Regarding Healthcare

The most fundamental point that I can make regarding healthcare and healthcare systems is that they require significant state oversight to maintain their functions. One can talk about “red tape” and the costs of regulations, as the CATO institute has, but it misses the overall point: the push to rid the U.S. healthcare system of government involvement creates perverse incentives, makes it less efficient and pushes a higher cost burden onto the consumer. Some industries shouldn’t be utilized through the private sector, historically this references the Commons and natural monopolies.

For the next 4-8 years, the U.S. is going to be subject to an administration that seems to reduce healthcare policy discussion to rhetorical buzz phrases: “Government takeover of healthcare”, “sell across state lines” and “promoting competition” are a few that are chaotically thrown around.

To be fair, Trump does have actual policy proposals for reform, but it’s a very truncated view and has been estimated by the Commonwealth Fund to increase out-of-pocket spending by  $2,500 on average. Regardless, the political hoopla over keeping or reforming/replacing the Affordable Care Act (ACA) doesn’t take enough into consideration;  a pro vs. con list isn’t going to get the U.S. system very far.

Instead, a comparative policy analysis that factors in as many variables as possible is what seems to be missing in the political landscape. This is where T.R. Reid’s book ‘The Healing of America: A Global Quest for Better, Cheaper, and Fairer Healthcare’ comes in. Mr. Reid’s book combines statistical information with personal experience because he actually went and visited hospitals in Germany, Japan, England, Canada, France and India to inquiry about his shoulder which was so severely damaged that it required a total shoulder arthroplasty; a procedure with an average cost of around $10,000.

A Few Problems With U.S. Healthcare

It’s important to identify a few essential problems with the healthcare system that’s currently in place so the realization for a change is understood:

• Between 1995-2007, the uninsured rate (non-elderly) was around 16% (KFF)
• 45,000 people die every year from lack of access to health insurance (Harvard, 2009).
• Compared to 19 other industrialized nations, the U.S. comes in last when it comes to Preventable Mortality–deaths that might have been prevented with effective and timely care (Commonwealth Fund, 2008).
• Despite being less efficient, the U.S. still spends 17.1% of their GDP on healthcare, vastly higher compared with other nations like France (11.6%), Canada (10.7%), or the UK (8.8%) (Commonwealth Fund, 2015)
• Most for-profit insurance companies in the U.S. have administrative costs between 15-20%. Comparatively, it’s 3% for the Medicare system and 5% for Britain’s National Healthcare Service. (T.R. Reid, pg. 38)

Overall, there are 4 different models that encompass the countries with an established healthcare infrastructure, all of which I’ll garner from Mr. Reid’s book. For a more succinct online reference, look here.

The Bismarck Model

Named after Otto von Bismarck, a Prussian chancellor in the late 1800’s who was mainly focused on building a unified, powerful German state. He despised the spread of socialism in Europe and worked to introduce health insurance and pensions.

This model is currently used in Germany, Japan, Belgium and Switzerland. These countries are similar to the U.S. in the sense that they utilize the private sector for financing healthcare plans. However, unlike the U.S., the industry basically functions as a non-profit charity. Even though hospitals and insurance companies are private entities, there are tight medical regulations which serve as cost-control mechanisms.

The Beveridge Model

Named after William Beveridge, a British economist and social reformer in the early 1900’s who galvanized the National Health Service. The NHS launched in 1948 and provides free healthcare that’s funded purely from taxation to about 64 million residents in the UK.

This model is used in Britain, Spain, Italy and most of Scandinavia. There are no medical bills and healthcare is treated as a social utility analogous to a public library. Most hospitals and clinics are owned by the government where the staff are government employees. There are some private doctors and insurance plans, but polls have shown that only about 13% of (mostly upper-class) citizens in the UK belong to these plans. The exorbitant prices of these Private Medical Insurance plans are the main self-reported deterrent for individuals not subscribing to them.

The National Health Insurance Model

This is a blend of the Beveridge and Bismarck model: the payer is a government-run insurance program where every citizen contributes, but the providers are private. It’s mainly used in Canada with Australia, South Korea and Taiwan adopting some of the tenets.

With no need for marketing, profits, or offices of people who contribute to high administrative costs by denying claims, this system tends to be much cheaper than America’s for-profit system (T.R. Reid, pg. 19).

