The US health care non-system

I spent much of yesterday thinking about the past, present, and future of the American health care system. I’ve largely chosen classes with an international or methodological focus so this was a bit of a departure from my normal fare. In one day I finished up some readings on health reform, wrote a brief paper speculating on what US healthcare will look like in 2030, attended a talk by Uwe Reinhardt largely based on this paper (PDF), and went to a three hour lecture on US health care (part of a class on the economics of the US welfare state).

It’s a mammoth subject, and there are many bloggers who write exclusively about domestic health policy — the guys at the Incidental Economist have smart stuff to say on it every day. There’s so much to be said and done even on the somewhat narrowed subject of the Affordable Care Act (ie, “ObamaCare”).

But that’s not what keeps popping into my head.What keeps getting reinforced is how our system really isn’t a system at all, but a weird conglomeration of lots of different approaches for various fragments of our society that emerged for quirky historical and political reasons. I found this description — from a report comparing various industrialized countries’ systems — humorously understated: “The U.S. does not have a ‘health system,’ but rather a variety of private and public institutions and programs that regulate, finance, and deliver care.” (source)

Paul Starr’s classic Social Transformation of American Medicine is a good start for trying to understand how we got to the ‘variety’ we have today.  The end result is that it doesn’t serve very many people well at all. The US is a great place to get the most advanced care if you can afford it, but even then you’re going to pay a lot more for it. For the non-wealthy the expenses are amplified and we end up rationing care by ability to pay. By pretty much every standard other than innovation (ie, including the delivery of that innovation to those who really need it, not just those who can pay) the US falls dreadfully short. We get poor life expectancy, magnified inequalities, and spending that’s roughly twice as much per person as in any other wealthy country.

Ironically, whether the Affordable Care Act goes into effect in 2014 depends largely on whether Obama gets reelected, and whether Obama gets reelected or not depends largely on what the unemployment rate does between now and November. So the future of the US health system depends in a very real way on fluctuations in the economy over the next eight months, and no one really understand that well at all.

If you’re just looking at the trajectory of the American health system the ACA is a major reform, even a fundamental one.  It will do (and has already started to do) a lot of good things, but I’m skeptical that it will do all that much to fix costs or shift our focus to public health —prevention over treatment. There are a lot of good small fixes in there, but nothing revolutionary when you compare us to other countries.

And this is why I find domestic health policy profoundly depressing. It’s why I’ve chosen to focus more on international health than domestic politics. In international health I think the prospects for witnessing and contributing to massive, heartening, orders-of-magnitude positive change in my professional lifetime are quite real. On US health policy, I’m less optimistic. My friend and classmate Jesse Singal wrote a description of the US health system — in the context of astonishingly ridiculous remarks by some conservatives on contraception — that I think about sums it up:  “…our medical system is an octopus riding a donkey riding a skateboard into a sadness quarry.”


03 2012

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  1. Krista #

    Brett, I echo your feelings on domestic vs. international health policy, although I also follow the Incidental Economist and have been meaning to read Starr’s book. Are you familiar with “The Healing of America” by T.R. Reid? I highly recommend it.

    • 2

      Krista — thanks for the comment, and the book rec. I haven’t read the book but looked it up and it sounds like a nice comparison of health systems in wealthy countries. But I did note this on the Amazon description: “For all the scope of his research and his ability to mint neat rebuttals to the common American misconception that universal health care is socialized medicine, Reid neglects to address the elephant in the room: just how are we to sell these changes to the mighty providers and insurers?” I guess that’s the frustration I’m feeling here — policy solutions that would fix at least some of our ills seem straightforward, but the politically-possible policy solutions are harder to find. Do you think he did a better job of addressing that then the reviewer says?

  2. Mamta #

    Hey Brett- I agree that the ACA probably doesn’t go far enough in many ways, but I think there are definitely elements that focus on prevention, namely Accountable Care Organizations (ACOs) and the Patient Centered Medical Home (PCMH) model. These models-which switch payment methodologies away from fee-for-service models-reward providers for keeping patients healthy rather than for simply administering more services. I think these models give providers the incentive they need to focus more on prevention. Again, I don’t think the ACA goes far away in many ways, and it’ll be interesting to see what the fate of all of this is, but just a reminder that it’s not all doom and gloom in domestic health! There are lots of cool and innovative things going on, especially in federallly qualified health centers (what my program focuses on).

    • 4

      Mamta — I don’t mean to disrespect your work of course! Those models are the sort of things we’d hope would become more widely adopted, but it appears the former at least is restricted only to Medicare/Medicaid. Do you think PCMH’s will spread within employer-provided health insurance (still the bulk of American insurance)? I guess I need to know more about federally qualified health centers? There are definitely a lot of ways in which the government-sponsored insurance can move towards more preventive and cost-effective models, but I’m less certain that private insurers can or will move in that direction. And there’s also the question of whether such models (which I take are largely pilot-stage?) will survive politically if they become large enough to really threaten the same interests that blocked first single-payer and then the public option. I know it’s not all doom and gloom, but it’s certainly a long hard slog uphill!

    • 5

      Also, I think my relative levels of pessimism vs optimist for international and domestic health makes more sense for a macro level than a micro level. On the micro level some of the changes you describe in the US might result in more rewarding / less frustrating work than with the problems encountered in international contexts, while on the macro policy level there’s more prospect for really big change in the places where the baseline health levels are so much lower. So where one feels most optimistic about working might depend on what level you’re most interested in working at. Maybe.

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