50 Meds for a Sick Health System

By Randy Stapilus

America's health care system is bankrupting its people, businesses and society while it both over-treats and under-treats, with poorer results than in most of the industrialized world. Its ills are so many there is no single cure. But there are many things we can do, and this book includes 50 of them. American health care can be better than it is now. This book was written before passage of the Affordable Care Act, and includes a few ideas which were built into it - and many others that were not.

• Language: English
• Publisher: Randy Stapilus
• Release date: May 29, 2012
• ISBN: 9781476492704

Randy Stapilus

I'm a journalist - editor and publisher, in my meaning of the words, which have changed in connotation a lot over the years. I worked for 15 years as a reporter and editor for daily newspapers, and since then have published monthly periodicals on Northwest politics and public affairs, and on the subject of water rights.

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Introduction

All great truths begin as blasphemies. - Oliver Wendell Holmes, Sr.

Who am I to talk about how to solve the health care mess? I'm not a doctor or lawyer or politician.

Well, who do you have to be? Most of those people with lots of expertise come at the issue by looking through a particular lens. A doctor's perspective will be a lot different from a lawyer's, which will vary from a politician's or an academic's. Remember the old quote from Upton Sinclair: It is difficult to get a man to understand something when his salary depends upon his not understanding it.

Maybe this needs to come from a non-specialist.

I'm a journalist, which gives me no medical expertise. To be clear: Nothing here can or should be considered any form of medical advice.

But it does give me some experience in information gathering and analysis, and in watching how governmental and private systems work. And it is those systems we're mostly talking about here.

Consider this a collection of ideas - broad-based, with recognition that we have not one problem coming from one source but many problems coming form many sources - that might realistically help us hike out of the dark health care forest we're in now.

Ideas are circulating out there. Most politicians worth their salt will mention a few. There has been an explosion of terrific reporting and analysis about our health care troubles in the last decade, but valuable as much of it has been, most of it has focused on the nature of the problem and trod lightly when it comes to solutions. Many of the best works do include suggestions, but they tend to be lost in the mass of text and data, and much of it is scattered or hard to find.

Most of the really visible discussions of health care policy, sadly, have concerned either ideological chatter or broad brushes, or focused on a small handful of ideas, while the larger picture goes unmentioned. Solutions large enough to matter, while narrow enough to be concrete, visible and easily grasped, often are bypassed.

The specific ideas for fixing health care in America are usually buried leads.

There is, of course, no lack of scholarly studies, some of which point directly toward useful ideas. But few people outside the realm of the scholars will ever read them. The National Conference of State Legislatures in 2003 actually developed a list of 50 ideas to help cut health care costs; it is posted online and has plenty of useful material. But it is obscure (have you ever heard of it?), and not even formally endorsed by the NCSL but only by one of its committees. Most of the ideas brought forth visibly in recent years have grown out of agendas that have little to do with health care. And many of the problem-solvers point to just one component of the problem, sometimes taking on one villain. In some cases, useful ideas have emerged this way, but bypassing much of the extended (problem-strewn) waterfront.

The object here is to pull together an array of ideas, from across the spectrum (no one person or side has a monopoly on reasonable ideas) that suggest at least how we might think about repairing what's broken.

And be blunt about it.

The criteria: What are those things that we can specifically, concretely do that would be likely to have a major effect on repairing our health care cost structure while improving or at least not harming (do no harm) health care delivery?

A few of these ideas I've not seen noted elsewhere, but I doubt any of them are original with or unique by me. (In most cases I cite people or organizations who have written about them or proposed them before.) A number have been cited in scholarly, governmental, or other reports frequently though they receive little public attention. A few are more broadly discussed.

There are not just 50 things we probably ought to be doing; an exhaustive list would be much longer. And among other considerations, this one specifically does not zero in on handling of treatment for any specific ailments.

Nor, with a few exceptions, are these 50 tasks individually essential. And for the most part, they are not inter-dependent; you don't have to do them all to get benefits from those you do.

But these are the kinds of things that have to be done if we're going to get serious about one of the true crises of our time.

My story

We all come at this thing from particular points of view; we all have stories to tell. Individual experiences differ widely, of course. Your story will vary from mine. But here's some of what informs my thinking on our health care situation.

By way of context, I'm medically uninsured.

