.
    As for paying for health insurance, I’m sure that you know as well as I do that most economists believe that even when the employer nominally pays for health insurance, the employee is really paying in the form of lower wages than he or she would have otherwise been paid if the employer were not covering that cost. The same is true with respect to the employer’s share of FICA taxes, by the way. It’s just another part of the employee’s total compensation. Most employees, unfortunately, have no idea how much their employer is paying for benefits. This could easily be rectified if employers either provided annual statements listing the employee’s salary, bonus (if any) and the employer’s cost of all benefits for which the employer pays cash including FICA taxes, health insurance, disability insurance, life insurance, 401-K match, etc. All of this information could also be posted on a secure, password protected employee portal section of the company’s website. Some employers already do this but many do not.
    Finally, with respect to the reform proposals that cap the percentage of income that the employee would have to pay for health insurance, I don’t think this will work as well as advocates believe. The reason relates to the comments in the above paragraph. Take, for example, an employee earning a $40K salary plus family health insurance coverage costing $12K with $10K paid by the employer and $2K by the employee. Assuming $5K in other assorted benefits (employer share of FICA taxes, 401-K match, etc.), the employee’s total compensation is $55K – $40K salary + $10K employer cost for health insurance + $5K for employer cost of other benefits. So, this employee is actually paying 21.8% of income for health insurance ($12K employer + employee share of the premium) out of total compensation of $55K. However, the employee probably only thinks or perceives that he is paying 5% of income – $2K employee cost of health insurance from a $40K salary. This would all be much clearer to the average person if something like Senator Wyden’s proposal became law which calls for employers to “cash out” their current contribution to health insurance by paying it to employees in wages instead and then letting the employee buy his or her own health insurance. Income tax liability related issues connected with such an approach would have to be sorted out and would greatly complicate getting Wyden’s proposal through the legislative process. If Congress really wanted to cap the employee’s out-of-pocket cost for health insurance at 6.5% of total compensation for everyone earning, say, up to $100K per year (again, in total compensation), the taxes required to pay for the subsidies would be enormous and, probably, unaffordable. Even if the out-of-pocket cap were set at 10% of total compensation, the tax burden required to pay for both subsidies and for providing the currently uninsured with health insurance would probably be more than taxpayers would accept. My own view is that the middle class should probably expect to pay approximately 15% of total compensation for health insurance (excluding out-of-pocket payments for deductibles and co-pays) or close to what it currently pays to finance Social Security and Medicare.

  5. .Chuck and Barry–
    thanks for your comments.
    Chuck—unfortuately, the research shows that when patients have more “skin in the game” they are just as likely to skip a necessary test or procedure as they are to skip something that is unnecessary. Most of the time, patient’s just are not in a position to know what is and what isn’t medically necessary.
    Barry– I agree with almost everything you say.
    But on the last point, as to whether young people will be “losers” if we require that everyone have health insurance. . .
    Let me put it this way: if you had a health 23-year-old daughter how would you feel about her walking around without health insurance? I would be very unhappy if either of my children decided to take that risk unless I knew that I had the means to pay out-of-pocket for the very best care if either of them developed a brain tumor, was in a car accident etc.
    Since I don’t have the means, I would know that if something terrible happened to them they would receive the kind of care that uninsured people usually receive in this country– substandard.
    So I don’t think young people who are forced to buy insurance will be “losers.” They may think they are immortal, but we know they are not–and that they will be safer with insurance.
    They also will be safer because they will be more likely to go for the preventive care that young people frequently skip: Pap smears, going to the doctor to check out that sports injury that never seems to heal, going to the doctor to get some advice on weight control or stopping smoking, going to the doctor to find out why you’re tired all the time, and finding out that you’re malnourished and anemic from eating too much junk food . . . etc. etc.
    Secondly, since most proposals for universal care put a cap on what percentage of your income you will be expected to pay for insurance (with subsidies above that amoung) the only “losers” in a financial sense will be young people earnign very high salaries. Young people earning salaires typical for their age will not be paying $12,000 (or anything close to that) for a family policy. (And note $12,000 includes both the employer and the employee payment for a policy that covers a family. Under universal coverage, employers will still be contributing .