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By mentioning Canada, I feel obligated to write a quick rant about the waiting times argument because it’s often brought up as the holy grail of counterpoints.

First of all, it’s worth mentioning that the ostensible influx of Canadians migrating to the U.S. for healthcare is an exaggerated myth; from the source:

“This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients’ dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross-border flow of care-seeking patients appears to be very small.”

Secondly, the dreaded wait times are mostly for non-elective procedures; anyone that requires urgent care can get it (T.R. Reid, pg. 130). The wait times are also partially attributed to choice; Canadians voluntarily choose not to spend more on their healthcare system which would result in decreased wait times. Canada spends about 10.4% (2012) of their GDP on healthcare, up from 8.9% in 2002 so there’s legitimate cause for concern.

Lastly,  Americans are more frequently observed as heading north for cheaper drugs or treatment compared to their Canadian counterparts (T.R. Reid, pg. 130).

The Out-Of-Pocket-Model 

To put it bluntly, this is a system where the wealthy receive medical care and everyone else stays sick or dies. This is mostly seen in rural regions of India, Africa, South America and China where millions will go their whole lives without ever seeing a doctor. As a result, these are regions where people are forced to rely on unsubstantiated alternative medicine for their main method of treatment.

Out-of-pocket spending accounts for 91% of health spending in Cambodia, 85% in India, 73% in Egypt, 17% in the United States and 3% in Britain (T.R. Reid, pg. 19-20).

So which system does the United States use? Well, it’s complicated. From page 20 of T.R. Reid’s book:

• For most working people under 65, they use the Bismarck Model.
• For Native Americans, military personnel, and veterans, they use the Beveridge Model.
• For individuals over 65, they use the National Health Insurance Model.
• For the 45 million uninsured Americans, they’re Cambodia.

With these 4 systems in mind, which one should the U.S. adopt? Should we keep the system we have now where a myriad of for-profit insurance companies contribute to an inefficient, bureaucratic system? Yes, that’s a loaded question fallacy, but it doesn’t make it untrue.

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My personal, opinionated solution is to adopt a “health care for all” single-payer system. Physicians for a National Healthcare Program have a detailed FAQ on their website that addresses a lot of the common objections to this model.

I think this country would benefit immensely from a healthcare system that has been proposed by Vermont Senator Bernie Sanders.

Although a 2015 Center for Medicare and Medicaid Services report highlighted that healthcare spending is about $3.2 trillion/year, Bernie’s plan posits that it can reduce this spending by $6 trillion over the next 10 years. Admittedly, it’s not very clear on his website on how these savings will be accomplished. However, his recently published book ‘Our Revolution: A Future to Believe In’ paints a more lucid picture.

From page 324-325 of the book:

“Private insurers’ overhead currently averages 12 percent, as compared with only 2.1 percent for fee-for-service Medicare. The complexity of reimbursement systems also forces physicians and hospitals to waste substantial resources on documentation, billing, and collections. As a result, U.S. healthcare administration costs are about double those in Canada, where the single-payer system pays hospitals global budgets and positions via simplified fee schedules. Reducing U.S. administrative costs to Canadian levels would save over $400 billion annually.”

 I think the $400 billion number by solely adopting Canada’s system is overestimated, the closest number I found was in a 2014 Commonwealth Fund study which concluded that reducing our administrative costs–costs that also have no link to higher quality of care– to Canadian levels (2011) would result in $158 billion annual savings. The PNHP FAQ sourced above corroborates this by stating the U.S. would save $150 billion a year.

Reducing administrative costs to the Medicare level of 2.1%, however, would certainly get the U.S. to the $400 billion number. The New England Journal of Medicine did a study that found replacing our for-profit, multi-payer system to a national health program would save $320 billion in administrative costs.

