Saturday, February 17, 2007

Health Care and the Uninsured

An interesting article by Karen Davis (President of the Commonwealth Fund; Head of Health Policy at the US Department of Health 1977-91) has appeared in the BMJ (17th February 2007 334:246-8) concerning the "uninsured" in America. It is a condensation of her 2006 Presidential address. I have seen figures of 30% or even 40% of Americans being not covered by health insurance. How true is this?

Strictly speaking there is 41% of the population who don't have health insurance: 54% have employer-based insurance and 5% individual insurance. But on top of that 12% are covered by the Federal Medicare program for those over 65 and those who have been disabled for 2 years or more. Then 13% are covered by State Medicaid programs, mainly children of low income families and in some cases their parents, as well as some long-term care programs, and some interaction with Medicare for low-income families. This leaves some 16% of the population without any cover, around 47 million people - about the same as the population of England and Wales.

Despite this, the United States spends far more on health per head of population than any other country - around $6100. In contrast Britain spends $2500, Australia $2800, Germany $3000, France and Canada $3100.

What does America get for the extra money? The 5 year survival for breast cancer in nearer 90% than the 80% that other countries achieve, but the life expectancy at the age of 60 is a year or two less than in most other countries, and whereas in most countries around 90% survive for 30 days after a heart attack, in the US it is closer to 85%.

I don't believe most of these outcome statistics that compare one country with another. Seldom are the statistics collected in the same way and apart from differences in disease definition (eg "hypotension" is a very common condition in Germany and consumes a large chunk of the drug budget even though it is virtually unknown in other countries), diseases like cancer have had artificial improvements in survival because of earlier diagnosis (breast screening and PSA). Nevertheless, it appears that America is spending an awful lot more money without a commensurate improvement in outcome.

This may be because outcomes are an average of superlative care for the insured and terrible care for the uninsured, but I would need to see some figures to convince me of this.

Those who don't have access to a Healthcare program are likely to be people between the ages of 18 and 64 in low-paid jobs. Healthcare insurance for a family is on average more than $11,000 per year: a large burden for a small employer to bear. It is a large burden for a big employer to bear and makes American industry less competitive. Accessing regular Healthcare options is more expensive for the uninsured who don't have the bulk-buying capabilities of the Insurance companies, though the uninsured would be well advised to shop around and negotiate.

Many of those who are uninsured are immigrants, often illegal immigrants, in casual jobs, often part of the 'black' economy; they are paid in cash with no questions asked. For health care they resort to Emergency Rooms in County Hospitals. They are likely to default on taking their medicines because they can't afford their prescription drugs. They are likely to take part in informal drug exchanges, swapping unused (sometimes out of date) drugs with others in the same predicament. Medicine cabinets of the recently deceased provide a constant supply: not a good omen.

I have seen statistics somewhere that the poorest 30 million Americans are no better off than they were 20 years ago: but it's not the same 30 million. People come to America to better themselves and most of them do. I hope it is not patronizing to say that it takes years for those coming from developing countries to free themselves from the lifestyles of their former abode and buy into the ways of a liberal democracy. America welcomes more immigrants than anywhere else. They come wanting what America can give and most of them will eventually get it. It should not be assumed that providing a 'free' health service to this group of the population will make the problems go away.

Britain has experienced unprecedented waves of immigration over the past few years. Apparently, London schoolteachers have to deal with children who speak 900 different languages. Healthcare is available free at the point of contact. Everybody is registered with a family practitioner.

For the past 3 years I have been privileged to attend at Kings College Hospital in South London. Kings is one of the world's top hospitals. The liver unit is world renowned for its pioneering work in hepatic transplantation; the neurology and hematology units are similarly famous. Kings sits in an area of South London rich in ethnic diversity - which is a euphemism for it's a mostly black area. Many of the patients I see there are illegals keeping their heads down. The area has recently been in the news because of a spate of teenage gun crime. I see at Kings diseases that had been almost eliminated when I was a young doctor and common disease appear in their late stages because they have been neglected. I previously practiced in Bournemouth, a middle class, mostly white, affluent community with an excellent health service, where we could worry about chipping off 0.1 per thousand from the infant mortality rate, where we could honestly say that we would not expect anybody to die from a stem cell autograft and that induction chemotherapy for acute leukemia was safe. The Hematology service at Kings is better than that; it takes on cases that middle class hospitals couldn't imagine.

Britain comes out bottom (with Ireland and Portugal) in the number of deaths before the age of 75 that would have been saved with appropriate medical treatment. These three countries (America is almost as bad) are almost twice as bad as France. I would put it down to lifestyle, but France is as boozy as Ireland and Portugal has a Mediterranean style diet. More likely this is an example of different methods of statistical collection or different definitions.

According to the statistics the French have one of the best health systems in the world. It is an insurance-based system like the American one. The French have a large immigrant population too, with many illegals. Why are they doing so much better? My suspicion is that they are manipulating the statistics (their figures on cirrhosis are notoriously unbelievable). But if not perhaps we should all be living on red wine, garlic and olive oil.


Anonymous said...

As usual, you cut through a lot of the politically correct stuff and get to the heart of the issue.

America does not have a healthcare problem, it has a 'problem' with healthcare insurance.

As you say, many of the people without insurance are illegal immigrants who have flooded the country. One out of every 25 people is an illegal immigrant, mostly Mexican, but also from elsewhere in Central and South America and Asia.

One solution that will help rid the emegency room from illegals who use it when their child has a cold is to open a free health clinic, and refer people who don't need emergency care to that clinic.

A person with a 102 degree temperature will have to wait up to four hours so that illegals can get waited on first. True.