  6. Maggie,
    You and others have written that our healthcare costs would be as much as 30% lower if everyone practiced as cost-effectively as the most efficient providers including Mayo and Inter-Mountain. I wonder how much of that 30% we could actually capture under the best of circumstances. It does seem that it will take numerous strategies on several fronts to attack the problem including:
    1. Comparative effectiveness research to help doctors determine which drugs, devices and therapies offer the best value for the money.
    2. Price and quality transparency to help referring doctors choose the most cost-effective specialists, labs, imaging centers, etc. Information on hospital infection rates would also be helpful here.
    3. Shared decision making, especially for expensive surgical procedures like hip and knee replacement, back surgery, prostate surgery, etc. where research shows that patients often choose to not have the surgery or at least postpone it as long as possible once they are fully informed about the risks and benefits.
    4. Litigation reform to, hopefully, reduce defensive medicine over the intermediate to longer term.
    5. More widespread use of living wills to reduce futile and often unwanted care at the end of life.
    6. QALY metrics where appropriate, which could include everything from very expensive late stage cancer treatments to many types of routine preventive care.
    QALY metrics will probably be a tough, but, I think, ultimately necessary approach to implement in the U.S. I remember the furor in the late 1990’s when insurers did not want to cover very expensive bone marrow transplants for late stage breast cancer patients because they considered it experimental and not cost-effective. The insurers were roundly criticized for being uncaring and profit hungry, but they ultimately proved to be right on that particular issue.
    The ultra expensive biologic specialty drugs to treat cancer and other diseases that have been reaching the market in recent years are no more expensive in the U.S. than in Europe and Canada. There may be considerable differences among countries, however, in how likely doctors are to prescribe and administer them. If cancer drug X turns out to cost $1 million per QALY, for example, it seems that we as a society have to have the intestinal fortitude to just say no, taxpayers will not pay for it. If the family is willing and able to pay out of pocket, fine.
    Separately, the reform concept of a public sector alternative to compete with private insurers on a level playing field is a good idea, I think, as long as the playing field is truly level. One key aspect of this is that the public sector entity, which should be completely separate from the existing Medicare program, should have to negotiate reimbursement rates with providers that providers are willing to accept. If they can’t work out a satisfactory agreement, those providers will not be in the public sector entity’s network, but it should not affect their ability to continue to see and be paid for Medicare patients. Negotiating prices with drug companies is also fine as long as the negotiation is based on comparative effectiveness vs price. If a deal can’t be worked out, the drug is not on the formulary, but the government should not simply attempt to dictate prices.
    The bottom line here, as I’ve said numerous times before, is that there is no silver bullet but lots of silver pebbles. While no one pebble is likely to have a huge impact by itself, if we can find and exploit enough of them, it can and should make a meaningful positive difference.
    Finally, while I have consistently supported the concepts of universal coverage, community rating, and mandatory participation, we should be honest and acknowledge that such an approach means that young, healthy people who previously either did not buy insurance or bought a very inexpensive policy in the underwritten individual market, will pay far more for health insurance than they did previously. The Kaiser Family Foundation estimates the average cost of family coverage at about $12,000 per year. By contrast, car insurance, which many states also mandate, costs well under $1,000 per year. I’m currently paying $675 per car for two cars in a fairly expensive state (NJ) for car insurance. The bottom line here: young, healthy people will be significant financial losers under virtually any healthcare reform scheme that includes universal coverage including an employer mandate and an individual mandate with the premium capped at some reasonable percentage of income.

  7. Consider raising co-pays, and breaking out each test with a separate co-pay. When people have to decide what THEY’re willing to pay for, the additional testing and procedures tend to be greatly reduced.