These savings are combined with the following revenue-raising taxes:

• 6.2% income-based health premium paid by employers ($630 billion/year).
• 2.2% income-based health premium paid by households ($210 billion/year). Also, any household making under $28,800/year wouldn’t pay this tax and households making $50,000/year would only pay $466/year under this plan.
• A progressive income tax ($110 billion/year) which includes the following:

1. 37% on incomes between $250,000-$500,000
2. 43% on incomes between $500,000-$2 million
3. 48% on incomes between $2-$10 million (this only affects 113,000 households, or 0.08% of the taxpaying population)
4. 52% on incomes above $10 million (this only affects 13,000 households, or 0.01% of the taxpaying population)

Also thrown into the mix is taxing capital gains, limiting tax deductions for the rich, and an estate tax which combines to $128 billion/year in revenue raised. Add all of this together combined with the savings listed above and you have a grand total of $1.398 trillion which pays for the $1.38 trillion cost of implementing this system.

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With all the dry economics out-of-the-way, I think the moral imperative of our system lacking healthcare equity is the heart of the issue . Alleviating the burden of healthcare costs for the poor, working class people who need it the most is an accomplishment that we should ultimately strive for. Currently, medical bills are the number one cause of bankruptcy in the United States. This unnecessary stress on our nations poorest people, which leads to higher vulnerability to diseases later in life, is something that our policy makers are exacerbating as a matter of choice.  That is simply immoral and a systemic failure.

Poor Americans live in areas with worse air quality which can lead to a litany of problems like  lower birth weights, kidney problems and even an increased propensity for heart attacks and strokes. All of this leads to an estimated 470,000 deaths per year and perhaps even millions when different factors are included, from the study:

“Using simulated concentrations for 2000 and 1850 and concentration–response functions (CRFs), we estimate that, at present, 470 000 (95% confidence interval, 140 000 to 900 000) premature respiratory deaths are associated globally and annually with anthropogenic ozone, and 2.1 (1.3 to 3.0) million deaths with anthropogenic PM_2.5-related cardiopulmonary diseases (93%) and lung cancer (7%).”

Until we get a strangle hold on man-made pollution, these problems will continue to persist and intensify.

A Change Of Culture

Americans today are seeming to become increasingly hostile towards the mere mention of any sort of tax increases regardless of context. We seem to view the government as a school yard bully who takes our lunch money; this is true in some areas. For example, The Army Corps of Engineers spending $74.5 million on an unused airport and $29 million on a harbor with no roads connecting to an Alaskan town of 75 full-time residents.

Healthcare isn’t one of these areas. As I’ve explained above, in the context of healthcare, the for-profit, private system is actually less efficient, less equitable, more bureaucratic and wasteful than the government. As a nation, we’ll simply have to do the hard work and look at the profound long-term benefits of a meager tax increase for a single-payer system. If we don’t, the U.S. will continue to fall further and further behind other developed nations in all categories of health.

Let’s talk efficiency

I’m starting to notice a lot of people use the word ‘efficiency’ in a very narrow reference. The word is most often used when trying to compare the idealized free market to the government. For example, the free market system is more efficient than government because it has built-in incentive structures such as appeasing stockholders, pressure from competing companies and the necessity to remain profitable. These are seen as intrinsically positive and more efficient than government because the public sector doesn’t have to worry about a bottom line  so they’re ostensibly careless with their funds. However, if I wanted to use that same logic I could argue that the government has a strong incentive to use taxes efficiently in order to avoid raising them considering  that 57% of Americans think that their federal income tax is already too high. Or I could highlight the Economic Policy Institute findings which show that millions more would be in poverty without government programs. Debating within these narrow parameters–parameters which dominate political discourse at the moment–is a false duality and will just lead down a rabbit hole that solves very little. We need to have a more tangible, scientific view of efficiency that addresses structural problems with respects to sustainability. Utilizing the scientific method in tandem with psychosocial  and environmental considerations is a good way to reference efficiency.

In Zeitgeist Movement circles, they like to differentiate between what they define as market efficiency vs. technical efficiency. I don’t want to use too much loaded language here, but establishing the foundations of this particular train of thought is important.

Market efficiency is mainly grounded in economic theories that are predicated around the assumption that anything promoting monetary growth & profit is efficient. Basically, anything that fosters GDP growth, lowers employment numbers, or shows optimistic PPI outlooks is interpreted as efficient because it yields positive results on the stock market. Other people may have different perceptions of market efficiency, but that’s how I see our most market-successful industries discussed in common conversation.  Unfortunately, these figures are erroneous and don’t address the real world; look here for a more sophisticated way of referencing societal well-being. These include time use, community vitality and good governance. Another exemplary example is the study comparing the low-income population in Costa Rica and the United states. The study highlights that poor Americans under 65 die at a rate 3.4 times higher than the rich while the rate is only 1.5 times higher for Costa Ricans. This is despite the fact that Costa Ricans are about as poor (referencing GDP/capita) than Iraqis. Universal healthcare probably plays the biggest role in mitigating the poor health of low-income individuals, or so I would assume.

