I’ve been thinking about the US healthcare system thanks to a fascinating Facebook discussion with other Stanford Medicine X epatients. Each of us are too familiar with the strengths and weaknesses of the US healthcare system and its mix of insurers: Medicare, employers, and private insurance companies.
My focus is this: whatever healthcare system we decide to have in the US, we need to be able to pay for it. The reality is that healthcare resources are not unlimited.
Whether or not a healthcare system is government run and/or devoted to serving the good of all people, the resources required to operate the healthcare system are driven by a free market. Governments and nonprofits fund only a small percentage of healthcare research and development. Healthcare providers still choose what type of work they want to do and where they want to live in order to enjoy life and perhaps support a family. For-profit companies still choose when and how to develop and manufacture drugs and technology, which are required to provide treatment and services. The government can’t afford to fund and/or control all these resources completely (even if some think it should).
Even if healthcare were universally acknowledged (and it isn’t) to be a basic human right, any comprehensive healthcare system will still have to ration healthcare services such as time with providers, technology, and treatments. As a metastatic cancer patient, I am acutely aware of the rising cost of cancer care. The drug keeping me alive would cost about $10,000 per month if I weren’t getting it free in a clinical trial. Even if we acknowledge that everyone deserves to receive the treatments they need, we simply can’t afford to treat everyone with leading edge medical care at those prices.
A good example of this quandary is the new drug Sovaldi, which offers a breakthrough and long-awaited cure for Hepatitis C. More than 3.2 million people are chronically infected with hepatitis C virus in the US. A cure with Sovaldi currently costs about $84,000 per person. A little math shows curing all the US patients would cost around $270 billion–and the cure is not permanent (people can get reinfected with the virus). Having health insurance cover that $270 billion could break the healthcare system and put premiums out of reach for many, no matter whether the system is structured as private pay, single payer (government health system), or a mixture of the two. So who gets the treatment?
Other countries with single payer, government-funded health plans solve this problem by limiting services they cover. For instance, the National Health Service in the UK will not pay for the lung cancer drug, crizotinib (approximately $10k/mo), even though the drug can give a small population of lung cancer patients years of quality time. When the government must consider how to use its resources to provide the best care for the nation as a whole, they decided the cost to keep that small group of cancer patients alive for only a year or two is too high. So people who can afford crizotinib in the UK pay privately, creating a two-tiered health system.
You can’t duck the issue by simply saying, “Get rid of the gatekeeper insurance companies.” Because healthcare resources are limited, and provided by a market economy, SOMEONE or SOMETHING is going to be the gatekeeper. Who should it be? Insurance companies? Government? Healthcare providers? Medical societies? Pharmaceutical companies? Companies that manufacture generic drugs? Research institutions? Individuals?
To me, the most important questions are these:
1. What guidelines should our healthcare system use to determine who gets healthcare, so that everyone is treated in the same fair and ethical manner?
2. Who gets to make and enforce those decisions?
You might want to learn more about these questions. The next person who declares bankruptcy due to a health crisis such as a heart attack or metastatic cancer may be you. Or your child.
Gray Connections 
One thing I would say is that the people paying for all of this are us. No matter if it’s health care corporations or drug companies it is a user pay system and whether we pay through taxes or through individual payments or insurance, the money all comes from patients always.
So it stands to reason that we as patients should have a voice in how the resources are allocated.
I am so glad that I live in a country where there is more control on the private and for profit part of the equation.
For example we have long term care homes that many complain about, but at least there are some regulations. In the private “retirement residences” where you pay the whole bill yourself the care can often be worse and only the rent portion (relatively small) is controlled at all. Money does not ensure better treatment and more care for the elderly. The prices are very high, and if you run out of money too bad. You’re out.
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Yes, the patients definitely need a voice in the process.
As the person who held power of attorney for both my parents, I know too well the costs associated with long term care of our elders. It’s a small comfort, but I believe many private nursing homes are Medicaid certified, and will allow a patient to remain as a Medicaid patient after their money runs out (I dealt with this). In the world of nursing homes, it’s essential to do one’s homework — the quality of care does vary a lot.
Unfortunately, money does seem to make a difference in quality of care in skilled nursing facilities. In recent years, Medicare and Medicaid have cut the amount they pay to skilled nursing facilities. Private pay facilities can afford to have better staffing. However, the staffing still doesn’t seem sufficient in many facilities. Residents who have family members checking on them often seem to get more attention.
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