  8. JL, Cascadia, Michael, Janna, gjudd, Kathleen, John, Jayne, Peter, dn16, Barry, ced, Eric–
    Thank you all for commenting.
    JL–You wrote “Those who persist in holding up the French system, [single payer] as something to strive for fail to understand that while the govt could certainly step in and lower cost in the States, the medical community would pit patient against government (‘how dare the govt tell me and my doctor what treatment I can get!) and it would be a mess.”
    I agree that if the government stepped in at this point and said it was going to proivde a single-payer, “medicare for all” system, with no private insurers, then everyone would blame “government” for everything they didn’t like about the new system (For instance, being told that they had to have insurance and couldn’t be a free rider, and that the insurance would not cover treatments that haven’t been shown to be effective–whatever the TV ads might say about those treatments.
    The 3 leading Democratic candidates have each said that that they would offer a public-sector insurance (ie. something like Medicare) as an option for everyone. Individuals under 65 could choose to buy into Medicare (with help from employers) or they could choose to buy private insurance.
    Under the Democrats proposals the private insurance would be regulated so that insurers would be forced to cover everyone (young or old, sick or healthy) without charging them more if they are sick (just as Medicare does) and private insurers would be required to offer an insurance package that was at least as comprehensive as Medicare (plus including coverage younger people need like maternity). Private insurers would not be allowed to sell “Swiss Cheese” policies filled with holes that open, like trap doors, when you get sick.
    Then, under the Democratic proposals, private insurers and Medicare-for-all could compete on a level playing field and Americans could see which was providing better value for the money. This, I think, is a good strategy.
    Cascadia– group visits for diabetics and smart cards that carry a patient’s record and carry advertising are both good ideas. But as you say, an entire region or group has to work together–and that’s where gov’t is needed. Gov’t is also needed to regulate the for-profit players so that they are not profiteering.
    These things are easier to do in Germany and Italy because rather than letting 10 or 20 different players come up with 10 or 20 different competing “smart cards” the government establishes a platform or model for the system. We tend to let free market creativity create free market chaos. (This is what we did with the cell phone when we had too many competing standards and you had to pay “roaming charges” when you went outside your community.)
    But I disagree that we only need to overhaul how we deal with chronic illnesses which account for 70% of the costs. In order to create an affordable sustainable system, we need to look at how we care for people before they become chronically ill. We need more preventive care.
    In addition, some of the 30% spent on people who are not chronically is as wasteful as some of the 70% spent on people who are chronically ill. We need to try to wring out that waste as well if we want to be able to afford high quality care for everyone.
    Michael Kane–
    I agree with much of what you say. And I believe that you and other doctors in your town know which doctors are gouging.
    But the problem isn’t just the gouging. Many doctors overtreat without consciously try to boost their income. They think they are doing the right thing. Or they are uncertain as to what the right thing is because we haven’t done the head-to-head comparisons needed to see which drugs, devices and procedures are most effective. (Manufacturers and some surgeons making money on those products and services haven’t wanted head-to-head comparisons because they know there would be winners and losers. And their very expensive product/service might turn out to be a loser.)
    So, today, $1 out of $3 of our health care dollars are wasted on overtreatment, unncessary tests, unnecessary procedures and over-priced new drugs and devices that are no more effective (and often riskier) than the old drugs and devices that they replaced because in many cases, we don’t have good medical evidence as to what is the most effective treatment–or we do have good evidence, and it is being ignored.
    Too many doctors do things because that is the way they have always done it; or because they have been “sold” on a procedure or a drug or a device by another doctor who may well have been paid by the manufacturer to teach all of his residents to use a particular knee implant , etc.
    We need more evidence-based medicine.
    For example, we now know that there is “no evidence that PSA testing for early detection and early treatment of prostate cancer in any way alters the progress of the disease”–this according to the National Cancer Institute. The American Cancer Society also says that it is “inappropriate” for doctors to recommend PSA testing to average risk men . . .
    Yet how many doctors continue to send patients over 50 for PSA tests, and how many urologists recommend surgery or radiation (rather than watchful waiting) when the test proves positive—even though we know that, because the disease usually grows so slowly, 17 out of 20 men who are diagnosed will never experience symptoms of the cancer. They will die of something else, long before the cancer hits them. Meanwhile, radiation and surgery can have life-changing side effects-i.e. incontinence and impotence.
