We Don't Have Grayson To Call Them Out On It Any Longer But Republican Health Care Is Still "Die Quickly"

This week NBC News and the Wall Street Journal released a poll showing Trump with an unfavorable rating from 46% of Americans and a favorable rating with 40%, an improvement for him since last month, but the lowest favorability rating of any president-elect about to take office ever. Although he's being installed by an antiquated, anti-democratic electoral college that should have been abolished at the turn of the century (the 20th Century), Trump actually lost the election to Clinton 65,844,610 (48.2%) to 62,979,636 (46.1%). Trump has no mandate to make any drastic changes-- not that that will stop him, of course.

And the first drastic change he and his party want to make is to health care. Everyone wants "change" but we'll soon see if the kind of change the GOP has been talking about-- basically, less health care-- is what Trump voters are going to feel comfortable with. As Steve Benen explained it, the long-standing difference between the progressive approach (embraced by most, but not all, Democrats) and the conservative approach) embraced by all Republicans, is that "Dems saw a system in which too many Americans paid too much and received too little, while the GOP saw a system in which Americans’ health coverage was too good and families enjoyed too many benefits." That second one takes a lot of tap-dancing to explain to constituents. Benen references an unremarkable right-wing backbencher, Bill Huizenga, from west Michigan who admits that when the GOP starts rolling back Obamacare parents will have to consider waiting and thinking about more carefully before bringing in their sick or injured kids for costly treatments.

The Republican congressman explained to the Michigan outlet that he and his wife thought about taking their son to the emergency room, but they decided instead to wait and gauge his injuries the next day, to see if the child’s arm improved. (It didn’t.) Huizenga sees this anecdote as a model for how the process should work on a more systemic level.

“If you don’t have a cost difference, you’ll make different decisions,” the congressman said, adding that financial burdens should be shifted to consumers because the current system “continue[s] to squeeze providers.”

Huizenga went on to say, “Way too often, people pull out their insurance card and they say ‘I don’t know the difference or cost between an X-ray or an MRI or CT Scan.’ I might make a little different decision if I did know [what] some of those costs were and those costs came back to me.”

This is not a new argument. Among Republicans, it’s not even unusual. It is, however, kind of terrifying.

I first started writing about this about seven years ago, right around the time former House Majority Leader Dick Armey (R-Texas) summarized the Republican position in just 17 words: “The largest empirical problem we have in health care today is too many people are too over-insured.” Two Republican congressman had a Wall Street Journal op-ed around this time making the same case: “When was the last time you asked your doctor how much it would cost for a necessary test or procedure?”

It wasn’t a rhetorical question. For most of us, if we have an ailment, we see a doctor and follow his or her recommendations. If physicians recommend tests they consider medically worthwhile, we naturally agree, knowing insurers will cover most of the costs.

And for Republicans, therein lies the problem. If the system shifted the cost burden away from insurers and employers and onto individuals and their families, the result would be amazing savings-- because consumers would seek and receive less health care.

The GOP idea, in other words, is to create a medical environment in which Americans are acutely aware of costs, to the point that we turn down recommended treatments. Our kid may have a broken arm, but can we really afford an emergency-room visit? My doctor says I need a CT scan, but can I really afford such an exam? My friend has a lump and an unsettling family history, but can he really afford to have it removed and sent to pathology? His spouse was prescribed medication by her doctor, but does she really have to take it or can she save some money by going without?

In the Republican model-- by GOP officials’ own admission-- these are the kinds of questions Americans should be asking themselves. Having excellent health coverage, Republicans argue, is a problem in need of a resolution. As the aforementioned Rep. Bill Huizenga (R-Mich.) put it, “If you don’t have a cost difference, you’ll make different decisions.”

As Republicans move forward with repealing “Obamacare” and looking for some kind of alternative blueprint, keep this simple fact in mind: much of the GOP is convinced your insurance is too good, and they intend to help improve the system by making your coverage worse.

I was delighted that on the same day Benen wrote that, Jonathan Rothwell, writing for Gallup about American healthcare inefficiency made the case against Obamacare that progressives have always made and that I wish-- futilely-- Republicans would adopt. The only social health insurance plan that actually works is single payer-- the polar opposite direction in which Trump, Pence, Ryan, Price and McConnell intend to take the health care system.

Rothwell starts from the supposition that "costs are increasing much faster than any incremental improvement in quality... From 1980 to 2015, healthcare expanded from 9% of the national GDP to 18%. Some of this is natural and good. The aging population requires more healthcare, and even modest economic growth has freed up spending power for healthcare. The problem is that the per-unit costs of healthcare-- actual procedures, visits with doctors, pharmaceuticals-- have all soared. So the question must be asked: Has it been worth it? I conclude not."

