Many folks believe that universal health insurance coverage is a panacea to the fractured U.S. health care finance system. But take a few minutes to read this masterful Robin Fields/Atlantic article on the unexpected consequences of the nearly universal coverage provided for kidney dialysis patients:
IN OCTOBER 1972, after a month of deliberation, Congress launched the nation’s most ambitious experiment in universal health care: a change to the Social Security Act that granted comprehensive coverage under Medicare to virtually anyone diagnosed with kidney failure, regardless of age or income.
It was a supremely hopeful moment. Although the technology to keep kidney patients alive through dialysis had arrived, it was still unattainable for all but a lucky few. At one hospital, a death panel-or “God committee” in the parlance of the time-was deciding who got it and who didn’t. The new program would help about 11,000 Americans for starters, and for a modest initial price tag of $135 million, would cover not only their dialysis and transplants, but all of their medical needs. Some consider it the closest that the United States has come to socialized medicine.
Now, almost four decades later, a program once envisioned as a model for a national health-care system has evolved into a hulking monster. Taxpayers spend more than $20 billion a year to care for those on dialysis-about $77,000 per patient, more, by some accounts, than any other nation. Yet the United States continues to have one of the industrialized world’s highest mortality rates for dialysis care. Even taking into account differences in patient characteristics, studies suggest that if our system performed as well as Italy’s, or France’s, or Japan’s, thousands fewer kidney patients would die each year.
In a country that regularly boasts about its superior medical system, such results might be cause for outrage. But although dialysis is a lifeline for almost 400,000 Americans, few outside this insular world have probed why a program with such compassionate aims produces such troubling outcomes. Even during a fervid national debate over health care, the state of dialysis garnered little public attention.
Yet another example of what Arnold Kling has observed about U.S. health care — why do we think that that we cannot possibly afford high-quality health care if we have to pay for it individually, but we can afford it if we pay for it collectively?
tom,
wrong emphasis, i think. the different outcomes in dialysis patients, country to country, likely reflect different demographics ie we have more fat diabetics = harder to do well.
the american dialysis system is, in fact, a model of socialized medicine with everyone involved getting good profit and the care IS excellent–the flaw is that it is not affordable and it is morally unfair to compel the american taxpayer to foot the bill for the next guy’s misfortune.
multiply this model by all health care issues and you might actually exceed national gdp in cost. dialysis reimbursement has always been so fair to providers, with all other government reimbursement NOT fair-market that i have assumed it was likely created from a single power-politician’s family member’s bad luck and a Utopian, unaffordable response.
” — why do we think that that we cannot possibly afford high-quality health care if we have to pay for it individually, but we can afford it if we pay for it collectively?”
Can’t imagine, but somehow most of the rest of the industrialized world has it figured out.
Hey, let’s let the military/security complex take over the costs for our current wars. Why should we pay for the costs of their investment?
When the “customer” is a faceless government, the value of the product is not determined by the means if the patient. We need to find a means to continue research, but with the intention of delivering products that the consumer can afford.
Once we take the patient out if the position of determining the economic value, costs will not be checked. The argument to the insurer or government is the same, “How can you withhold care?”. It’s an emotional argument at that point for which an elected official cannot have a rational answer and expect to stay in office. Americans have less and less incentive to take care if our bodies, yet we have an expectation that someone should pay to keep us breathing.
Our lives all end the same, death. It is a fact of life that we continually ignore by posting facts about how many people die of X, Y, or Z…what manner of death is acceptable? When do we accept the reality of our being and not burden our brother? The answer becomes more and more expensive the further it is asked from the individual and family.
Tom:
The article says, “as care expands and the national health care debate staggers on, our four-decade experiment with dialysis is worth bearing in mind.” To use it as a criticism of universal coverage as a whole is somewhat of a misrepresentation, however, as it also says:
“Other countries provide universal access to dialysis care, much like the United States. But some, notably Italy, have better patient survival and cost control.”
and:
“Zoccali and other doctors credit much of their success to the Italian practice of sending patients to specialists earlier than in the United States. There are fewer financial barriers to such referrals. Those with less-advanced kidney disease have equal coverage; patients don’t need to have reached kidney failure. Intervening sooner “delays the need for dialysis and reduces the number of patients,” said Dr. Francesco Locatelli, who oversees the nephrology and dialysis program at the hospital in Lecco, near Milan.”
Similarly, the last paragraph says:
“A potential bright spot in health care reform, she said, is that extending better coverage to persistently under- or uninsured Americans could lead to earlier intervention for kidney disease. ”
–this after the article states that one of the prime reasons for Italy’s success is early detection and treatment and no financial deterrent for potential patients to visit the doctor sooner.
In other words, according to the article, universal coverage hasn’t been the problem. A system that does little to promote early treatment, and a Medicare payment system that promotes “efficiency” and incentives to over-medicate instead of quality of outcome is the likelier culprit.
Interestingly enough, dialysis may be one area of treatment where the patient can take greater control. Home dialysis offers a lower cost, high outcome alternative for some patients. While I’m certainly not an expert, this appears to be an emerging market that until recently neither the government or major providers spent much time promoting.
I believe Dr Kling’s assumption that we will take better care of ourselves if we pay more out of pocket expense for health care is deeply flawed. Please correct me, but I’ve not seen him provide statistical evidence backup to this claim, and quite the opposite appears to be true Europe–folks in countries with cheap health care seem to healthier than we are. Are we that pathetic as a nation? (it may be best to not answer that…) I think it’s as likely that the higher cost, the more the consumer will ignore lifestyle changes (It won’t happen to ME!) and avoid the doctor. Avoidance is not prevention.