Quora Query: Is there Only One Universal Coverage Alternative to the Current US Health Insurance System Which Would be the Most Efficient ?

Gentle Reader –
My son suggested I pay attention to Quora – an on line Q&A system – and I now do. Here is a question I was asked to answer. Interesting question, for sure.



The answer to this query is not exactly straightforward, as we would have to define “efficient”, “universal”, and I’m not parsing words simply to be pedantic. Let me take a stab at this.

# 1. Efficiency:
If we define efficiency as getting the most value for a dollar spent, then we would simply have to consider a Canadian or Medicare type system for our people.

For example, Stephie Woolhandler, several years ago did a superb study published in the New England Journal of Medicine suggesting strongly that the ADMINISTRATIVE cost of private health insurance – you know, United Health, Blue Cross, the private for-profit health insurance companies – was about $ 0.32 of every premium dollar taken in by the companies.  For the Canadian National System is was about $ 0.16 and for Medicare, our “National” system, it was about the same as the Canadians.  Of course, the Insurance companies would disagree, but adjudicating the disagreement depends upon how you define “Administrative” versus “Clinical”.

Doctor Woolhandler defined the armies of administrative personnel hired by insurance companies to make sure claims are denied as “Administrative”, while the insurance companies would like to call them clinical decision makers.  Well, you get it.

But the difference between the $ 0.32 for the privates and the $ 0.16 for Medicare doesn’t tell the entire story about “efficiency”.  The $ 0.16 saved won’t allow us to care for all of our people.

If we simply provide access to healthcare for most of the 50 million Americans who are either uninsured or under-insured, as President Obama’s Affordable Care Act does, we run the risk of bankrupting our country.  American medicine does some things superbly, but other things not so well (see “Problems in Paradise”, Parts 1 through 3 on my health blog at Notes from the Southern Heartland).

We need to determine if technologies work  – strange thought that ! – if we are to use them.  This could be done by a national institute such as the British National Institute of Health and Clinical Excellence.  We don’t have this and our conservative Republican and Democratic legislators made sure it was not funded.

We need to ensure that evidence-based medicine / best practices (EBM/BP) are used.  Now, I suspect you think this is done at present.  Think again.  It takes, according to more than a few studies, up to 20 years to get EBM/BP incorporated into the practice of physicians, even at academic medical centers.  How can this be ?  Not because physicians are stupid or don’t read the literature, or are lazy.  No, it actually is pretty easy to read this stuff and KNOW what needs to be done.  But the operationalization is often a very big deal.  And in order to make the operational changes in hospital / clinic processes we need to work as teams.

And if there is one thing we are not too expert at, it is working as teams.

One of the really cool things about the place I am now working is that most (not all) of the Departmental / Divisional silos separating clinicians have been pulled down, and teamwork is the EXPECTATION.  As a result, The Geisinger Health System has logged some notable success in providing care that utilizes EBM / BP and is team driven; not a perfect system, but certainly a model.

# 2. Universal
It is inhumane and uncivilized that we, a strong and rich nation, have some 50 million of our people who are uninsured or under-insured.  The meaning of uninsured is obvious, you don’t have insurance.  Under-insured goes something like this. You work for McDonald’s.  You have insurance that provides $ 2,000 of benefits….total.  That doesn’t even get you out of the Emergency Department most days.  You are effectively uninsured although you have “insurance”.  Do you think I am joking ?

While there is some controversy as to degree of the effect, most studies note that being uninsured is an independent risk factor for a worse outcome, like death.  The uninsured are screened less often for breast cancer and colon cancer.   Their elevated blood pressure is cared for more poorly.  Their abdominal aortic aneurysms are noted later and operated upon later.  Their diabetes is less well controlled.  And on and on.

Humanity aside – did I just say that ? – it is also bad economics to have our people in this position.  They are less able to become “entrepreneurial”, as Thomas Friedman loves to point out, because they can’t leave a lousy job to get more education to then – hopefully – get a better job, because if they leave the job they may well be without insurance for a while.  And we all should know where that could lead.

Finally, not having a universal system leads us, as a nation, to do stupid things. For some years while I was at a major University Health System in the South – no names here but you can figure it out if you have the desire – I was in charge of the Emergency Department.  I was always fighting with our lawyers who wanted to put liens against the homes and trailers of patients who were cared for in our ED but couldn’t pay.  Yes, you have not mis-read this: They wanted to take away the homes and trailers of people who needed care, couldn’t afford it, and came to our ED to be cared for.  I fought this as best I could; you can be sure that the administrators made sure they “paid me back in full” for that transgression.  Inhumane, indeed.

In a nutshell, the Affordable Care Act gives us something similar to the German and Dutch systems of financing, more or less.  I think ideal would be a not-for-profit National Health Insurance System that cuts the for profits out almost completely.

Happy to discuss further.

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He served as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders) through 2018 and is presently an intensivist in Florida, struggling through the SARS-CoV-2 crisis. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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