Not only are they stealing our jobs, depressing our wages, but they are monopolizing our healthcare resources.

I favor absolutely no immigration of any kind for perhaps 50 years, so we can absorb the illegals we have already, and that Bush and the Democrats are welcoming with open arms.

Jim McVey said...

To answer your first question the figure for the uninsured is usually given in the media as 46 million. This is close enough to your 47 million.

From my observations here are my comments of Healthcare in USA. Remembering that I have a bias since I am an ex patriot Brit. I was looked after for most of my life by the RAF and then by the NHS. If I was ill I went to see a doctor and I got the necessary medical care. In USA if you are not covered by an employer under the medical insurance they supply or, if you haven’t purchased your own medical insurance, you can still get seen by a doctor by attending the Emergency Room. There is a notice in the ER which states that medical care must be given to anyone whether they have insurance or not. E Rs because of that, are usually overflowing because of the uninsured and illegals making use of this facility.

It is a source of total frustration to the citizen who is insured, unless one is accompanied by some advocate who can command attention, the really ill people have to wait in line. In my experience the way to get attention is to be taken in by ambulance, then you may get attention of the medical staff depending on your condition, the rub here, is you may have to pay for the ambulance. If your condition is bad enough the cost is immaterial, you choose your own urgency this way, the dollar is king again. There are usually a cadre of interpreters in attendance for the non American English speakers, I believe they may have some effect on the priority of being attended too. They probably know the ropes as they are there every night, my suspicious thought is, it might just be a nice little earner for them. One other hurdle to negotiate.

I have also heard it said that hospital bills are padded for the insured citizen, to offset the uninsured and the illegals. This maybe why there is huge cost difference between countries. The hidden cost for the uninsured and illegals.

In USA during your working life you are covered by your employer’s healthcare. However your employer must be able to afford to supply healthcare. The practice of some employers is to employ people for less than the hours which would require them to pay for healthcare. People working those jobs are I am sure many of the uninsured. I have known of people working 3 jobs to try and make enough to live on.

Now to describe Medicare I am sure it is not realized but Medicare is really Socialized Medicine. In my experience if I describe The National Healthcare System depending on the listener he or she will immediately say oh! you mean Socialized Medicine. For old Americans that is a derogatory system, perhaps it came from the cold war era. What they don’t seem to realize is that Medicare is just such a system. Each State has an Insurance Company chosen by the Government to administer Medicare, it kicks in at age 65 usually when seniors stop working when they are living on Social Security and pensions, when their income is fixed. They have to pay Medicare Insurance and take out a Supplementary Insurance to cover costs that Medicare doesn’t cover. The latest Insurance wrinkle is The Prescription Drug Plan introduced by the present administration. It was introduced with the statement that the administration would not negotiate a bulk buying price reduction. So the senior citizen possibly has been covered all his working life by his employer’s Health Insurance, is now faced with having to buy three insurances to cover his or her health care, probably when they require more healthcare than ever before and when their income earning power has been drastically reduced.
The system is flawed from the start, with costs not shared over a working life, but compressed into the Golden Years. Seniors refer to the Retirement years as Golden Years ( tongue in cheek) I believe they are golden years for insurance companies maybe.

These are my observations but as I said I am a young American of 16 years with most of my life experience in UK, so I am biased. I abhor the situation here, where the individual has to choose between eating or going to the doctor or buying prescription drugs. People become blasé about their health, which cannot be good for their mental outlook, so their quality of life is impacted.
It is just so un-American not in keeping with U S A’s representation of Human Rights throughout the world. Healthcare is in my opinion a Human Right in any civilized country.

David Arenson said...

Major health care reform is finally on the horizon in the USA because large employers such as Wal-Mart are pushing for it. Things have gotten so bad that businesses, large and small, are taking a major hit trying to provide insurance. Employers such as Toyota are opening factories in Canada, where the state provides insurance, and not in the US, where they would face an addtional burden.

So the market will drive reform. It is long overdue.

A final comment: illegal aliens are but one piece of a many-faceted puzzle and are not the major cause of problems in American healthcare. Most of the people in those ER waiting rooms are American citizens.

Terry Hamblin said...

Yes, my son and I agree on this. Over on his blog illegals have been extimated to account for 0.3% of healthcare costs. Man for man they are more expensive than citizens, but there are too few to make a difference.

Anonymous said...

Too few illegals to make a difference???

There are probably 15 million illegals in the US. That means one out of every 20 people here, is here illegally.

There is no incentive to play by the rules, is there?

When I travelled to Eastern Europe, when it was Communist, there were long lines outside of every US Embassy. I should have stopped and told them just to come to the US, don't bother waiting in lines.

What fools they were!!!

As far as buying insurance when you qualify for Medicare (indeed it is somewhat like socialized medicine, but you do have a choice of doctors), as far as I know, you aren't forced to, but you may purchase 'gap' insurance to cover what Medicare does.

As far as someone who choses to live here, yet bellyaches about medical care, I say, move back home!!!

Socialized medicine means that no one can get better care than the drug user bum on the street.

Forget that you planned well, and saved for your retirement, you can't get better care than the crush of the masses can.

In Canada, it is illegal to hire a private doctore.

As Dr. Hamblin pointed out, the numbers of uninsured is overstated.

Many are young people who don't feel they need it.

Vance Esler said...

David Arenson is correct that major health care change is underway. However, I'm not sure I would call it reform. Any time something gets fixed by politicians, I worry.

As I have said before on my blog, universal health care will probably be easier for the doctors, but patients are not going to like it.

But I am interested in the British perspective on this since you guys have been living under it for years.