Health Care on Less Than You Think: The New York Times Guide to Getting Affordable Coverage (tt) - Softcover

Fred Brock, a former business editor and current contributor to The New York Times, is the author of Retire on Less Than You Think (0-8050-7374-4) and
Live Well on Less Than You Think (0-8050-7725-1). He has previously been an editor and reporter covering politics, business, and finance for The Wall Street Journal, the Houston Chronicle, and the Louisville Courier-Journal. Now the R. M. Seaton Professor of Professional Journalism at Kansas State University, he lives in Manhattan, Kansas.

Chapter One
Spending More, Getting Less
 
The American health-care system is collapsing around us.
--FORMER SENATOR JOHN B. BREAUX
 
The health-care crisis that is engulfing workers is by far the most important and difficult domestic issue facing the United States today. According to a 2005 poll by the Kaiser Family Foundation, a nonprofit health-policy research group based in Menlo Park, California, Americans ranked health care behind only war and foreign policy--and just ahead of the economy--as the most important issue for the government to address. No wonder. Our system is in shambles, and the near-term prognosis for fixing it is not good. Workers whose insurance is provided by their employers face constant cuts in coverage and increases in costs that threaten their savings. The 76 million baby boomers are beginning to retire and are likely to stretch Medicare's budget to the breaking point; Medicaid, the government health-care program for the poor, is in critical condition in many states. Still more dire, the ranks of the uninsured--between 45.8 million and 81.8 million, depending on whether those with sporadic coverage are counted--continue to swell. Given the nature of the American political system, things are certain to get much worse over the next decade or so before they get better.
 
Understanding how we got into this mess is important to getting out of it, so this chapter looks at the broad systemic problems of American's health-care system. The central aim of this book, however, is to help you deal with the system as it is--not as it was or might be--so if you'd like to go directly to practical matters, skip ahead. You can always return to this chapter later.
 
How Bad Is the Crisis?
 
If you have a job and your employer provides comprehensive health insurance, you probably have access to pretty good care. You have some choice in selecting your doctor, you can usually get an appointment in a matter of days, and if you are hospitalized you can be reasonably confident your care will meet certain minimal standards. You also have some peace of mind in knowing that most of your medical bills will be paid. Yet that care is likely not as good as you have been led to believe. If you have a serious illness or accident, your pretty good health insurance may leave you responsible for some pretty big bills. America is facing a health-care crisis not simply because so many lack insurance; we have cobbled together an irrational and inefficient system that is filled with loopholes, obstacles, and unmarked hazards even for those with insurance.
 
Many Americans think our health-care system is the best in the world. Unfortunately, this is no longer true. For certain expensive, high-technology surgical procedures, medical care in the United States is unrivaled. But this is only a small portion of the overall medical picture. Much of the rest is an increasingly dysfunctional system the benefits of which don't come close to matching its outrageous expense. Its failure is not just hurting the health of our citizens but is a drag on our economy.
 
Because most people get health insurance through their employers, the spiraling costs of health care have been cited in layoffs, bankruptcies, and announcements of low profits or losses. The chief executive of General Motors--where annual health-care costs approach $6 billion or an estimated $1,500 per vehicle, more than the cost of steel--warns that "the health-care crisis is putting our future at stake." The chairman of Starbucks, whose company spends more on employee health insurance than it spends on the raw materials needed to brew its coffee, calls the situation "completely non-sustainable." The costs are squeezing American companies that compete with companies from countries whose citizens have guaranteed national health care that is less expensive and--better for the bottom line--not provided directly by employers. Toyota recently decided to locate a new plant in Canada instead of Alabama, partly because of savings the automaker will enjoy under that country's national health insurance. GM, which operates several plants in Canada, has lobbied the Canadian government not to change its national health-care system. As Dr. Arnold S. Relman, a Harvard Medical School professor emeritus and former editor of the New England Journal of Medicine, wrote in the March 7, 2005, issue of the New Republic, rising health costs "are threatening the financial stability and competitiveness of many American businesses and are discouraging the hiring of new full-time workers."
 
