Honest Unironic Question about the US Healthcare Reform Debate.

[beccatoria]

Hello US flisters (or others with information). I have a question. I am aware this will probably sound quite dumb, but I assure you this is an honest, unironic request for information because I am confused.

I keep seeing the claims - even from like, the "reputable-and-not-crazy" side of the anti-reform people - that public healthcare is bad because doctors will be accountable to the government, not the patient and that it will compromise a doctor's focus on the wellbeing of the patient.

But surely this is already the case, except the doctors are accountable to an insurance company rather than the government? Right? I mean, the only difference being that the government is paying the doctor/hospital rather than the insurance company?

How does following government guidelines while treating patients differ from following insurance-company issued guidelines?

Is this just a massive sleight-of-hand they're pulling? As I said, this is a completely honest question because I actually feel like I must be missing something, because I don't see how the double-standard there isn't blazingly obvious?

(Context for the curious: while not as pressing an issue as it must be for those of you living there, I'm interested in this as slightly more than a nosy british person in that I'm also a US national, that's where half my family lives, I have strong ties there and visit frequently.)

Comments

[pellucid.livejournal.com]

I think the best context here is the conservative ideology that is automatically skeptical of the government (too big, too expensive, too inefficient, too controlling, etc.) and in the converse, generally inclined to look favorably on capitalist enterprises (the theory being that the competition in the insurance company marketplace raises the quality of service--as does competition in any marketplace). So there is a fear that any single-payer system, but especially one run by/accountable only to the government, would be inefficient and possibly contribute to some vast conspiracy to turn the United States into a communist country. It's not an ideology I subscribe to (I'm far more likely to support big government and be mistrustful of capitalism, myself!), but it's a pervasive one in much of the US. Lots of intelligent conservatives have well-reasoned arguments for this, but there's also a very high degree of knee-jerk government=BAD going on for many people who haven't bothered to think things through very much.

As far as doctors' accountability, though, isn't that a matter of medical review boards? I admit I don't know that much about this part of things, but I don't understand how doctors would be accountable to any payer--public or private--at present or in any future system. My experience with health insurance in the States is that the doctor usually tells you what tests she wants to run, then it's up to the patient to ask, "will my insurance cover this, and how necessary is it?" and on the basis of the answers make an informed decision. Patients regularly get screwed, though, when doctors assume insurance will cover a test or procedure that it doesn't, or things like that. (My sister once spent an entire year fighting her insurance company on something that should have been covered but the doctor's office billed incorrectly, so it looked like something that wasn't covered, and of course the insurance company didn't want to pay.) But none of that has anything to do with the standard of care [ETA: or rather, the potential standard of care as suggested by the physician; if the patient can't afford what the doctor thinks she needs, then obviously there is a probability of standard of care falling, but that's with the payer, not the doctor], or with what medical decisions doctors do and do not make. Those kinds of things are regulated by the American Medical Association, I'm pretty sure, which is an independent peer review board (I think).

So...I'm not really sure what kind of accountability you mean? Or that the commentators you're reading mean?

To be honest, I've mostly been just skimming the health debate with my eyes half-shut because it all just makes me SO ANGRY. Bah!

[nicole-anell.livejournal.com]

You said that all much better.

[zepooka.livejournal.com]

You've pretty much said it with the theory about the competition improving the quality of service... except it never works out as well as it should, because insurance companies are, in the end, companies, that want more money in any way possible. So to get good care, not only do you need a good hospital (because not all hospitals are created equal), you also need to have a level of insurance that will get you whatever medical stuff you need. It's pervasive because capitalism runs the country, and the idea that universal health care might OMG RAISE YOUR TAXES terrifies anybody who already has insurance and is petrified to think that some immigrant or homeless person might live through the night and cost them their new iPhone through tax dollars.

...to say nothing of the facts that not all employers offer insurance, some of the things they cancel insurance for are Truly Utterly Ridiculous (along with the fact they can cancel it at all), and the imbalance in the system is completely absurd.

I think the primary reason people claim the system will suffer from government intervention is that doctors won't have a financial incentive to keep practicing. Which (as several countries have demonstrated) is not true at all. But I guess it's kind of like the idea that private school is automatically better than public school, because people have a vested monetary interest in making sure it's The Best, even though it's totally bonkers to exclude people of a certain race/social class/tax level/whatever if they would flourish there (or to exclude people from particular medical care if they need it).