    Yet the American College of Urology continues to recommend PSA testing and early treatment. I’m sure most of the urologists believe that this is best practice—after all, how could we have been doing this all of these years if it wasn’t effective? But that’s what they said about tonsillectomies.
    “Watchful waiting”-waiting to see if PSA levels rise dramatically before treating makes most sense for most men diagnosd with early-stage prostate cancer–and even then we have no evidence that the treatment saves lives, or even extends life for one day. (The needed studies haven’t been done.)
    I’ve written about this on my blog http://www.healthbeatblog.org -click on “August” under “Archives” in the left hand margin.
    PSA testing is just one example. It will take more than “a little effort” to reduce the waste in our system–it will take more comparative effectiveness research–done by people who have no financial stake in the outcome.
    I entirely agree with you on the economics of becoming a doctor these days. Unless you are a physician who specailizes in very expensive, very aggressive procedures, you have a problem.
    I believe that we should do what other countries do–subsidize medical school education. Here, I think it would make sense for the govt. to give all medical students loans to cover their expenses during med school and then forgive the entire loan at the end of med school if the student has a)chosen to go into a specialty where doctors are needed (right now, we need more generalists, more family docs providing a medical home and preventive care) and b)agrees to practice, for at least a few years, in a area of the country where doctors in that specialty are needed. (In many cases, the doctor may wind up putting down roots and staying there.)
    I suspect many med students would be happy to take the offer– and it would attract a larger group of students to apply to med school. Knowing that when you graduate, you are going to be carrying this huge burden of debt is daunting–especially if you didn’t grow up rich. I’ve written about this on http://www.healthbeatblog.org–See “Why Aren’t More STudents Applying to Medical School” by clicking on Nov 2007 under “Archives.”
    Yana– I completely agree with you about HPV testing. The overblown fear of the HPV virus was created by Merck in order to sell its so-called “vaccine” against cervical cancer. Regular Pap smears provide better protection–which is why cervical cancer is now a rare disease in the U.S. The women who die of cervical cancer are women who don’t get regular exams. Now if we just spent a fraction of the money Merck has spent on those ads on a campaign to make sure women get Pap smears . . .
    But your solution– opting out of insurance– isn’t an answer. I’m guessing you are relatively young and realtively healthy. But what if you were in a terrible automobile accident and were paralyzed tomorrow? Do you have enough savings to pay, say, $1. 5 milion or $2 million in medical bills? Would you expect the hospital and doctors to treat you anyway (and then cover the cost by charging other people more? Or would you expect them to leave you to rot by the side of the highway?
    What if your mother (who, I am guessing, is insured) develops breast cancer when she is 50? If most relatively healthy people go without health insurance, her premiums would be triple or quadurple what they are now (because the pool would be made up of mainly sicker, older people.)
    This is why we have insurance–so that, together, we can weave a safety net, with the people who are lucky enough to be healthy helping to cover the people who are unfortunate enough to be sick. . .
    That doesn’t mean you have to accept unncessary treatment. If a gynecologist wanted to test me for the HPV virus, I would say “no, I don’t want that test”–even though my insurer would probably pay for it. I would explain what I knew about HPV. IF the gynecologist insisted, I would write a letter to the insurer, reporting him or her for insisting on billing for treatment that I did not want.
    Patients who ask questions can help keep providers honest.
    gjudd–I’m afraid we’re not going to “stumble onto” a high qualtiy health care system. It’s a clever book, but if you were sick, old and poor, reading it wouldn’t provide a solution to your problems.
    Kathleen–You’re very right about variations in surgery. I’ll look for the article. And to find “common ground” people need to focus on “the common good.”
    John– We’re confused …But fun? Italians are fun. (I’m married to one. He’s also a great cook.)
    They’re also humane. if you’re dying of cancer, and have relatives to care for you, Italy’s health care system will give you as much pain-killer as you need and let you go home. Then ,the doctor visits you at home.
    Here, too often, we give you another round of radiation, and do a few more tests, then stash you in an ICU, making money on you to the very end.
    Jayne–I am glad that AARP is doing something now. But I was very sorry to see the organization support the Medicare MOdernization ACc which gave billions to private insurers to offer prescription drug coverage and Medicare–while specifically refusing to let regular Medicare offer prescription drugs.
