Talking about what is wrong with our system is not going to fix our health care problems, just as anti-Obamacare rhetoric hasn’t solved the GOPs problems. We must offer, and promote, real world solutions to the problems we are having if anything is to improve.

Hate to break it to you, but so far, it’s not really looking all that great for Democrats in 2020—because we still aren’t providing better options.

How do we make it better? We have to learn what works and advocate for it, accepting nothing less. We’ve got momentum. We’ve got participation. Now we need to forge a path ahead that is different and is based in real solutions to the very real problems that are currently dragging our country in a downward spiral.

So, Who is Healthy and What Are They Doing?

First, it makes sense to see what works by determining which countries are the healthiest in the world, and then determine what they are getting right. Cultural and resource differences between countries can vary, but looking at what each system has in common can yield sensible ideas for reforms citizen activists can, and should be, advocating for. The information must be current, meet established standards for data collection, and the information analyzed in a way that cannot easily be construed as biased. The Most (and Least) Healthy Countries in the World meets these criteria for credible work, basing their analysis on World Bank data. They were also helpful enough to share their methodology with anyone who cares to review it, and are a source used widely for quality content in other publications.

In order, according to the work done by 24/7 Wall St:

10. Spain
9. Norway
8. Switzerland
7. United Arab Emirates
6. Finland
5. Sweden
4. Singapore
3. Italy
2. Japan
1. Iceland

Hopefully, the first thing Americans notice is that we are not on this list. Hello! We are not on this list! We pay an exorbitant amount of money as a country for medical care, and we aren’t even near the top of it. Depending on your source, we either spend the most, or a very close second to the most, per person on health care, and yet, we are behind dozens of other countries on health. Clearly, money isn’t the problem, which, in a way, is good news, because we spend enough to get better outcomes. How we are spending it is the only way to explain why we aren’t doing better.

You can see on this table that the data clearly indicates we are spending the most, or nearly the most, on healthcare. According to the OECD report, Why is Health Spending in the United States So High? “The United States spends two-and-a-half times more than the OECD average health expenditure per person.” While wealthy countries tend to spend more than poor countries, the United States is an outlier, with our population spending $3000 more per person than even the Swiss who enjoy the same income levels. That is approximately 50% more PER PERSON with far less healthy results. Where is all this money going? Our problem is caused by excessive administrative fees, how out dollars are allocated, and the way we access care.

Back to the table, nearly all of the countries that are most successful have some form of universal coverage. Some also include an option for private insurance for people who want greater access to services, or more individualized care. Even then, there is not one OECD country in the top 10 that spends significantly more money than Americans do. Universal care with a private option for additional services can be very effective in obtaining both healthy outcomes and additional services when needed.

How can we solve this problem?

The Organisation for Economic Co-operation and Development (OECD) provides support to countries wanting to improve health care policy. They help determine where to focus public money, advise countries how to structure medical payments for better healthcare outcomes, and help countries cut back on waste while promoting appropriate care. They work with countries, helping them adapt to new challenges and advances in healthcare and medications in addition to making sure adequate professionals are evenly distributed throughout populations. Finally, with our aging populations, they support countries making changes to adapt to the growing demand to serve them. According to the OECD, in addition to the many problems covered in my previous post, there are substantial inequalities in access to care in the United States (p. 24). Poor access to care undermines outcomes. We should be working alongside the OECD to improve our system using methods already proven successful in other countries where they make sense.

There is one thing that stands out that we are doing well at. The OECD report states that we actually do “very well in providing acute care for people admitted to hospital for life-threatening conditions.” Even though we are better at providing acute care, we spend LESS than Switzerland, Canada, Germany, France, and Japan on hospital care (chart 4 p. 3). Obviously, the efforts we have put into reducing hospital stays and reducing invasive surgeries has helped us spend considerably less on hospital care. This is one thing we are doing right.

On the other hand, when it comes to “regular monitoring and surveillance, involving patients in self-care, and providing them with counselling about dietary habits and the importance of regular physical exercise,” we have much more difficulty.

Consider Rebekah.* She went to her physician for a regular checkup. Having gained weight, she thought it was because of extraordinary personal stress she had been under. Her blood tests, on the other hand, showed she had elevated blood sugar levels. The doctor recommended medication or dietary changes and additional exercise. She made the dietary changes and increased her exercise, and within 3 months, she lost weight and her blood sugar levels had normalized. Had she avoided a visit to her clinic due to the cost of co-pays and blood tests, this could have gone undetected for quite some time.

Ongoing support in the form of routine medical care gives patients vital feedback and helps them reduce risk factors, leading to better overall health. Without it, far too many Americans are not getting the kind of personalized feedback that helps people make decisions that lead to healthier outcomes.

Spending

The OECD health spending per capita by category of care, chart 4 (p. 3), shows that Americans spend considerably more in each of the four categories of health spending when compared against Switzerland, Canada, Germany, France, and Japan, but Chart 4 also shows us that we spend tremendously more on ambulatory care, more than some of the top ten countries do on their entire health care expenditures. The Harvard Business School published a paper (p.24) saying, “The United States is a prime example of the ill effects of a large uninsured population without access to primary and preventive care, the prevalence of late and expensive acute treatment, and the distortive effect of cross-subsidies to care for the uninsured.” We are spending lots of money. We just do it ineffectively.

Probably unsurprising to many, Americans do spend far more on pharmaceuticals and medical goods than do these other countries.

Startlingly, however, is that we spend considerably more on public health and administration, “more than two-and-a-half times the average.” After years of telling taxpayers that putting the government in charge will cost more because of bureaucratic waste, is it a surprise to learn we are the ones paying more? Because of our many insurers, plans, and a lack of consistency between them, our costs far exceed the government run programs in every other nation on earth!

