Public Opinion and Health Care

Volume 358:1881-1883 May 1, 2008 Number 18

1994 All Over Again? Public Opinion and Health Care

-->The current moment in U.S. health care reform is eerily reminiscent of the lead-up to the 1992 election. Then, as now, the country was facing an economic downturn and had been engaged in a war in the Middle East that threatened to distract attention from domestic matters. There was also unusually broad agreement among Americans and the presidential candidates that health care arrangements needed reform — a negative consensus that still holds today. At the end of the 1992 primary season, as now, Americans ranked health care among the four most important problems facing the country.

Between 1991 and the summer of 2007, about 90% of Americans were fairly consistent in agreeing that the U.S. health care system should be completely rebuilt or required fundamental changes (see line graph). About 70% of Americans consistently believed that the system was in a state of crisis or had major problems (see line graph), and the proportion dissatisfied with it had increased to 81% by November 2007. Despite this negative consensus, however, there is no convergence on proposals for reform. Instead, public opinion is characterized by ambivalence or divergence regarding future directions, which may foil efforts to forge agreement on the best way to improve the system.

http://content.nejm.org/cgi/content/full/358/18/1881?query=TOC

What are your take on this guys? Are the public being mislead on the realities of Socialized medicine?

I don't understand socialized medicine as I am not sure of the validity of the minimal amount of literature I have read on it. For example, someone in another forum suggested that Cuba was lying about its infant mortality rates.

Part of me feels that when profits are mixed with taking care of people the outcomes are not as good for the people vs. a system that was non-profit driven.

 LK

How can it be in the best interests of the share holders of an insurance company to keep the high users on the books?

On the other hand when you eliminate competition from the equation, the status quo will remain for years.

The only difference between a profit and non profit is who pays taxes, has nothing to do with quality care.

The fundamental question is: Is healthcare a right or just for the privileged ?

Once you answer that, the rest follows. 

I have the right to food, clothing and shelter. basic rights. But I can not demand for steak, an Armani suit and a 5 star bedroom. How about transportation, why are we not all in business class?

What Basic health care is have to be defined. Carte blanche for now is what we have, yet is not enough.

It is human nature to want more. We have more in this country and is unappreciated.

Great question though

Rogerven:

What Basic health care is have to be defined.

DrMurdoch:

It is of course, impossible to please everyone and essentially impossible to define -

It is simple, and summed up with a simple phrase " WHAT IS THE BUDGET". Accountability and responsibility can not be placed solely on the traditional Doctors decide and the government oversees, the public have to make choices as well, just like purchasing any commodity, how much one is willing to spend.

I'm not sure that healthcare should be likened to a commodity. I also don't think that there is a basic right to food and shelter. If one is an able bodied citizen and just plain refuses to contribute anything to society in the form of work, it is not society's duty to cloth and feed that individual.

Healthcare, I think is more akin to free speech, national security or clean air. I have a problem with for-profit healthcare, just like I would have a problem with for-profit, mercenary, defense forces. 

All these discussions on how people need to become fiscally responsible when it comes to how they spend their healthcare dollars is pretty scary to me. So here's a question, if you only have limited financial resources and you develop, say, some form of cancer that requires expensive treatments and has a decent, but not certain, survival rate, will you spend your money on your own treatment, or would you spend it to send your little girl to college?

I don't think anybody should have to face that question in the, supposedly, wealthiest country in the world. I know I'm being naive and people are faced with similar decisions every day in the current system, but at the very least, we should not come up with a solution where dealing with questions like this is part of a, so called, proper fiscal responsibility.

Margalit 

elidan:

I'm not sure that healthcare should be likened to a commodity. I also don't think that there is a basic right to food and shelter.

elidan:

Healthcare, I think is more akin to free speech, national security or clean air. I have a problem with for-profit healthcare, just like I would have a problem with for-profit, mercenary, defense forces. 

Margalit, Healthcare is a commodity, it is regulated and overseen as a business. Heard of anti trust? (http://en.wikipedia.org/wiki/Antitrust, http://www.usdoj.gov/atr/).

You suggest entitlement and indeed that is what we have in this country. A benevolent country indeed, and all one needs to do is live 3 to 6 months outside of the United States and spend time in a health care system, area of your interest, to appreciate what we have. Medicares inplementation (http://www.medicarerights.org/maincontenthistory.html) in 07/1965, was a great time I suppose, Doctors with their black bags doing house calls. Question is what were in those black box, not really much and the hospital probably did not offer much as well. The ensuing decades saw a significant improvement of Primary, secondary and teritary prevention, which indeed cost money. Without money I am sure there would have been no motivation for any branch in Medicine/pharmaceuticals etc. to develop drugs, diagnostics and so on.

National security entails money, its implementors and administrators have to pay into the system with our taxes, clean air acts will also hopefully bring upon breaks on buying alternate energy for our vehicles. Will you tell Chrysler, Ford, Toyota to drop the price of their cars, like what they do to the medical providers except of course the hospital? Can we outsource, care? What about the punitive system, not allowing "errors," with damages costing 6 to 7 figures for services provided costing 2 to 4 figures? No Tort reform until it becomes socialized.

