Health Care in the US as Seen From Down Under: "Mens Sana in Insanus Patriae"

Thursday, 14 November 2013 00:00 By Niall McLaren, Truthout | Op-Ed
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Physician.(Photo: Alex Proimos / Flickr)Australia's national health service, Medicare, treats health care as a human right for all, including illegal immigrants - and it costs less and delivers better outcomes than US health care, according to McLaren.

Article 25 (1) of the Universal Declaration of Human Rights, adopted by the UN in 1948, states: "Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including . . . medical care . . . and the right to security in the event of . . . sickness, disability . . . "

These days, most people would say that an adequate standard of living includes readily available health care of a proper standard, that "health care delayed is health care denied." Most people would also expect that citizens of a wealthy country should be able to expect better health care than the benighted citizenry of a poor country. So it comes as something of a shock to learn that the United States, which spends almost 50 percent of the world's total health expenditure, ranks way down on most health statistics. Let's start with the World Bank Health Indicators, which show that, in 2009 (latest available figures), Germany, for example, spent $4,724 per capita, some 11.7 percent of GDP, for which citizens received 8 hospital beds per thousand people and a princely four doctors per thousand. Germans are generally pretty healthy, but they pay for it. My tightwad country, Australia, spent $4,118  per capita, 9.0 percent of GDP, to get four beds and one doctor per thousand patients for slightly better standards of health than the Germans. Since then, our government has committed to spending 8.0 percent of GDP on health, and we are on course to get that (now down to 8.4%).

However, when we look across the Atlantic, we find that the United States spends $7,990 per person, an astounding 17.7 percent of GDP, to get only three beds and two physicians per thousand population. To make things worse, US figures are rising rapidly, now thought to be over 18.0 percent of GDP, but where are the standards of health? In a word, they're nowhere. In fact, they're worse than that, as the statistics conceal a grossly inequitable distribution of health expenditure. A Hollywood starlet's boob job, at $65,000, crowds out any number of poor people from even a look at a clinic, as Joe Bageant's biting reportage shows. Health costs are the biggest single cause of bankruptcy in the United States, while disabled veterans can be seen on street corners in any city, begging for money, not to mention all the mentally ill people crammed in prisons, the new asylums.

But the most bizarre fact is, alone among the world's hundred or so wealthiest countries, the United States does not provide health care for its most vulnerable citizens. Oh sure, the wealthy can book into some very fancy, ultra-high-tech institutes to have a total body rebuild, but that's the sort of stunt that got Prince Grigory Potemkin a bad name: Behind the facades, the poor are warehoused in the charity wards, if at all. Anybody with an interest in the health game (and that's all of us) knows perfectly well that the true measure of a nation's health is not the tiny heads of rich old people getting heart transplants, whose expenditure drags the national average up, but the very large tail of poor children who drag the health statistics down, because their untreated throat infections end up as rheumatic heart disease, perforated eardrums, chronic bronchitis etc. What counts is not expenditure, but what that money achieves. Now the interesting thing is that, if we look at the very large, naturalistic experiment going on around the world, the one called "health care delivery and funding," it would seem that providing treatment for all those poor people does two things: it actually lowers the total cost  to the country and  it yields improved health standards.

Why is the United States playing hold-out when everybody else has jumped on the national health-service wagon? That's a difficult question, so let's look instead at what they are missing. We can use my miserable excuse for a developed country as an example, since our economy and social structure are fairly similar to America's in many respects. With a few blips, we've had a national health service since about 1971. It provides universal health care at practically no cost to the patient. Those who want more, such as my unworthy self, pay for the pleasure. Medicare is partly funded by a 2 percent levy on each person's taxable income, but that gets buried in your income tax so you don't notice it: I don't know what I pay. For additional private insurance, my family of four pays $3,980 a year additional to the Medicare levy. This gives all sorts of benefits like your choice of doctor and private hospital, one pair of spectacles a year, dental care, physiotherapy, psychology, chiropractics, hearing aids, wheelchairs and so on. If you'd like to get a quote on your own case, go to Medibank Private and insert your details in the box, then click "Go" to see what benefits you get for your payment. Remember, there are no arguments about this. Even if you have a serious chronic illness, you can't be rejected by an insurer. You can't be disqualified after the event unless you really cheat. It may happen, but I've never heard of it.