Technical efficiency refers to using natural laws (which we are all bound by) in order to reduce waste, promote public health, and economically optimize our industries in the most logical way using scientific and technological applications. If we understand efficiency in this context we should realize that the contemporary free market system is in direct contradiction to one of the core principles that justify its own validity. Of course, not every conceivable technological advancement can be brought into fruition. This is where I separate myself from a lot of extreme futurist thinkers. They seem too focused on the theoretical–instead of scientific– capacity of existing technology. While this is fun and we should of course consider these, it’s easy to get carried away and completely ignore physical resource limitation. I will try to curtail this post around technical efficiency that’s tangible, but ignored by our current market efficiency logic that financially rewards obsolete products.

Negative Market Efficiency

A recent report sponsored by the UN found that virtually no industry would be profitable if environmental/natural capital costs were included; capital costs are defined as

 “those which are non-renewable and traded, such as fossil fuel and mineral ‘commodities’; and those which provide ecosystem services (renewable goods and services), and for which no price typically exists, such as groundwater, biodiversity and pristine forests.”

We are haphazardly destroying our ecological biodiversity for mere market gains. Some highlights of the report include un-priced natural capital costs such as

• Green house gas emissions
• Water and land use
• Air, land and water pollution
• General waste

The estimated total cost of these unaccounted externalities is $7.3 trillion, or 13% of global economic output in 2009. These natural capital costs that pervade our current economic model are a catalyst for the destabilization of the environment; this surely doesn’t seem efficient or optimal. The study recommends that companies and governments pursue internalizing these costs and focus on more on natural capital assets.  I would agree because this natural capital which factors environmental degradation is the only sustainable way to think about our economy. However, I admit this will be nearly impossible to pursue because of the underlying necessity to remain profitable in the sort of market-efficient logic that permeates our system at the moment. This example is one of economics, let’s look at a more human and psychosocial consequence of this market efficiency logic.

Most people are aware of the competitive ethos that is necessary in order to survive in Western society. This competition makes itself present in the market sense and in the human sense. The market manifestation of competition can create perverse incentives that plague critical fields such as mental health. Eric R. Maisel explained this in an article in Psychology Today. Eric made the observation that

“a mental health professional has a real incentive to support a system that helpfully creates mental disorders and clients or patients.”

This is because the workers in this field need a steady flow clients in order to sustain a living for themselves. I wouldn’t suggest a  conspiracy theory and claim that the mental health system is doing this intentionally; they’re simply playing by the market rules while still trying to perform a social service. From a technically efficient point-of-view, they would seek to provide a sort of stress relief that contextualize the patients specific behavior/lifestyle rather can doing a by-the-book checklist and diagnosis. These aren’t my words, they are the authors. I have no experience in the field so I’m not going to throw in my opinion on the solutions.

The story of Antony Breeze encapsulates another, albeit isolated example of the economic and social stress that is brought on by competition. Antony committed suicide after being bothered by loan sharks for a £1,600 debt. This is a relatively small amount considering the average British citizen was £8,431 in debt two years prior to the Antony story. Mr. Walsh, the deputy coroner, described Antony in a statement

“He was anxious to provide for his partner and his daughter, and he was a good man who provided for them. He was a man who had everything to live for and he was always looking forward to the future as a family unit.”

 Unsurprisingly, this was just an honest man who was socially pressured into making a couple of regrettable decisions. I’m cognizant of the fact that–in a limited sense–he is personally responsible for amounting that personal debt. No one literally forced his hand into signing *insert debt-bonding document here* that lead to Antony’s inevitable stress. Much could be said about how this particular point-of-view doesn’t address how our current debt-based system that revolves around fiat currency encourages this sort of behavior in order to keep the machine running. With our current system build upon these foundations, it’s no mystery why many feel the necessity to go into exorbitant amounts of debt.