We may likely have a free for all system but the question is will we have enough providers? Does the media address the Physician shortage? Are you aware of these?http://www.im.org/AAIM/Pubs/Insight/Volume5Issue2/EvolutionofMedicine.pdf ,

http://www.massmed.org/AM/Template.cfm?Section=News_Releases&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=19285

There is free speech in health care, we the public and the media continue to lambast the medical system, and we see a trend on isolating data that may be inconclusive or vague with bias academicians isolated from the "business" of medicine and possibly face to face personalized care, limiting available treatment alternatives. With antitrust the system can do anything to Physicians, and if we band together we can legally be prosecuted via the antitrust law.

gchiu:

How can it be in the best interests of the share holders of an insurance company to keep the high users on the books?

It's not of course.  That's why Canada outperforms the private US hospitals in dialysis. 

 I must admit I have found this thread to be very entertaining as pretty much every point of view I have ever had thrown at me regarding healthcare is represented here.  Bravo, everyone.

Before I share my point of view with all of you, allow me to say a few words regarding some of the comments we have here.

Between 1991 and the summer of 2007, about 90% of Americans were fairly consistent in agreeing that the U.S. health care system should be completely rebuilt or required fundamental changes (see line graph). About 70% of Americans consistently believed that the system was in a state of crisis or had major problems...

Two things here:  First, I love it when people suggest that a system a large and massive as something like healthcare should be "completely rebuilt."  Systems this large cannot be torn down and rebult from scratch as many would like to do as that would take years and be to disruptive and expensive.  Think of it this way, would you rather the state fill in the pot-holes on the road in front of your house or tear the entire thing up and re-pave it?  For those who opt for tearing it down and repaving it, I'm certain that idea sounds wonderful until you are the one have to get up 30 minutes earlier for work for months because of the delays created by all the contruction.  Revolution vs. Evolution. 

Second, yes we do have problems with healthcare, but most everyone seems to be misunderstanding why.  And I'm getting to that.

Part of me feels that when profits are mixed with taking care of people the outcomes are not as good for the people vs. a system that was non-profit driven.

Both profit and non-profit systems have their issues and I think that upon closer examination you'll find one is not better than the other.  In a for-profit-system, companies stay solvent by taking care of those people who can pay.  Those who cannot pay are turned away (or at least they try to turn them away) or the minimum amount possible is done.  Right now, 50% of hospitals in the United States are not financially solvent and this is mostly because of them having to see patients that cannot pay and have no insurance.

On the other hand, non-profits that have no bottom line to answer to also have no incentive to become efficient.  What you often see are administrative procedures that waste time, people who have jobs that do not contribute much to the work flow (i.e. a plethora of administrative assistants), employees that goof off and are not managed appropriately, red tape, and management bloat. 

Six of one and half a dozen of the other.

How can it be in the best interests of the share holders of an insurance company to keep the high users on the books?

It's not.  Insurance companies depend on a ratio - so many healthy people paying in for every one person sick.  Think about it:  Let's say you own an insurance company.  A 25 year old male who doesn't smoke, only drinks occassionally, is not overweight, and works at a job where the company just celebrated 1 million safe man working hours approaches you wanting health insurance.  What do you say?

The next day, another person walks into your office and he is HIV positive and he is asking for insurance.  What do you say?

The fundamental question is: Is healthcare a right or just for the privileged ?

Like everything else, healthcare is for whoever can afford it.  There are groups that doctors belong to who hold seminars every year on how to increase collections.  Do doctors spend half their life in college just to work for free?  Do we all think doctors are all super rich?  They aren't.  Doctors may make a lot of money, but they have expenses such as employees, rent on the building they are in, utilities, equipment, certifications, etc.  I know doctors who make $500,000 a year but by the time you subtract their expenses, they bring home around $80,000.  The engineers who make the MRI machines and other equipment used by doctors expect to get paid as well.  They didn't get degrees in electronics or computer science for nothing.

If you say healthcare is for the priviledged, then you say those who have the money get it and the poor may or may not.

If you say healthcare is a right, then you will have to get government intervention to cover the cost of those who cannot afford it and the cost is spread out to the taxpayer and then you get to pray they don't vote you out of office.

Notice that either way a check is being written - it's just a matter of who is writing it.

It is simple, and summed up with a simple phrase " WHAT IS THE BUDGET". Accountability and responsibility can not be placed solely on the traditional Doctors decide and the government oversees, the public have to make choices as well, just like purchasing any commodity, how much one is willing to spend.

And the public makes those choices by either coughing up the cash or going to court.  The court part helps explain the high liability insurance many docs pay.

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I can't speak for other countries since the only country I have ever lived in is the United States.  What I can say about healthcare here is that it is a head-on collision with a train that cannot be avoided.  In the next 3 - 5 years, 65 million people are going to retire.