The reality is that we need a better system, and if we are going to have a better healthcare system, charging sick people more as the GOP is proposing will not put us on a better path. Their proposals have very little to offer in regards to to reducing actual costs, which should be more than feasible based on how we are currently allocating our healthcare dollars, nor do they do anything to improve American health.

Solutions

The following is a list of recommendations for our legislators to focus on in order to provide a better system, and better care for all Americans, to ensure a healthier future.

We should introduce methods of keeping costs lower and healthy outcomes higher by reducing waste and the inconsistencies in medical insurance providers, while also incentivizing providers to provide better care, helping consumers spend less overall. We spend more for almost every medical intervention than anyone else in the world on like-for-like medical care and receive fewer health benefits from it. Structuring payments to provide incentives for healthy outcomes and reduced costs has been shown to improve outcomes while simultaneously improving health.

We need a unified system of care. Harvey Jay Cohen, director of the Center for the Study of Aging and Human Development at Duke University Medical Center envisions “a system where all levels of care are linked.” Susan Love, in the same article, agrees, and advocates for a “team approach” to care. One of the biggest problems in our current healthcare system for people who have, and use, coverage are the gaps in care, gaps in coverage, gaps in available specialists, and gaps in the transfer of information from one caregiver to another, much of which is hard for patients to monitor due to the complexity of medical practice and even, in some cases, the ill health of patients, themselves. A nationalized or even state-wide systems of communication and collaboration among caregivers could help patients be better informed and obtain better care, reducing the stress and administrative burdens on medical staff.

This collaborative approach is not just smart financially. According to the The Commonwealth Fund, costs for chronically ill patients skyrocket “when the care they receive is poorly coordinated.”  In poor transitions, “patients may undergo the same lab tests multiple times, they may get the wrong combination of medications, and serious conditions may get misdiagnosed.” This poor coordination means the quality of care goes down, “for the patients who most need help.” In addition to coordinating internally, hospital re-admissions could be reduced if a patient’s care team works with community services, nursing homes, and rehab facilities in a seamless manner, making sure patients and caregivers have clear instructions for self-care and follow up appointments.

We need transparency. When Elizabeth Agnvall interviewed 11 physicians asking them for one thing they would do to improve our healthcare system, three pointed out transparency as being critical to making healthier choices. Patients should be in charge of their own medical records, information regarding their health status, the expected outcomes for care, risks, and the costs associated with care, so they can make more informed decisions about activities and behaviors that are impacting their well-being.

Bundled payments & global payments are lump sum payments that go to a physician, care team, or healthcare organization “to treat a particular illness, condition, or injury,” incentivizing medical professionals to focus on healthy outcomes rather than procedures and procedural payments. Not only does this change the focus of care, it cuts down on administration considerably. Medical teams are then enlisted to help save money while achieving healthy outcomes, not to complete paperwork, and can earn incentives for doing it well.

We need to separate our employment from our medical coverage; with our employer sponsored health coverage, the United States is an oddity among industrialized nations. No other country in the industrialized world does this. We are the only ones in this boat, and it’s harmful to our overall financial well-being when we change jobs, can trap people in a jobs that are ill suited to them, or cause an employer to under employ workers simply to save money and avoid paying for mandatory benefits. According to Uwe E. Reinhardt in his article titled, The Illogic of Employer-Sponsored Health Insurance, “Citizens in any other industrialized country have permanent, portable insurance not tied to a particular job in a particular country.” In our increasingly transitory employment market, we need to uncouple our healthcare from our place of employment for the sake of both our personal bottom lines and for our overall health and well-being.

We probably need a single-payer system as part of the solution to our problems. The vast majority of first world countries have them (map), and they definitely can help support a coordinated system of care, relieving the excessive administrative requirements healthcare providers have to follow in order to comply with our overabundance of providers and policies. This also eliminates the confusing gaps in our medical care that patients deal with routinely. An organization that has been actively advocating for a single-payer along with various improvements to our current medical system is the Physicians for a National Health Program. They’ve been working hard to coordinate change, and support improvements to the current system such as the Medicare for All Act, H.R. 676.

Conclusion

The Senate has been working behind closed doors on legislative changes to our healthcare system, fighting transparency and avoiding public input. McConnell has even gone so far to tell people who disagree with him on policies that, “Winners make policy, losers go home.” Trump’s latest nefarious tweets are publicly urging them to repeal the ACA without a replacement, leaving millions of Americans’ health care and financial well-being at-risk.

Nothing that has appeared in print suggests the GOP has any interests beyond cutting expenses to employers and the wealthy, and charging more to people who are already struggling with health problems to begin with. They even put out a message saying they need Democrats to solve their problems. Saving our money by decreasing inefficiencies is not on their agenda. They also aren’t trying to improve the health of ordinary citizens.

It’s time to answer the GOP’s clarion call for help. Single-payer reforms work around the world, and better. The costs shown here, recommendations for reducing the exorbitant costs of healthcare in this country, and a list of solutions that could solve a host of problems that patients experience in our healthcare system every day due to the lack of consistency, transparency, and collaboration of care. Government involvement should not increase costs, and this data needs to be used to drive the decisions being made right now in the Senate.

Everyone needs to communicate with their senators, and in California, communicating with their local representatives and the governor. We have to tell our government representatives what we expect them to do, and use the energy that was harnessed by the election of this unpopular president to push for better healthcare at a better price for all of us.

With the frenetic pace of activity in Washington D.C. and Sacramento, and leaks coming out of D.C., it’s imperative to contact our representatives right away, and let them know exactly what we think about the work they are doing, that failure is not an option, and we need to make sure they know what solutions we want them to provide.

*pseudonym

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