    This was part of the Bush administration’s attempt to “privatize” Medicare. First, they wanted to “privatize” social security (by turning the system over to Wall STreet) and then they began this effort to privatize Medicare.
    The result is that many retirees who are getting prescription drugs or Medicare through “Medicare Advantage” (the private sector program) are now paying more than the did in the past, while insurers make enormous profits on the program.
    Meanwhnile, the insurers have engaged in a game of “bait and switch”–offering lower co-pays and premiums, extra benefits and lower prices for drugs during the first couple of years of the program, and now they’re raising them.
    I’ll be writing about this on http://www.healthbeat.org in the next few days.
    Peter–You are right that everyone thinks his or her own lawyer is honest, and Republicans hate the plaintiff’s bar until they decide to sue someone.
    And I can believe that you were dealing with idiots while getting your cataract surgery covered. That said, going without insurance is not a solution–either for the individual or for the society as a whole. We need to think collectively about this problem– please scroll up to see what I wrote to Yana.
    dn16–I do believe that doctors practice defensive medicine–and particularly if they have been sued once. (The odds of being sued are actually much lower than most doctors think –though some specialties like OB/GYN are particularly vulnerable.) But once you’ve been sued it certainly would focus the mind. As Justice Brandeis once said: “There are two things to fear: , death and litigation.”
    I think the jury system is not the best way to deal with malpractice claims. Most importantly, I think we need to make greater use of medical evidence to set up guidelines (not rules but guidelines) for appropriate care.
    For instance, spinal surgeons recently came out with guidlines for treating low back pain saying specifically that a patient with “non-specific back pain” does Not need an MRI. These guidelines need to be drawn up by the doctors in each specialty, and then the law needs to recognize them as the guidelines for “best practice.”
    I know that we face a shortage of general surgeons and that more and more specialists are unwilling to cover the ER. Though some hospitals are using “surgical hospitalists” to very good effect to address this problem. See this excellent post on Wachter’s World (written by Bob Wachter who is associate chariman of the dept. of medicine at the University of California, San Francisco http://www.the-hospitalist.org/blogs/wachters_world/archive/2007/11/18/the-surgical-hospitalist.aspx
    On replacing retiring doctors– as I suggested in my response above to Michael, I think we should set up programs giving loans to medical students and than forgiving those loans if the students chose to a)go into a specialty where we need more doctors and b) practice in a part of the country that needs more docs in that specialty for 3 or 4 years.
    As Eric suggests, there is no way to pin down– or even estimate –how much defensive medicine costs. When a doctor orders an extra test, he typically have five or six reasons for doing it which can include: genuine concern for the patient; an intuitive feeling that he’s “missing something”; a fear of being sued; remember that this is what he was taught to do when he was a resident, though he now suspects it may be overtreating, but isn’t sure; the patient is elderly, fearful and pressing for another test . . .”
    Even the doctor himself can’t know how much of his practice involves defensive medicine.
    I agree with you that it would definitely help if specialists adopted evidence-based national guidelines, and if the law recognized those guidelines.
    I entirely agree with Edwards that we have to mandate insurance. (If we expect insurers to cover everyone, even if they are sick, without charging the sick exorbitant premiums, then everyone has to sign up for insurance. Otherwise, no one would sign up until they were sick–and then they would enroll, knowing that insurers had no choice but to cover them. Meanwhile, most of the people in the insurance pool would be sick or old, and premiums would be very , very high. .. ) The system can’t work without a mandate.
    And to enforce the mandate we may well have to use Draconian methods. We can’t afford universal care unless everyone plays a role in weaving that safety net–see my post to Yana above. And many people won’t voluntary buy health insurance, just as many people drive without auto insurance—putting everyone else at risk.
    But as a matter of political strategy, I don’t think Edwards was wise to announce this while running in the primary. Too many people will vote for Obama because they don’t want to pay for insurance, and because they don’t understand the issue (of why if we want universal coverage, we have to have a mandate.)
    Eric-you are right we can’t eliminate defensive medicine. And if you look at the nation’s healthcare bill as a whole, it’s not the major cause of waste.
    But for individual doctors, fear of malpractice can be a huge problem, particularly in certain specialities. And, as you say, a healthcare court system could reduce the portion of the medico-legal bill paid by physicians.
    Have you written about this on THCB or elsewhere?
    Could you give us a URL:
    Thanks to everyone. I’ll come back to check for more comments.