All those people are going to retire, go on Medicare, stop paying taxes (for the most part), and live off their pensions/401k's.  So let's assume that each of those 65,000,000 spends a mere $1000 in year in healthcare. 

65,000,000 * 1000 = $65,000,000,000.  Now let's assume that each of those persons stays alive 15 years after retirement:

15 * 65,000,000,000 = $975,000,000,000

Oh, wait, we forgot about Social Security.  So let's pay each person $800 a month.  So that's $9,600 a year.

65,000,000 * 9600 = $624,000,000,000 and let's not forget our 15 years so ANSWER * 15 years = $9,360,000,000,000.

So let's add both of those number together:

$9,360,000,000,000 + $975,000,000,000 = $10,335,000,000,000.

And that's with the low numbers for healthcare expenditures ($1000 a year) I was using.

Like insurance, even when you get the government to foot the bill we still have that ratio we have to deal with.  You must have so many young working people paying taxes in for every elderly retired person drawing out.  And because of the large number of baby-boomers retireing, we just don't have that ratio now.

The young people are going to write their congressmen and president citing that they don't have the money to foot this bill, they have college to pay for, etc.  The retirees are going to write their congressmen and president citing they were promised retirement and have no other way to live.

I'm going to assume that other countries that have an aging population, such as Canada, the UK, and France are going to have similar problems.  And since their government takes care of their ENTIRE populations, not just the retired, I hypothesize they will have similar severities if not worse.

JamesNT 

JamesNT:

Two things here:  First, I love it when people suggest that a system a large and massive as something like healthcare should be "completely rebuilt."  Systems this large cannot be torn down and rebult from scratch as many would like to do as that would take years and be to disruptive and expensive.

I love suggesting that US Healthcare should be completely rebuilt.  I do know that it is extremely unlikely to happen.  If the US adopts a Single Payor System I think it would be one of the World's Greatest Accomplishments Ever.  With Mega Mega bucks behind private care I think it would be hard to eliminate it entirely.

Think of it this way, would you rather the state fill in the pot-holes on the road in front of your house or tear the entire thing up and re-pave it?  For those who opt for tearing it down and repaving it, I'm certain that idea sounds wonderful until you are the one have to get up 30 minutes earlier for work for months because of the delays created by all the contruction.  Revolution vs. Evolution.

Think of it this way.  You want to re-pave the road, but I think the road is actually on a bridge and the foundation is faulty.  Time to make a better bridge or your pot hole plugged road will fall in one piece as the bridge falls.

On the other hand, non-profits that have no bottom line to answer to also have no incentive to become efficient. 

How so ? Institute some basic benchmarks and reward the systems doing well.

Q: The fundamental question is: Is healthcare a right or just for the privileged ?

A: Like everything else, healthcare is for whoever can afford it.

Not here.  Everyone has access to HealthCare.

"HealthCare" is just like purchasing any commodity, how much one is willing to spend.

Private insurance is banned in Canada.  So that pretty much dries up your market.

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I can't speak for other countries since the only country I have ever lived in is the United States.  What I can say about healthcare here is that it is a head-on collision with a train that cannot be avoided.  In the next 3 - 5 years, 65 million people are going to retire.

Herein lies the biggest impending train wreck in every Rich Nation.  All of these government's budgets are entirely unsustainable.  There is going to be alot of old people wanting expensive healthcare and too small a tax base to pay for it.   Intergenerational warfare ! I had 3 people in the hospital last week for Lung Cancer Palliative Care and I see the patients on ultra expensive chemotherapy drugs so they can last another week.  MEH. 65 million Americans retiring in 5 years seems a wee high (not that the exact figures are needed to highlight this important point !)

 While I would enjoy, thoroughly, responding to the rest of your reply, I think for now I would like to zero in on one point you made:

Herein lies the biggest impending train wreck in every Rich Nation.  All of these government's budgets are entirely unsustainable.  There is going to be alot of old people wanting expensive healthcare and too small a tax base to pay for it.   Intergenerational warfare ! I had 3 people in the hospital last week for Lung Cancer Palliative Care and I see the patients on ultra expensive chemotherapy drugs so they can last another week.

If this train wreck is true for all rich nations, then why do you tout Canadian Healthcare as being so totally awesome and superior since, by definition, Canada is heading for the same train wreck and can't do anything about it just like the rest of us?

If you guys truly were so totally awesome and superior, then you'd have an answer for all this - at least for your country.

JamesNT

I have worked in the healthcare industry since the 1980's and have seen many drastic changes like managed care come along which never existed before. The bottom line is that the fat needs to be trimmed in the system and reverted back to when the healthcare system worked in this country back in the 60's 70's and 80's. It started down turning in the 90's up to today. 

We have become an "entitlement" society relying on being taken care of with more and  more social programs are being created costing so much money for our country.  We need to revert back to a "non-entitlement" society and be responsible for ourselves again.  This would help our economy tremendously.  I don't think socialized or universal healthcare is a good idea.  We need to dissolve the "entitlement" thinking and make all americans accountable for themselves again.   

My 2 sense