Sunday, July 19, 2009

The Healthcare Conudrum

Like many conservatives and middle-of-the-roaders, I find the idea of a unified, nationalized health care system, which many analysts predict will be the only possible outcome of the legislation that President Obama is pushing congress to pass this summer, frightening.

Like many Americans, I have watched elderly parents struggle with the Medicare system. Medicare patients are forced, if they are unable to pay for supplemental insurance policies or to ante up out of their own pockets for costs not covered by standard Medicare Part A and B coverage, to enroll in Medicare Advantage Plans – HMOs which are set up specifically for, or which accept Medicare patients at a set fee by the federal government – and thus have an incentive to cut costs in every way possible to make a profit of the business of providing health care for their elderly patients.

When my father, of blessed memory, was sick, every decision by his MAP created a nightmare of a clash of wills between my brother and me on one hand, and the MAP’s care director on the other.

The push-and-pull we had to engage in, as bad as it was, would have been impossible had we not had one trump card on our side; we could have pulled Dad out of that MAP and put him in standard Medicare Part A and B coverage. Therefore, while the MAP seemed intent on saving money on Dad’s back, they could be swayed on some decisions out of fear of ultimately losing an enrollee. But as Dad became sicker and sicker, that trump card became next to worthless.

(Lest one think that I am attacking indiscriminately all MAPs, after a geographic shift we enrolled Dad in one in the new state and its care decisions were mostly quite reasonable.)

With a nationalized health care system, for which there would be no alternative, one loses that trump card altogether; all decisions concerning provision of care would be in the hands of faceless bureaucrats who could stand behind their offices and would have no compulsion to even reveal their names to disgruntled patients.

I experienced this in a smaller way recently with my son’s care. As a military retiree, my family and I are covered under Tricare, the Department of Defense’s managed care system. Retirees and their families, and the families of active duty personnel, have two options: Tricare Standard and Tricare Prime. Tricare Standard works something like Medicare Part A and B – one makes one’s own care decisions but has to pay a large part of the costs – while Tricare Prime works like an HMO or MAP. Just as with Medicare patients, those without supplemental insurance plans or extensive cash resourced to cover out-of-pocket expenses, choose Tricare Prime for the additional coverage for a reasonable annual premium. The system is divided into regions, with a different contractor managing the care of patients in each region for the government.

Eyal needed to see a certain type of specialist for several visits, but we had a hard time finding such a specialist ‘on-network’ close enough to his school that he could be taken to his appointments. The Tricare Prime standard is that, if an on-network specialist can be found within a specific radius of one’s zip code, then the contractor does not need to cover a visit to an off-network specialist. The radius is, if I am not mistaken, 80 miles. If Eyal were home, I would drive him that far to get the care he needed without question. But he is half a continent away, and he is a fourteen-year-old boy who cannot drive himself. But those facts would not move the contractor, and they were under not compulsion under the terms of the contract to provide me with redress other than to go off-network in which case Tricare Standard reimbursement rates (and deductibles) would apply; in other words, I would have paid mostly out of pocket for the specialty care. So I’ve already had a ‘taste’ of the challenge we all would face under a nationalized health care plan, and believe me it does not look enticing.

I have been stationed abroad in four different countries, each of which has nationalized health care: The UK, Germany, Greece, and Turkey. These are four very different countries, and the quality of care varies greatly between them. As an American family stationed in these places, we did not find the prospect of being referred to the local system for care as frightening in the UK or Germany as in Greece or Turkey. The language issue was only part of the frightening aspect; we also knew that mortality rates in those countries’ systems were considerably higher than in the American system, with all its problems.

We hear horror stories all the time of higher mortality rates in ‘the best’ of the nationalized systems (e.g. Canada) due to advanced procedures being severely rationed and advanced drugs being unavailable. These stories are not just anecdotal; hard statistics back them up. Survival rates from various cancers and other illnesses are markedly higher in the US than in any of these countries. Surgeries that we take for granted as being available, surgeries that prolong life or improve quality of life, are severely rationed in these other countries.

Most Americans, knowing these statistics and stories, do not want a nationalized health care system that will make us imitate the experiences of our neighbors in Canada, or our European cousins. And President Obama, in his campaign for office last fall, promised that his health care program would only provide a ‘government option’ and not interfere one iota with the coverage of Americans who are happy with their present care and coverage – which is to say, that of most Americans.

The concern of detractors is only in part that, whatever the government’s intentions, a government ‘option’ will ultimately kill competition in the marketplace and we’ll end up with a Canadian/European-style system with no options. Add to that, the President’s own recent backpedaling on the campaign rhetoric to open admission that – under his plan – many Americans will see changes to their health care. And finally, the President’s intense pressure on congress to pass legislation according to an artificial and rushed timetable – and the willingness of many Democratic legislators to be pressured out of loyalty to Obama – raises fears that, at the very least, the congress will pass sweeping, complex, game-changing legislation that will be signed into law without even having time to consider the many aspects of what they’re approving, not to mention unintended consequences thereof.

I agree that fears of a nationalized, ‘single payer’ health care system are not irrational; I believe that unintended and intended consequences of this rush to produce legislation that the President will sign, will conspire to give us a system along the lines of the Canadian/European system that will satisfy no one, except perhaps those who have no insurance coverage now.

The last time such a sweeping change in our health care system was attempted, by President Bill and Hillary Clinton, it failed because of a groundswell of public opinion against it. President Obama seems to be taking as the lesson of that failure, that the quicker he can ram through the legislation and sign it into law, the greater his chances of success in enacting this legislation that most Americans, given time to chew on it and consider, would tell their representatives to reject.

Instead, I and other sceptics would prefer the President take a much different lesson from the experience of the Clintons: he should instead work for a reform of the present system to fix its shortcomings and make better insurance coverage available to those who fall through the cracks now. Our fear is that America has elected a ‘Hard Left’ President who is so enamored of the idea that Government is the Answer to All Our Problems, that he is not really concerned about what most Americans think.

All Americans who know people who have experienced nightmares in getting health care under Medicare and other government programs such as Medicaid and Tricare and whatever, should ask themselves: Do I want the government providing my health care? If the answer is no, please do two things: send your congressman and senators e-mails telling them to reject the legislation currently underway on Capitol Hill, and sign the petition found at