  9. Barry– the figure for ‘defensive medicine’ is unknown– though estimates run, I believe from $25 billion – $75 billion… It is not trivial, to say the least, but its ‘elimination’ is neither feasible nor a panacea.
    A ‘health court’ system, either along the lines of Common Good or somewhat different would have some advantages (written about by me previously– and many others), but would not likely reduce the overall bill for medico-legal in health care— it likely would, however, reduce the portion of the bill covered by physicians.

  10. You have clearly outlined the various obstacles facing real health care reform.
    I also agree that on the whole that presidential candidates have not offered real solutions because they fear a backlash from voters.
    However, yesterday, John Edwards did address the payment issue for universal health issue in a rather bold way:
    “If Edwards gets elected and has his way, every U.S. resident who can afford to pay for health insurance would be subject to having their wages garnished or tax refunds withheld if they do not obtain coverage within the allotted time period.
    However, the federal government would still subsidize health insurance premiums for low-income individuals under Edward’s proposal.
    Edwards adds that by enforcing participation by using such Draconian methods would ensure that those signing up for universal health wouldn’t have to foot the bill for those looking for a free ride.”
    While this is not a total solution by any means, it is, in my opinion, a step in the right direction.

  11. If I don’t get the MRI scan ($1000+) for just about anything that hurts and I miss something in my diagnosis I will be sued. It’s that simple.
    Here is another example from the trenches of defensive medicine being far more prevalent (and costly) than single payer advocates would have us believe. I wonder if dn16 (or Eric Novack) could give us a sense for how much defensive medicine could be reduced, at least in their practice and their specialty, if we had a medical dispute resolution system that took these cases out of the hands of juries. Instead, suppose we had specialized health courts that could engage neutral experts paid by the court. Suppose further that if the doctor followed the generally accepted national (not community or regional) standard of care as developed with input from each of the medical specialty societies, he or she would not be liable for damage or injury from an adverse outcome or a failure to diagnose what ultimately turned out to be the problem. Cases would be decided objectively, rationally and fairly nationwide, and, in a reasonable timeframe, doctors would come to perceive the system that way. If such an approach would not make a dent in both the prevalence and the cost of defensive medicine, what would?

  12. I am an orthopedic surgeon and am forced to commit massive wastage of health care resources to protect myself. If I don’t get the MRI scan ($1000+) for just about anything that hurts and I miss something in my diagnosis I will be sued. It’s that simple. Once you have been sued, your attention will be forever focused on minimizing the chances of being re-sued for anything else. As long as we have a freewheeling tort system with no control, this will go on forever.
    Another thing you should be aware of – The average age of surgical specialists is now 57. That means half will be gone in the next 5 years or so. Most graduating residents do fellowships that allow them to make large salaries with no responsibility for ER call. That means that soon there will be few if any surgeons (general, urology, orthopedics, neorosurgery) to do the every-day nuts and bolts emergencies that everyone assumes will be taken care of if they get hurt or are severely ill. I don’t know where the new “in the trenches” surgical specialists will come from, but I don’t see anyone in the pipeline to take my place – I am 57.

  13. If you think health surveys are confusing then try asking about lawyers. Society thinks they’re scum, but ask individuals about their own lawyer and he/she walks on water. Republicans apparently hate trial lawyers, but I’ve never seen a Republican hesitate to turn to them when they need one. I also wonder if the people asked actually have used the system to any great extent other than simple doc visits? I blindly and happily paid my medical insurance for years (BCBS) but when I had simple cataract surgery and tried to collect a pittance of what I’d paid in premiums, it took me over 6 months of fighting with idiots. I now don’t carry insurance and self insure, with the option of getting serious treatment in India or Canada if I ever need it.

  14. It’s really just the fact that American’s dont feel they are getting what they are paying for with their health care, and this is true.. So we can’t help but ask why, and what can be done. How about all of the elderly people that are paying high and increasing premiums that they cant afford, because they are at the point in their life where they need medical care the most! Thankfully, AARP has set up http://www.thisissoridiculous.com so that we can all sign a petition to make our voice heard. While your there you can also read updated news, watch videos, and even e-mail your congressman to let him know how you feel. I’m working to help AARP promote better Medicare because this is an important issue that isn’t getting enough attention.

  15. Actually, I don’t think this is an unusual disconnect at all. Americans often express dissatisfaction with things they later turn around and claim to like. It’s completely in keeping with tradition. We’re confused. That’s why we’re fun.

  16. Very interesting article. We recently completed a poll in Iowa: The CodeBlueNow! Pulse–which asked what was important to Iowans around some key principles and core elements of a health care system. The findings are on our website:
    There is more common ground and consensus than we are told by pundits, press and politicians. I think if we focus on our common ground and continue forging consensus that we may have the opportunity to impact reform.
    It is clear to me, however, that we need to get reform out of the hands of the candidates and quickly.
    We are also publishing an article next week about the tremendous surgical variations of common surgical procedures. Eliminating those variations means not only higher quality, but lives are saved and costs reduced.
    Keep up the good work. Kathleen

  17. Today, I’m beginning to wonder if Maggie Mahar simply needs to read Dan Gilbert’s Stumbling on Happiness for clues to a reconciliation of her ‘confounding’ information about people’s personal satisfaction with the caliber of their care, vs their assertions about the quality of health care generally.
    I would personally encourage Dan to write a sequel entitled “Stumbling on Healthiness”.

