caveat that national
health-care systems are excessively bureaucratic -
as well as being the breeding ground for terror.
It has been endlessly repeated that the
United States is the world's only major industrial
society without a government-financed system of
ensuring health care to all its citizens.
Actually, among the 20 largest economies in the
world by per capita gross domestic product (GDP),
the only nations where the
government contribution is
less than 50% of total national health-care
spending are the US (with government contribution
at 44.4% of total health-care spending),
Singapore, and Cyprus.
The average
government share of health-care spending in the
Group of Seven industrialized nations minus the US
(Canada, France, Germany, Italy, Japan and the UK)
is 78.5%. This does not mean that the US is a land
of cheapskates as regard to health-care spending.
Quite the opposite: 15.4% of US GDP, more than
US$5,700 per capita, goes to health care; the
comparable G7-minus-US figures average out at
9.25% and just over $2,533 per capita.
About 15% of the population, about 47
million Americans, don't have health insurance;
the number has increased by about 1.3 million
people a year since 2000. For these people, US
health care is represented by a leaky safety net
of emergency-room visits, overburdened
public-health clinics for the indigent, and
utilization of questionably effective herbal,
nutritional and homeopathic supplements.
As former senator Fred Thompson plays
Hamlet in his latest role and decides whether to
be or not to be the next president of the United
States, he has recently said that poor Americans
receive better care than do Britons from their
National Health Service; this, of course,
conclusively proves that neither has he ever
accessed medical care from the NHS, nor is he a
poor American.
Whatever the US gets with
its Cadillac-priced health care, it is not better
health. The United States is well down in the
tables in almost all measurements of health
status; in terms of infant mortality, according to
the Central Intelligence Agency's World
Factbook, this year the US ranks 41st, just
ahead of Belarus and Lithuania, whose health-care
delivery systems collapsed with the fall of the
Soviet Union.
Historic failures, and
successes It's not as if there haven't been
attempts to provide universal coverage. In 1945,
president Harry Truman introduced a measure that
would have instituted a system of national health
insurance for every American; the doctors' lobby,
the American Medical Association (AMA), would have
none of that. Two years later, prime minister
Clement Atlee and health minister Aneurin Bevan
faced similar opposition from the British Medical
Association to their plan to set up the NHS in the
United Kingdom; Bevan later reported that the
doctors' resistance only abated after he "stuffed
their mouths with gold".
In the 1960s, US
president Lyndon Johnson intended that his
Medicare health program for senior citizens would
soon be expanded to include citizens of all ages;
this foundered on the government budget deficits
generated by his trying to fund the Vietnam War
and the Great Society without tax hikes. In
1993-94, Bill and Hillary Clinton's ideas for a
fully inclusive health-care system failed in the
face of opposition from health-insurance companies
determined not to lose to the government a very
profitable market, and Republicans in Congress
determined not to hand the Democratic president an
epoch-making domestic-policy legislative victory.
The 44% of US health-care spending funded
through the government mostly represents Medicare,
the government-run program for those over 65.
Medicare is run very simply; in fact, to its
recipients, it looks a lot like a national
health-care system just by itself. A Medicare
recipient sees a doctor, or has an X-ray or a
surgery, and the federal government gets sent a
bill.
Therefore, the administrative costs
required to run this program, what is called the
Administrative Cost Ratio (ACR), is very low,
about 3% of total costs. (This is roughly in line
with ACRs in national health-care systems.) It's
still a very expensive program; at $374 billion,
it's 14% of the federal budget, only surpassed by
military spending, slated to be $740 billion in
fiscal year 2008.
US medicine is very
technological, and its practitioners are very well
paid (not that there is much evidence that these
two preceding factors improve health-care
outcomes), and the elderly use a lot of it, but at
least in regards to the Medicare budget, a
relatively small percentage goes for paperwork,
bureaucracy and administration.
It's an
entirely different situation for those under 65
who mostly rely on the private health-insurance
industry. These are the businesses that receive
the paycheck deductions and employer co-payments
that represent how most employed Americans pay for
their health care. The largest of these is the
United Health Care Group, which for the first
quarter of 2007 reported $1.58 billion in profit
from $19.05 billion in revenues, for a rather
healthy 8.3% profit margin.
Wall Street
currently values the company at $71 billion; other
leaders in the industry are WellPoint (valued at
$50.3 billion), Aetna, (valued at $25.3 billion)
and Cigna (valued at $15.5 billion). These four
companies alone possess a market capitalization of
$162 billion; to put that in perspective,
America's three major automobile companies,
General Motors, Ford and DaimlerChrysler (with
most of that company's value originating in
Germany) put together have a market capitalization
of $135 billion.
Providing for a profit to
be delivered to the stockholders is, of course, a
factor that does not drive up costs in
government-run systems. A greater inefficiency in
US private-sector health care is the fact that
this industry operates with very high ACRs. A 2003
study by the New England Journal of Medicine
reported the US private health-care industry's ACR
at just under 25%; add in a profit margin, and it
turns out that almost one-third of America's $1
trillion annual private-health-care bill goes to
costs and services that have no direct benefit to
the patient.
Growth
industries One might think that US
business, now so ruthlessly competent in slicing
away whole office parks full of superfluous
workers so as to improve the bottom line, might
apply the same skills to health care.
They
don't. In profit health care, the administrative
side of the business is worth every penny it costs
- and a whole lot more after that. Billing costs
is easy in government-run health systems. Doctors,
along with most other medical personnel, are
government workers; they show up in the morning,
go home at night. If the hospital needs more
syringes, they go to the budget and get them.
Patients get served, suppliers get paid, and
paychecks get printed.
It's nowhere near
that simple in private US medicine. Whether they
be Shinto or socialist, Anabaptist or anarchist,
all US medical personnel must daily prove their
fealty to The Book, or, more accurately, The
Books. These books are called ICD-9-CM
(International Classification of Diseases) and CPT
(Current Procedural Terminology) Standard Edition,
both published by the AMA.
You go to the
doctor with a sore throat. The doctor is worried
that you might have a strep throat, so you get a
throat culture. When that is concluded, you get a
few minutes of advice on topical measures to
alleviate the pain, maybe a prescription for a
painkiller.
But it's far from that
uncomplicated with the insurance companies. To get
paid from the patient's insurance carrier, the
doctor must find, classify and submit every one of
his actions according to the tens of thousands of
diagnosis and treatment codes found in The Books.
Sore throat? That's a 784.1, unless it's chronic,
then it's a 472.1. The immune assay code for
Streptococcus, Group A, is 87430, but if it's for
Streptococcus, Group B, it's an 87802.
If
you're a new patient, the doctor's assistant will
take your medical history and do a cursory
examination. If this takes 10 minutes or less,
that's a 99201; 10-20 minutes, 99202; up to 60
Head
Office: Unit B, 16/F, Li Dong Building, No. 9 Li Yuen Street East,
Central, Hong Kong Thailand Bureau:
11/13 Petchkasem Road, Hua Hin, Prachuab Kirikhan, Thailand 77110