AMA does review people, but they're a bunch of whackjobs themselves sometimes. FDA also plays a big part.

This is about as far as I can get into the discussion without going all bananas and wanting to eviscerate the head of every major insurance company in the country. Watch "Sicko", it's tres informative. :)

[pellucid.livejournal.com]

Oh, yes, I completely agree with you. I was just trying to give the conservatives a tiny bit of the benefit of the doubt--sort of as a mental exercise. Mostly they make me want to hit them with very big sticks because I know all too well what it's like to be without health insurance in the US (and to have loved ones with no health insurance AND chronic health issues), and then I moved to the land of milk, honey, and socialized medicine Canada, and there is not enough capslock in the world to emphasize HOW MUCH BETTER IT IS HERE!!!!!!!

[beccatoria.livejournal.com]

I have actually seen Sicko! And it was fairly horrifying. But I also wasn't sure if I was seeing the worst .01% or typicalness or what? And like, I knew that it did nothing to ease my already massive fear of the US healthcare system, but if anything, if it's already that bad that only added to my above confusion about how anybody could think this would be worse?

Hence my belief I must be missing something?

Fortunately, I do feel a little less adrift now that I'm factoring in pathological fear of the government, even though I don't really understand that at all.

That and the fact that I have just discovered apparently there is disinformation being spread around that in nations with public healthcare like the UK we sometimes decide to flat out deny people care because they're old. o_O

[beccatoria.livejournal.com]

Aah, thank you. This actually helps a lot. I mean, I know I'll never agree with neocons even a little but generally - even when I find the thought process horrifying - I at least don't feel quite so at sea about it as here.

I think what I was doing was underestimating the fear of too much government. While I have a better grasp of American culture than a lot of my British peers due to my upbringing, it's easy for me to forget that my hippie leftist mother may well have failed to instill in me the true scope of anti-government pro-free market sentiment.

I tend to get it confused with British anti-government sentiment, which, while invariably focusing on how incompetant they are and how poorly they treat us (and even how much they try to control the minutiae of our lives), ALSO is always about how they need to do more for us rather than less. So most of my experience with government criticism is all about how they ought to be doing MORE for us (while, of course, not expecting anything of us) rather than about how they ought to leave us the hell alone. Which is very counter-intuitive to me.

But...yes. I can see how that works within the USA and I feel a little... Better clearly isn't the right word because I think the attitude is stupid but I feel less lost.

As to your discussion on actual regulation, that sounds somewhat similar to the UK except that since the doctor already knows the boundaries of the NHS's various provisions, and I have no experience with private care, there's less of a "here's what I want to do, now go off and find out if I can," thing. I'd like to think that's because the NHS is fairly expansive in what it'll sponsor, and I think in large part that's correct. But at the same time, I have to be honest, our system isn't the best in the world either and there is something of a post code lottery in terms of which health care trusts will fund newer drugs for example. Though the variation is nothing like what it is (I believe) with different healthcare coverage.

So yes, sometimes the issue of "going private" is raised, either simply as an option to pay extra and get a better room, or to jump a waiting list, or to get a drug the NHS does not fund, etc.

In theory the NHS will fund the best drugs for the condition, but as I said, in practice, with newer drugs especially, there's often variation. THAT SAID, I am 100% more comfortable with that decision being down to people I elect (with guidance from medical professionals) than people who have no allegiance to me at all but making money off of me. But there's that capitalist/"socialist" difference again. ::eyeroll::

Anyway, thanks. That really did help.

[nicole-anell.livejournal.com]

Is this just a massive sleight-of-hand they're pulling?
Pretty much. There is *already* a third party (insurance company) getting "in between you and your doctor" as they like to say. They're just stirring up concern about this being a government entity because some people fear and distrust the government above everything.