  18. I am for universal health care, complete choice and access to medical, dental and vision care, for every citizen, at government expense. I’m also for a government and societal system that is not based on debt, but that’s another story.I vote with my wallet. I do not have or want health insurance. I prefer paying at the time of service. I recently went to a doctor and asked for a pap smear. He also ordered an HPV test. My opinion is that the HPV test is unnecessary, and a complete scam, particularly if it is done routinely. A person who has insurance most likely would get the expense of both tests paid, and would not complain. This serves those who profit from the $99 HPV test as opposed to the $75 for the legitimate pap smear, but it does not serve the patient or victims of today’s medical industry. Insurance companies DO pay every day for things that are not medically necessary, but are necessary for the financial exploitation of the citizenry, yet they also routinely REFUSE to pay for necessary care. And until consumers revolt with their wallets, this will continue. I just wrote for the second time to the lab, telling them I will gladly pay for the pap test after they remove the charge for the HPV test that I did not ask for.

  19. The waste on the provider side can be reduced and managed if performance was measured using fair outcome assesment tools. A small proportion of the providers account for a vast majority of the waste. I am a provider and I know who in my town is doing it properly and I also know who is gouging it. Unfotunately, I have no way to impact that as an individual and I get punished when an HMO crashes down on an entire provider group(and then profits from it without passing savings onto consumers). If docs are measured against acceptable norms the outliers can be peer counselled back into the fold.
    Also, not that it’s an excuse, but docs have been ghetto-ized by the HMO’s and many wrongly feel they need to over utilize in certain areas to make up for the loss in other areas. So then more cuts are made and create even more pressure for the docs to find the lost revenue again.
    You have to realize it’s very difficult to be a provider nowadays. You graduate at the top of your class in high school and undergrad and then go on for another 5-10 years of post-grad work running up $200k in student loans. Then you bascially start your career at 29 years old and need another decade just to break even financially. At 40 you start to make some money. And all because you were the best and brightest in school. Then your income gets slashed, and slashed, and slashed…although the patients are happy and getting great care. How do you expect to get the best students to pick that life if you make it even harder?
    I’m sorry, yes there is waste and it can managed with little effort, but we need health insurance reform more than we need health care reform. Why should the money pool with the MCO’s and not be used for care? Monitor the docs and cut the waste but, geez, the good docs need to be rewarded for what they go through to get this done especially if you expect anyone to choose the career.

  20. When 10% of the population account for 70% of the cost of health care you start to realize that you don’t need to change the entire system just the care provided to those with chronic conditions. Since there isn’t a business case for any one insurance companies to invest in preventive care (the churn rate in insurance is now about 40% a year)our current employer based insurance system can’t be expected to produce the “product” or value that we need.
    If however we use a community approach to provide the infrastructure to track and treat these people as they move across and through the system we can cut the unsustainable growth in this sector. For example, this doesn’t need to be a high-tech solution – simple things like registries of patients (you can do it on excel at the provider level) and group visits for diabetes patients are very effective. (lots of RWJ funded studies).
    We could also shift the focus to the patient without expecting them to suddenly be able to negoiate with provider for better care. One simple example would be instead of trying to develop and find the businesss case for a RHIo to provide people with smart cards. (very secure credit cards with a computer chip on them) that would carry both their insurance coverage on them, as well as meds and a secure medical history. In the EU (Europe) over 50 million people in Germany will have smart cards by January and 7 million in Italy already do. No more duplicate tests, a patient centered care model, inexpensive technology (the readers are less then $20) real time access to data in an emergency.
    But the model only works if an entire region or community works together. That is where government can play a role but let the creative free-market implement it. You know that everyone would want their brand on the card and it would pay for itself out of marketing versus health care dollars. (this is just one small example not an attempt at a comprehensive solution)

  21. great entry. it’s nice to have someone point out that even if you could remove insurance company profits, we still have a big problem on our hands. as you stated in Money-Driven Medicine, docs help drive patient demand. Those who persist in holding up the French system, et al, as something to strive for fail to understand that while the govt could certainly step in and lower cost in the States, the medical community would pit patient against government (‘how dare the govt tell me and my doctor what treatment I can get!) and it would be a mess. Great article in today’s NYT about how that’s been happening for years with oxygen providers who grossly overcharge CMS, but who organize the seniors to lobby against any politician that tries to change the reimbursement.