There are "incentives" to encourage people who can afford it to take private insurance, which amount to penalties for those who don't (go here for details; click on FAQ). A single person who has not joined an insurance plan by 31 years old will have to pay a penalty for the rest of his life. This is to stop "free-riders," because people of that age are unlikely to make a claim anyway. A national health service is a bit like a conscript army in a national emergency, it only works properly when everybody is in.

I've always thought we got our $4,000 back by about February each year. My wife had two emergency caesareans; both babies were in neonatal intensive care (my son for eight weeks), and we paid a total of $430 for some stray fees. Pathology tests, optometry, hearing tests and the like are free, but some radiology tests are charged extra. In the past 15 years, I've had three hernias repaired, two cataracts replaced, a cervical fusion, and the total cost was . . . nothing. That varies, of course; you have to choose a doctor who charges by the book. If you don't, you can end up with a large bill, like some unhappy women in Sydney who complained their obstetricians charged them $10,000 for a confinement, but the insurers would only pay about $3,000 (actually, the women were all warned in advance). The Medicare rebate is fixed by a committee in Canberra, but private practitioners can charge what they like. However, it doesn't do to stand out too much from the crowd: Word very quickly gets around. Having fixed universal fees for services keeps costs down very significantly.

An excellent article in Care2 says it all: ". . . the total average cost of having a baby (in the US) is $37,341, making the United States the most expensive place in the world to have a baby. This covers prenatal care ($6,257), birth ($18,136 on average), postpartum care ($528) and newborn medical care ($12,419).  . . . America has one of the highest rates of infant and maternal death among industrialized countries. Insurance doesn’t necessarily help: 62 percent of private plans come with no maternity coverage." Those prices are outrageous; prenatal care simply does not cost $6,000.

The net effect of health care as a human right under Australian Medicare is that every person in Australia gets the same standard of health care. Rich and poor alike get renal dialysis and kidney transplants . . . if they need them. My elderly mother was knocked down by a car recently, sustaining quite a nasty fracture of her neck. She was in hospital for several weeks, treated by the spinal surgeons, and has had many visits to the physiotherapist since. All her costs were covered by the Motor Vehicle Insurance Trust, which automatically pays all medical costs for any person injured in a car accident, even for a drunken driver. We didn't have to pay anything. MVIT is funded by a levy on the vehicle's licence, so the fund will never go broke. Regardless of the cause, anybody injured at work, or traveling to or from work, is fully funded by the compulsory workers' compensation insurance and is paid their salary for the time off work (it drops to 75 percent after six months). A worker doing something stupid at work, who is left with a long-term disability, may have his benefits reduced, but he will still get something. There are people who try to cheat on this type of insurance, but even that's not easy. And for every worker cheating, there are two insurance companies trying some fast move. 

Rich people can buy cosmetic surgery as Medicare doesn't pay for it, but anybody with bad scars or significant blemishes can get them repaired under Medicare if they are prepared to wait. There are caps on some forms of treatment, including some outpatient psychiatric treatment. Unfortunately, this has led to an increase in cases of people being admitted to private hospitals when they didn't actually need it, but Medicare operates a highly sophisticated data analysis system that watches that sort of thing closely. That's another advantage to a national health service. The statistics are excellent just because they are so comprehensive. But don't worry, they are protected by layer upon layer of privacy (well, we thought they were, thank you, NSA).