[beccatoria.livejournal.com]

Thanks. As I said above this info really is helping. I'm so used to being a little above the curve in terms of general American Culture knowledge over here in the UK that it was...disconcerting to suddenly come face to face with something I flat out did not "get" on a very basic level. And I'm pretty sure now it that yes, that difference is the ways in which vocal parts of the country bitch about the government. Both hate it and think it's too incompetant to administrate a piss-up in a brewery, but in the UK that's usually met with righteous indignation and an insistance that the other side would do better, while in the US it's met as evidence that they should just leave them the hell alone?

Still though...I'd rather have someone elected by the people as that third-party rather than someone elected by a board of directors to make money. Fortunately, I don't seem to be alone in that view, and I very, very much hope you guys get something good out of this. I really believe the current level of healthcare many people are getting must be a violation of some kind of human right.

[coffeejunkii.livejournal.com]

as someone from europe who has grown up with state-sponsored health care, i do not understand this paranoia that many americans seem to have re: the government getting involved in health care. it will not be the end of america as we know it! ugh, so frustrating.

[beccatoria.livejournal.com]

No, neither do I! It's kind of why I asked. I'm used to, even when I don't understand on an emotional level or agree at all, at least have some technical understanding of the logic the opposition uses ot reach its conclusions, no matter how horrifying. But this is like...every yes/no question I ask gets answered with "Fish!" It's...disorienting.

[metatxt.livejournal.com]

YUP. Not only that, but the public option as proposed really is no different than expanding Medicare as an option for all citizens, rather than universal health care like the NHS. Far as I know, the only two changes this really makes is: access for all citizens + introducing competition in the insurance monopoly. Even though capitalism would assume that the insurance companies compete against each other, the only way they can quickly turn profit (rather than investing in patient health, predicated on longer-term returns) is through increasing denial of care.

And though I have dozens of critiques about capitalism as a system itself, even if you subscribe to capitalism, the big myth here is that the insurance industry can operate a for profit model with the same principles as say.... flower shops. Honestly, people who do believe in capitalism ought to be opposed to the health insurance industry as it stands, since competition is not between businesses, but between the industry and the consumer. Industries organized around human necessities will never have the same market threats guiding competition as less essential goods.

[beccatoria.livejournal.com]

I was at least aware that a "proper" universal healthcare system was not on the cards. :(

I also think that I'm getting a slightly better handle on it now that I'm factoring in the true extent of government distrust. I was thinking of it in UK terms which means, "Damn the government is incompetant and can't run the NHS properly. LET'S GET ONE THAT CAN!" rather than "LET'S PRIVATISE IT ENTIRELY!"

I also <# your comments about how the competition is between the business and the consumer. I already knew I thought it was a terrible way to run healthcare because an insurance company's vested interest is in giving you as little as legally possible; that's the business model of insurance companies, but I'd never seen it converted to that simple - and obvious but somehow easily overlooked - point that it puts the consumer in competition with the busienss.

(((poor americans)))

[greycoupon.livejournal.com]

*points to the people more verbose than I*

You forgot that doctors will make more money working at McDonalds.

[beccatoria.livejournal.com]

You forgot that doctors will make more money working at McDonalds.

*facepalm* Wow, that's a keeper. I hadn't actually heard that one before. I mean it is true I'm sure doctors make less here, but it's still a really well-paid job and competition to do it is fierce.

That said, I will not deny that actually a fair number of our doctors do come from abroad and part of that is, I think, to do with salary and how it's more in the private sector.

But there are plenty of british doctors who do stay with the NHS and it's hardly an indictment of an entire system. Especially since I think - and I may be wrong here - that it's not so much we're losing british doctors to places like America (thought hat happens too) but that we're losing them to our own private systems?

Which is another whole weird thing about this? People seem to think private healthcare is going to get banned or something? *sigh*

[sabaceanbabe.livejournal.com]

I'm glad you asked this question, Becka, 'cause I want to know, too, and I LIVE in the U.S. I have no clue what everyone is so worried about if we have some form of government-run health care. It CANNOT BE any worse than what we have now.

[beccatoria.livejournal.com]

(((hugs)))

Whatever ends up happening I just hope it's an improvement on what you guys have to put up with now. :(

[nightxade.livejournal.com]

More later since I'm not supposed to be on here at all but.. this was in the paper today. I only skimmed it, but something in a comment above regarding competition makes me think it may be relevant. Forgive if not.

http://www.nationalpost.com/news/story.html?id=1906549