That wasn't always the case, even for a number of years after launching my independent business, but eventually in the 90s the rapid rise of premiums at multiples of the inflation rate caught up with and surpassed us, as it has so many other people. (When we once asked why our rates were being raised so high and so often when we'd never put in a claim, we were told those increases were the maximum the state allowed - and the company, as a matter of policy, went for the max.) We wanted to eat, have a roof over our heads and operate our business; one or more of those things would have had to go to keep health insurance.

Not that insurers were clamoring for our business; although our health has been excellent (with the one recent exception I'll get to), we have been (like you too) moving on in years. Even without those notorious pre-existing conditions, we were an expendable part of the insurance system. Such limited competition in the world of insurance as does exist did us no good, and we can't easily imagine how it could absent the kind of really rigorous regulation that would utterly change the industry's practices. Reality is that the competition in health insurance is not for customers, who the companies have been mostly eager to shed (how many ads do you see from health insurers looking for customers?). The competition is for raw profit and stock price, and that competition does neither the uninsured nor even the insured much good. (You could reference here the endless stories of people who are insured and nonetheless medically bankrupted.)

So don't bother suggesting, in reading the following, that, well, I should've been insured. As a matter of economic incentives, it still would have made no sense: I would have paid vastly more in premiums over the last few years than I wound up owing. So far at least, for me, not being insured was the correct dollars-and-cents choice.

One Sunday afternoon in late June 2008, I collapsed at our house, with loss of breath and suddenly diminished energy. It was out of the blue. The docs never did figure out conclusively exactly why it happened, though they did work out the what.

My wife called the local ambulance. She did not pull out the phone book or get on the web to check out various options, as the marketplace theory would suggest a customer operating in economic self-interest might do. For one thing, there was no time. Besides that, there was no choice: As in most places, just one service was available. Take or leave it. The ambulance arrived quickly, the personnel were solidly professional and they did their job with speed and effectiveness. But there was no meaningful choice about the ambulance. You want a ride? You're dying here, and you want health care? Then you owe $1,100 (which had to be committed to, blindly, up front, undisclosed to the payers - us - until weeks later). Take it or leave it. Your money or your life. Literally.

Bigger bucks came into play on arrival at the hospital. There was no question about which hospital it would be; it would be the one closest. That was the only choice. There was no marketplace decision. Nor any shopping around for doctors, either. The doctors would be whoever was on duty. Choice? Marketplace? Sounds fine in theory. But when you're gasping for breath, and your wife is watching your fingernails turn blue, comparative shopping is not on the agenda.

I must say up front that, notwithstanding the many medical horror stories about how dangerous hospitals are, my case was handled effectively. I was quickly and accurately diagnosed - a double pulmonary embolism - and the treatment there of an imminently life-threatening condition resulted in recovery (and yes, I've felt fine since). Genuine medical knowledge and skill were on display; fortunately, my case wasn't something out of Steven King. I got well.

But a thriller of another sort was unfolding. On arrival at the hospital, my wife was informed she had to sign a series of forms for me to receive treatment there. One of them committed us to pay for whatever treatment was administered. It was a blank check, and she was pressured hard to sign it, which she did. Your money or your life. What might have happened had she not signed? She didn't dare find out. The metaphorical loaded gun was pointed at my head.

From there I received whatever treatment a doctor (sometimes presumably a nurse) decided I would have. Did I need them all? Almost certainly not. (Someone, of course, was making some degree of profit on every one.) Had we been consulted and given detailed information about cost, necessity and efficacy, the costs could have been cut greatly. (Public policy suggestion, a few chapters ahead: Require such talks with patients, insured or not, with the point made that you never can predict with total certainty what the insurer will wind up covering.) Neither my wife nor I ever were given any significant opportunity to question these bills as they were being racked up. When we did ask, we got no answers - only reassurances that all would be well. No dollar amounts were disclosed - until after I was released from the hospital.

There were actually semi-apologies for some of this. I was in the intensive care unit for five days, when no more than one (at a stretch, two) was really necessary, a fact that massively increased our bill. (Not my freestanding medical opinion: We were not told that intensive care was necessary past the first couple of days, but that I was held there because regular-care room space was full.) I was in the hospital eight days, at least two days more than necessary, in part because two of those latter days were on a holiday weekend, and the regular doctors were off and not present to sign off on releasing me. By day six I'd have stumbled out on my own except that I was still connected to