A Quick Side Note

A precursory step towards technical efficiency would be embracing and implementing the idea of a Universal Basic Income (UBI) which has a simple definition: a guaranteed income to every citizen with no work requirement or any other sort of test. I view UBI as more of a future inevitability rather than a pie-in-the-sky social or moral justice theory. This is because of the nearing technological unemployment phenomenon that will slowly engulf the menial, mechanical jobs. A 2013 study by Oxford researches concluded that around 45% of American jobs are under threat of automation in the next 20 years. Although data is sparse on UBI, we do have a few examples of it being implemented. Medicine Hat, a small city in Canada with a population of 60,000 (2011 census), decided to give the residents a UBI. They managed to house 885 of the cities 1,000 homeless people. This housing also saved an estimated $65,000/person in annual care costs according to Human Services in Alberta, Canada. This is because simply providing free housing/free money lessens the health impact these homeless people endure, thus alleviating some of the financial burden on the healthcare system. This UBI idea will become necessary if we want society to keep functioning while still pursuing technical progress in separation from the market logic. Many more caveats need to be explored with this idea, but I want to stick to talking about efficiency in this post.

Technically Efficiency: A Few Examples

Electric vehicles have a messy and complicated history. With its conceptual origins at the beginning of the 19th century in the United States, the Netherlands, and Hungary; it was France and England who developed the first workable electric vehicle around 1890. The electric vehicles in those times were horseless carriages that topped out at 14 MPH and only lasted about 18 miles. Continued developments continued to progress up until about the 1920’s. What happened then? Well, the need to travel long distances brought upon by a more efficient system of roads that connected cities needed to be met. These aforementioned roads required long-distance vehicles which couldn’t be met by the electric vehicles at the time. They were outperformed by the gasoline-powered vehicles that were necessary for progress at the time.

Roughly 90 years later, we now know that the electric vehicles are once again able to be utilized in a beneficial way. A recent MIT analysis concluded that

“Roughly 90 percent of the personal vehicles on the road daily could be replaced by a low-cost electric vehicle available on the market today, even if the cars can only charge overnight.”

This will become necessary if we hope to make a reduction in carbon emissions. The standard criticisms are still being thrown around about electric cars: not enough range, unsafe batteries, electrical grid overload, too expensive, etc., but an array of academic research can abate those fears. Electric cars, like anything, aren’t perfect. However, not pursuing this technological progress because of general market concerns for dropping profits is illogical.

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According to the Food and Agricultural Organization (a branch of the UN), around 11% of global land surface is being used solely for crop production. Our agriculture is also responsible for using 80% of the United States consumptive water use, meaning water withdrawn from water sources such as a lake, river, or aquifer. This massive waste is unsustainable and inimical to our ecosystem. It’s unsustainable because the FAO estimates we need around 300 million more acres of arable land–land capable of growing crops–to keep up with food production demands by 2050. Most of this land is in developing countries which, if used for crop production, would cripple their other ecosystems and economies. This is why we need a more technological focus on farming that can localize (the FAO recommends moving toward a global trading system that is “fair” and “competitive”, but this seems like an ambiguous solution that doesn’t really address the long-term ecological problem) all types of foods and rely less on globalization. Fortunately, we have a solution that’s been around for longer than most people think: vertical farms. The term was coined in 1915 by Gilbert Ellis Bailey in his book Vertical Farming  which detailed the crude origins of the farming method. The modern definition of vertical farming is the use of hydroponics in multi-story greenhouses. These buildings would eliminate the massive land/water waste used by our current farming methods. Vertical farms have been shown to use 95% less water, according to David Rosenberg, co-founder of AeroFarms. They also have the ability to be unaffected by weather which can cripple land-farms during periods of droughts or floods.

I can sense alarm bells ringing in some people, greenhouses are electric-intensive and simply not feasible on a large-scale because of the cost, right? Probably not, according to Dr. Dickson Despommier. He argues that the higher costs (mostly LED lighting) are offset by the elimination of farm equipment, transportation costs of produce into cities–FAO estimates that by 2050, 80% of the population will reside in urban environments–, and the elimination of fossil fuels in fertilizer which runoff into coastal waters causing environmental havoc. This is all despite the fact that profound developments are being implemented which reduce these electrical costs. Even after all this, I must concede that no study to my knowledge has been done quantifying the potential cost comparisons of a vertical farm building with the elimination of conventional farming methods.

