Friday 30 June 2017

Peculiar Institution

The American healthcare system is a moral abomination and a practical failure. This matters to me for personal reasons. For the world at large, it's a human tragedy; and a cautionary example of where bad policy decisions can lead, and how difficult they are to undo.


I am a bioinformatics software developer married to a US citizen. For professional and family reasons, it would make sense in many ways for me to live and work in the USA. But I refuse to entrust my life, and my family's lives, to this outrage that masquerades as a system of health care.

More capable commentators than me have explained in detail what is wrong. I'm just going to review the highlights. Of course US health care has been broken for a long time; but in important respects it is getting worse or at least more visible.

This is a country where begging strangers to pay for life-saving medical care has become big business.

Consider this well. If you're a cute little kid with leukaemia, you might have your treatment funded. Maybe. If you're pretty enough, and your parents are media-savvy enough, and you're lucky. The real winners are the crowdfunding sites, which take anywhere from 3 to 7 percent of donations as an administration fee. Total donations are reported at $3 billion per year, on GoFundMe alone.

If you and your illness are not sufficiently marketable, crowdfunding is not a viable option. You're left with an unreliable patchwork of government assistance and private insurance.

Obamacare was an attempt to fix the most egregious holes in the system, using the policy equivalent of plywood and duct tape. Better than nothing, but still not good. It has not eliminated the desperation which motivates crowdfunding. The uninsured still number 28.4 million.

That is not a trivial number. It's more than one in ten of the working-age population. Even those with "good" insurance have to fear losing that insurance through unemployment, or that their insurer will refuse to cover some needed procedure. At best, paying for medical treatment requires a great deal of bureaucracy and form-filling, by sick people and their families.

Now the Republicans are preparing to repeal important elements of Obamacare. The Bill before the Senate doesn't even pretend to address the many problems of the US health care system. It strips away health coverage, and gives a tax cut to the rich. That's all.

How many people are "uninsured" in the UK, Canada, Germany, or any other rich nation? Zero. In these countries health care is viewed as a right, not a luxury. Medical crowdfunding is nearly unheard of. The UK National Health Service has its faults, to be sure; but if you need medical treatment, you will get it, regardless of ability to pay. This is a great thing, but it's not exceptional; every other rich country in the world has a similar system.

As a child in Canada, I heard about the fear of unpaid medical bills from American television and films. It was a plot point in fluffy comedies like Ghost Dad (1990). It's like fish not having a word for water; it was just part of the background, something taken for granted as part of American life. I was young, but not too young to be very glad it didn't apply to me.

Why is the USA different? Does it save money? Does it reduce public spending? Does it produce better healthcare outcomes overall?

The answer is no, on all counts:
  • Life expectancy at birth in the USA is 78.8; UK 81.4; Canada 82.2.
  • Infant mortality per 1000 births in the USA is 6.0; UK 3.9; Canada 4.8.
  • Annual spending on health care per capita in the USA is $9451; UK $4003; Canada $4608. That's right; the USA spends more per person than the UK and Canada combined.
  • Annual government spending on health care per capita in the USA is $4672; UK $3163; Canada $3262.
It doesn't save lives. It doesn't save money. It doesn't even save public money. So why do it?

The main answer I can see is sheer institutional inertia. The USA does it this way because this is the way it has been done; because people fear change, in case it makes things worse; and because certain individuals and companies are making a lot of money from the system the way it is.

The human cost is incomprehensible: Not just in illness and death, but in financial hardship and the stress of dealing with a broken healthcare system. The nation which aspires to lead the world has made itself an object of horror and pity. To an outsider, it looks as cruel, pointless and wasteful as Chinese foot-binding or the Aztec rite of human sacrifice.

Some optimists hope the current situation will be a tipping point; that a critical mass of the American people will see how wrong and unnecessary the current system is, and demand fundamental reforms. I wish my American friends and in-laws all the best, but I am not much of an optimist. Meanwhile, the USA is a great place to visit, but I wouldn't want to live there.

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