Medications are subsidized by the Pharmaceutical Benefits Scheme, which has been around forever. Anybody on a pension, unemployment or parenting benefits, students, or anybody who just doesn't earn enough, can get a Health Care Card, which entitles them to cheap medications. They have to pay a maximum of $5.20 per prescription, regardless of the drug. If you don't have a Health Care Card, the maximum is $37.50 a script. I was once prescribed antimetabolites for a peculiar arthritis. The drugs cost $360 for 100 tablets, but I paid only $37.50 - which was lucky, as they gave me tinnitus, so I had to stop them after a few days. Medication costs are capped for a family at about $1,050 per year; after that, the price drops to $5.20 while, for pensioners, it cuts out altogether. I see where one of the core features of Obamacare, the caps on copayments ($6,350 for a single, $12,700 for a family), has just been deferred as "too difficult for insurers to implement." As though they didn't already have nifty caps that worked in their favor - reach the limit and the insurers don't pay.

How does a doctor fare in this socialist paradise? Actually, we do quite well. There are some who charge what they like as there are always patients who will pay to get to the front of the queue. I once sat in the waiting room of an ear, nose and throat surgeon and heard the fees as they were loudly announced to each new patient. He was pulling in about $1,000 an hour, which struck me as a bit gross as they earn very good money operating. As a psychiatrist, I can comfortably earn about $400,000 a year (49 weeks at 45 hours per week, no nights or weekends) seeing all patients on Medicare and charging private rates for legal cases. For military cases and veterans, the Defence Department pays private practitioners about 50 percent more than Medicare. Government psychiatrists can earn more, but working for the government isn't my idea of fun.

In our hybrid private/public system, there's room for everybody. Nobody in this country goes without. We provide full health care to every citizen, regardless. I have worked in the remote north, on the edge of the desert, and Aboriginals leading fairly traditional lives in their own communities get the same care as anybody else. Their health isn't as good; they still die younger than white Australians, but that's the subject of a massive drive by state and federal governments to "close the gap." People who enter the country illegally, which has been a hot topic for the past 15 years, are all provided with health care from the day they arrive. I've seen quite a number of them myself, as well as approved refugees who are given Medicare cards as soon as they land.

It may seem like rubbing salt in the wound, but pets can also be covered at a moderate price. This advertisement landed in my in-box the other day: "Pet Insurance from just 33c a day! Medibank Pet Insurance offers . . .  Coverage from 8wks of age; with generous annual limits from $8000 up to $15000 a year; and up to 80% off the cost of vet consultations, surgery and medicines." For a one-year-old dog, based on $200 excess (ie owner pays first $200), the scheme costs $117.50 a year. I'm sure a lot of Americans would be pleased to have that sort of coverage. They never will, because health insurance is tightly held by private insurance companies, who made over $100 billion profit in 2005. That was money the insurers took out of the system that should have stayed in it to provide better care.  

There's more, but this gives you the basic idea: Without too much effort, any country can have a national health service providing world-class care for a moderate price. Universal health insurance does not bankrupt the country. I often see complaints from the Rabid Right in the United States that having universal health care will make people irresponsible about their health, but this doesn't make sense. When a community decides they want universal health care, they are being highly responsible about their health. They have talked it over and agreed that this is the best way to go. They are taking perfect, democratic care of their health. How could anybody object? It's like conscription: Armies and universal health care only work when everybody chips in. My advice is: Just ignore the screechers, they'll get over it because the good thing about socialism in this country is that it's optional.

That's right. Once you pay your tax (that isn't optional, but I'm not aware that paying taxes is an option in the United States, either), you'll get your green Medicare card. If you're too poor to pay taxes, you'll still get one, but whether you use it or not is entirely up to you. You can be as socialist or as "privatist" as you like. If you don't want to stand in the queue at the public hospital with all the olfactorily challenging people, you don't have to but I know plenty of rich people who do. Or you can pay a bit extra and see one of those nice private doctors. You may be treated in a lovely private hospital, but you won't be treated any better. That's our boast. We have leveled health care up, not down.

Copyright, Truthout. May not be reprinted without permission.

Niall McLaren

Niall McLaren is an Australian psychiatrist, author and critic, although not necessarily in that order.

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