Employer-based insurance also has unpleasant consequences for workers. Those who would like to change jobs, retire early, or start their own business are often unable to do so because they fear losing health coverage or being unable to afford it on their own. (We'll look at the problem of so-called job lock and its consequences in chapter 3.)
 
To get a handle on how little we are getting for our health-care dollars, first consider infant mortality rates--one of several common, universally accepted measures for ranking nations on the quality and availability of their health services. According to the CIA World Factbook--yes, the Central Intelligence Agency, not some dewy-eyed liberal group--the United States' estimated 2005 rate of infant deaths per thousand live births stands at 6.5, giving 41 countries out of 224 a ranking higher than America. Even impoverished Cuba stands two notches above the United States, with an infant mortality rate of 6.33. Most industrialized nations have better infant mortality rates than America. Singapore tops the list at 2.29. As a whole, the European Union's rate is 5.1. Nicholas D. Kristof, an op-ed columnist for the New York Times, noted in a January 12, 2005, column that if the United States had an infant mortality rate only as good as Cuba's, we could save an additional 2,212 babies a year; with a rate as good as Singapore's, we could save 18,900 babies a year.
 
The more data you look at, the worse it gets. Life expectancy at birth in the United States stands at 77.71 years, ranking 47 out of 224 countries. Tiny Andorra tops the list at 83.51 years, with Singapore, Hong Kong, and Japan all hitting over 81 years, and the European Union, overall, standing at 78.3 years.
 
The World Health Organization ranks the United States thirty-seventh in terms of overall health performance; in fairness of health care, it ranks fifty-fourth.
 
A study published several years ago in the Journal of the American Medical Association by Dr. Barbara Starfield, a physician and distinguished professor at the Johns Hopkins Bloomberg School of Public Health, compared health conditions in the United States with those of twelve other leading industrialized countries. The United States ranked an average of twelfth for the sixteen health indicators examined. It was in last place for low birth weights, neonatal and infant mortality overall, and years of life lost. It edged up for life expectancy at the age of one for females (ranking eleventh) and for males (ranking twelfth) and for life expectancy at the age of fifteen for females (ranking tenth) and for males (again, ranking twelfth). At the time of the study, Japan ranked highest among developed countries in terms of health; France has since moved into that spot. Starfield points out that the United States tends to rank worse each year.
 
Starfield cited two causes behind America's poor showing: the huge numbers of people without insurance and a weak primary-care system. She said that while Americans without insurance, as well as many covered by Medicaid, are not getting good primary care, the same is true for a lot of people with insurance. That's because people often go directly to specialists. "We have a notion in this country that if you want to go to a specialist, you should be able to do that," she said. "In fact, that doesn't assure you the best care. Our research shows that the more specialists in a given area, the worse the health. The average person would have better health if he or she had better primary care instead of so much specialty care. Specialty care is important, but when it's appropriate." In her JAMA article, Starfield points out that of the seven countries in the top of the average health ranking, five have strong primary-care infrastructures. "Although better access to care, including universal health insurance, is widely considered to be the solution, there is evidence that the major benefit of access accrues only when it facilitates receipt of primary care," she states.
 
Other critics have cited the boom in managed care and health maintenance organizations in the 1980s and 1990s for reducing the quality of primary care by pressuring physicians to see more patients for shorter periods of time. Indeed, surveys and polls show substantial levels of dissatisfaction with the quality of the U.S. health-care system by both patients and doctors.
 
Here are some other health statistics that people who have always thought of American medical care as the best in the world might find jolting.
 
·           A University of California study projects that by 2013, one in four American workers under the age of sixty-five--nearly 56 million people--will be uninsured.
 
·           Nearly 20 percent--8.4 million--of the 45.8 million people the government says have no health insurance are children, according to the Robert Wood Johnson Foundation. The foundation says that 70 percent of the uninsured children would be eligible for free or low-cost coverage under Medicaid or the State Children's Health Insurance Program, know as SCHIP, but many parents are unaware of the programs or too overwhelmed by the paperwork and bureaucracy to apply for them.
 
·           Lack of health insurance causes 18,000 unn...