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Another thing that typically goes unquestioned or unchallenged in the market environment is the concept of ownership. In the TZM link listed above, they frame this as Property vs. Access. It’s essentially the concept that, from a technically efficient perspective, ownership of some utilities or goods is illogical. Most understand this concept in the view of libraries that give you access to resources such as books, magazines, etc., rather than owning these of part of your permanent property. Most don’t bother extending this logic into other commodities. For example, it’s more efficient in a market sense for 50 people to be driving 50 cars. This drives GDP, employment, and other technically non-contributing measurements I mentioned in the initial paragraphs to this post. Personally owned vehicles sit idle much longer than they are actually driven. Wouldn’t it make more sense to design a system that forgoes ownership and embraces utility based on measured time use? As an essay in TZM defined explains:

“If we analyze patterns of actual use of any given good on average, many types of products are found to be used intermittently. Transport vehicles, recreational equipment, project equipment and various other genres of goods are commonly accessed at relatively distant intervals, making the task of ownership not only somewhat of an inconvenience given the need to store these items, but also clearly inefficient in the context of true economic integrity, which seeks a reduction of waste at all times.”

From this they conclude:

“So, from the standpoint of technical efficiency, at the deep expense of market efficiency, a shared access rather than universal property oriented society would be exceptionally more sustainable and beneficial. Of course, such a practice would naturally challenge some deep value identifications common to the ‘propertied’ culture today”

I think the last sentence really poses the greatest challenge in adopting goods-sharing society. The cultural (I’m mainly talking about the U.S. and major Western European nations here) market system that value ownership and property regardless of context would be a hard thing to change. This value system relies mostly on flimsy, individualistic justifications such as personal freedom; having stuff for the sake of having it is a good enough reason for a lot of people. Personal freedom would not be sacrificed in a sharing system. In fact, about 500 cities (mostly in Europe) now have bike-sharing programs and it doesn’t seem that many people have a sense of lost freedom because of them. Most cities have actually seen reduced bicycle theft and vandalism while reducing the cost for the average consumer.

The Big Picture

I’ll try to wrap this up with some overall points of concession and clarification. I’m not saying that discussing the roles of governments and markets aren’t worth having, but they shouldn’t be at the forefront of how we look at the world in respects to efficiency and problem solving. I’m also not saying that these solutions would be perfect and bring about a utopia; the train of thought is the focus here: technical efficiency over market efficiency.

What I am saying is that government vs. market conversations don’t address the structural and technically focused view that is necessary if we ever hope to identify root causality with issues such as climate destabilization, income inequality, or any other bio-psycho-social problem I mentioned above. Also, the solutions that I referenced aren’t anything new or profound, it’s all being developed and discussed in the academic world but being ignored by most economically powerful institutions. This is why I went to great lengths to incorporate quotes, cite sources, and define terms because I’m not pretending to have some hidden knowledge that puts me on a pedestal above anyone else. All ideas and information originate from something else. No person is the sole arbiter of any idea or thought; there’s always some prior reference point for anything. This why the legal concept of intellectual property  is largely unhelpful because of the inherit market incentive to conceal new technological developments or ideas. Overall, most of our market institutions are unable to look past the very near future and completely disregard social and environmental factors in pursuit of monetary gain.

There are exceptions as Manoj Bhargava, founder and CEO of 5-hour Energy, showcases in the documentary Billions in Change. This is a massive company ($1.25 billion in annual sales) that is still involved with pursuing seemingly radical, technically efficient things such as free electric and limitless energy.  Manoj gave away about 99% of his fortune (which still leaves him with $40 million dollars, hardly roughing it) to charity by signing the Giving Pledge, a program started by the Gates family. If every CEO and corporation had this sort of ego-less social awareness, we could be miles ahead of where we are now in terms of technological capacity and ecological sustainability.

And that is the overall point: educating people on the ecological and technological benefits of escaping the market-centered way of thinking about the world. We need to think about and change our institutions in a vastly different way; a way that doesn’t involve corporate or government coercion. I just happen to believe that these trains of thought are a good starting point.