Why are certain U.S. healthcare system dysfunctions not endemic in other countries? Or are they?

 Note: All xpostfactoid subscriptions are now through Substack alone (still free), though I will continue to cross-post on this site. If you're not subscribed, please visit xpostfactoid on Substack and sign up!  

I’ve just finished reading the eminent healthcare economist Uwe Reinhardt’s last and posthumously published book: Priced Out: The Economic and Ethical Costs of American Health Care. Reinhardt passed away at age 80 in November 2017; the analysis in Priced Out of the Affordable Care Act and Republicans’ failed 2017 repeal/replace attempts continues to within months of his lamented death from sepsis.

The book, a characteristically caustic and ironic overview of the politics and economics of healthcare delivery in the United States, brings into sharp focus the core themes of Reinhardt’s scholarship and writing. Key takeaways:

• Republicans want to ration healthcare by ability to pay, but they won’t say it. The U.S. is the only developed country in the world that does not explicitly commit to providing equal access to healthcare for all (with some allowance for concierge service on a pay-for basis for the wealthy, which Reinhardt regarded as tolerable).

• The U.S. multi-payer system, in which each insurer negotiates its own prices, is insanely wasteful. Reinhardt pegged the cost of all the wrangling between providers and payers at close to $200 billion per year.

• It’s the prices, stupid*: Prices for medical services and drugs that are more than double norms in peer countries are also attributable in large part to our divide-and-conquer multi-payer system.

• No single-payer soup for you, U.S.: While Reinhardt helped design a well-regarded single payer system in Taiwan, and regarded single payer as one viable model for universal healthcare, he repeatedly asserted that the U.S. political system was too corrupt to manage it: industry would use its funding leverage to demand unsustainably high payment.

While these themes were familiar to me from Reinhardt’s prior writings (e.g., regular contributions to the New York Times’ old Economix blog) a few throwaway lines made me wonder why some U.S. dysfunctions that are not solely attributable to our failure to standardize prices are not shared by peer countries, or at least not to the same degree. 

Medical Billing: The Ten Do-well Commandments (after Elisabeth Rosenthal)

Elisabeth Rosenthal, reporter of the monumental Paying Till it Hurts series in the New York Times and author of  An American Sickness: How Healthcare Became Big Business and How You Can Take it Back, has been out front with the "Ten Economic Rules of the Dysfunctional Medical Market" with which the book leads off -- e.g., on Twitter and on Medium.

To those of us who have saturated themselves in Lin-Manuel Miranda's Hamilton (which already feels like a relic of a bygone era), "10 rules"  inescapably conjure up The Ten Duel Commandments. So I have set them to imagined music below. At bottom, the rules as Rosenthal worded them.

A disclaimer: While the rules in isolation may seem excessively cynical, I don't think Rosenthal's point is that all providers follow them all the time, but that the incentives in our dysfunctional system pull them this way.  Another disclaimer: I haven't read the book yet. Too much current bad news to absorb. But I'll get there.

The Ten Billing Commandments

Number one: The treatment. More is always better.
Feed the bottom line, be a real go-getter.

Number two: Keep 'em coming. More is always more.
A lifetime of treatment trumps a simple cure.

Number three: Amenities and marketing are the way it's done.
Look like Cedars-Sinai and the battle is won.