Your Money or Your Life

"I suggested this book because it raises some very important points about healthcare spending in the US. We spend a lot, and it’s generally believed there is a lot of waste. There are a lot of things we could cut, or ways we could save on spending that wouldn’t harm health. Looking internationally suggests that this must be true. But even so, Cutler’s argument is that we do receive great value from our spending on healthcare. He argues that even if you look at just a few health conditions – heart conditions, mental health, low-birth-weight infants – and work out the value that we’ve received from improvements in healthcare, quality of life and prolonged life, it is greater than what we spend. He says we get high value for all this money. That doesn’t mean we shouldn’t spend less and still get that high value, it just means that we’re still making, on average, investments that are worth it. If one is in favour of cutting health spending because there’s so much waste and so forth, then the next easy place to go – which is often where we do go – is to make very crude cuts across the board. To just cut Medicare, for example. That runs the risk of throwing out the baby with the bathwater. The book suggests that we do need to get smarter about how we make our health system more efficient. You can cut spending in a way that could be harmful to health or, in principle, you can cut it in a way that isn’t. We know ways to cut that aren’t going to harm health, we know some things that we shouldn’t be paying for. But we don’t know as much as we ought to. Things are very bad if you don’t have insurance. If you become ill, then not only will you suffer from that illness but you will also suffer from bill collectors. They don’t care – it’s not their job to care how badly you may be doing. They will harass you and repossess what they can. Eventually you’ll have nothing. You will be bankrupt. This does happen to people in the US. The reason it happens is that the safety net has a lot of holes in it. You mention Medicaid, which is supposed to be the programme for the poor. Ultimately, if things are bad enough, if you spend all your money and have no job or income, then you might be able to go on Medicaid. But actually, it doesn’t even cover all the poor. You have to be poor and you have to fall into one of a number of qualifying categories, like being pregnant, elderly, blind or disabled. Beyond those federally mandated categories, individual states have the discretion to cover more. Many of them don’t. Or if they do, they only cover them if your income is extremely low, a fraction of the poverty level. So it is possible in the US to be horribly poor and not have access to any health insurance programme. You’re at the mercy of charity care. And there is charity care. You can also walk into an emergency room and if it’s an emergency they will treat you. But that is no way to have a healthy, satisfying life. Yes. They will try to collect payment but eventually, if you can’t pay, they can’t take what you don’t have. Many states have uncompensated care pools, so they’ll try and collect that or just write it off. Sometimes hospitals don’t get reimbursement for the care they provide. There’s a lot of variation. In urban areas, there will tend to be better access and support for such things, because of population density and infrastructure. In rural areas, obviously there’s a lot less. And even though you may have access, it is constrained; you may not have access to many specialists, and you’re at the mercy of whatever quality those programmes are. There are many studies showing that your access is greatly restricted, and you’re not getting regular preventative care. Oh yes. Many doctors don’t take Medicaid. It’s not in any way a requirement and reimbursements are low. That’s widely misunderstood, and is one thing that the health reform law will change. As of 2014, anyone with income within 133% of the poverty level is eligible for Medicaid, independent of anything else."