One way to evaluate advances in healthcare is to compare new treatments with the current standard treatments (e.g., how a new fever-reducing drug compares with ibuprofen) in terms of both costs and effects on "quality-adjusted life years." University of Chicago economists have done this for every healthcare advancement analyzed in medical journals since 1976. The results suggest that the quality-to-cost ratio has fallen. Most new treatments introduced since 1976 have lower benefits per dollar than standard treatments. Indeed, for typical treatments, quality advances were very modest (1%) but cost increases were substantial (8%).

One can see evidence of systemic healthcare inefficiencies in the general health of the U.S. population, which collectively is much lower relative to peers in other developed countries despite the U.S. spending about twice as much on healthcare on a per capita basis. Mortality rates, which remain high by international standards, have fallen since 1980, but most of the progress has occurred among infants and the elderly. The working-age population has seen little improvement-- and for whites and American Indians, there have been no gains in age-adjusted mortality for people aged 15 to 64, at least since 1999.

Even as Americans are living slightly longer, the quality of life hasn't necessarily improved for people of working age. For U.S. residents, self-reported health status has fallen among each age group between 25 and 59 since 1990.

Additionally, the share of the working-age population suffering from a disability that prevents them from working rose from 4.4% in 1980 to 6.8% in 2015, adjusting for age.

One reason for the decline in Americans' self-reported health status is the extraordinary inefficiency of the U.S. healthcare system.

It may be tempting to dismiss these poor health outcomes as driven by cultural or demographic changes, but the broadest evidence suggests this would be misleading. The fastest-growing minority groups-- Hispanics and Asians-- are typically healthier than whites and blacks. Moreover, compared with 1980, Americans are exercising more, smoking less and eating somewhat healthier diets, and they are less likely to be abusing drugs and alcohol. The exception is the rise of prescription opioid use and related abuse, but our healthcare system bears much of the blame for that.

On the cost side, it is easier to identify specific causes for rising inefficiency.

Administrative costs related to healthcare billing are astronomical (hundreds of billions of dollars annually)-- especially compared with other advanced countries, where single-payer systems streamline procedures. Compared with their Canadian counterparts, nurses in the U.S. spend an extra 18 hours per week on administrative tasks and clerical workers spend an additional 37 hours. In 1983, Medicare started requiring that medical service providers identify the specific diagnostic code (out of roughly 90,000 in the latest system) to get reimbursed. Complicating matters more, Medicare and private insurance companies have different billing, documentation, and submission rules and procedures, making it extremely difficult to create efficient software.

Even without a single-payer system, Congress could reform the medical billing system with the goal of creating a simplified, universal, digital process. The goal should be to require only the minimum information that is necessary to avoid fraud. Reimbursement should be based on reasonable approximations of the actual costs to providers in terms of time and use of equipment, and the application process for providers to become a qualified biller of either private or public insurance should be streamlined.

Another issue relates to competition. Consumer advocates at the Federal Trade Commission argue that state laws protect hospital monopolies and raise prices by blocking the introduction of competitors into the market, driving up costs by tens of billions of dollars. State licensing regulations restrict qualified healthcare providers-- like nurse practitioners and dental hygienists-- from practicing independently, as pointed out by the Institute of Medicine. Addressing these restrictions could reduce the costs of medical care.

There are other problems with the U.S. healthcare system. The complicated practice by which pharmaceutical companies develop new drugs and set their (often very high) prices continues to come under scrutiny and provides the opportunity for potential reform. Likewise, agencies are forbidden by Congress to explicitly recommend or deny public funding for treatments based on the most widely used quality-to-cost comparisons.

The overarching point is that the absurd inefficiency of U.S. healthcare is not necessary or permanent. The system we have now is harming us through its exorbitant costs and weak efficacy, which drive down economic growth and deprive future generations of greater prosperity.

If only Price, Ryan, Pence and McConnell weren't so deeply committed to the right-wing ideological frame for looking at this. The only hope that this change that's coming won't be change for the worse is if the one person on the team not wedded to the ideology, the captain of the team, somehow gets persuaded to do the right thing for the American people. I'd say the chances of that are one in a hundred-- which was about the chances he had of winning the Republican nomination and then the electoral college.

UPDATE:

"The law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread." – Anatole France

"The GOP, in its majestic equality, prevents the ill as well as the healthy from affording the care that they need to stay alive." - Alan Grayson