Before we address the problem of a Healthcare crisis in America, we need to debunk the myth that America has the best healthcare in the world. Everyone wants to be number one, and certainly one doesn't want to hear criticism about the good old U.S. of A., so the natural tendency is to reject the idea that perhaps our medical system isn’t all it could be. But it is important to impartially look at the facts and realize that we need help. By almost every measure, we are hardly #1. Thanks to the quality of healthcare, surely Americans must live the longest. Unfortunately not. According to the World Health Organization (WHO), we are 34th out of 191 countries reporting, giving us a "B-". How about infant mortality per 1,000 births, a common statistic used to determine a healthcare system's effectiveness? Again, according to the World Health Organization we are 155th out of 192 countries. That’s a solid "F". But some have said that America's science allows women to who might not be able to have babies to have riskier pregnancies. OK, so let's look at our ability to keep our kids alive. The neonatal rate per 1,000 births is 54th out of 204 counties, a "C". We can go further afield and look at things like the availability of care, for example the number of hospital beds per capita (69th out of 161 countries reporting - just barely an "F") or the number of doctors per capita (44th out of 197 countries reporting - a "C"). Keep in mind some of these countries reporting are fairly dismal places. However, there is one area that the US is by far and away #1: the cost of healthcare. Using just the Organization for Economic Cooperation and Development countries (OECD - the 30 most industrial nations) as a peer group, we spend 15.3% of our GDP, the largest of any OECD member and much greater than the OECD average of 3.0%. Per capita we average $7,110 per American, 20% higher than Luxembourg and twice as much as the average OECD member.

Statistic after static shows that we pay more and get less. But how could this be? This myth is most often propagated by conservatives (in both sense of the word) who are resisting change, after all if we have the best healthcare system in the world, there is no need to change it. But why? Everyone can look up the statistics themselves - it doesn't behoove us to bury our heads in the sand and ignore the problem. In the halls of congress we hear antidotical evidence of long waits for procedures in European countries with their (include the appropriate sneer here) socialized medicine. So why would anyone want to cover up the lack of value that we get for our medical dollar? Some of the reasons:

1. People want to hear that we are great, not that we need improvement. Politicians want to get elected and will say what their constituents want to hear, not necessarily the truth (akin to ignoring upcoming Social Security crisis). In addition, this is a complicated issue with complicated solutions - yet another reason to ignore the problem.
2. The US, like all countries, have limited medical resources that need to be rationed. Those that currently have medical insurance coverage don't want to share these with those that don't have coverage. Hence the effectiveness of scaring Americans with threats of long waits for medical resources.
3. A knee jerk reaction among Conservatives against any type government intervention.

A second myth that must be debunked is the idea that the Democrats want socialized medicine. Neither Barack nor Hillary want the government to take over any part of the insurance, pharmaceutical, or medical industries. Rather they are requiring all be insured one way or the other. This is not socialized, government run medicine: private insurance companies will pay private medical doctors in private medical facilities.

A third myth that needs to be debunked is that our costs will rise with government mandated insurance. There are 47 million Americans without health insurance. When these individuals go to emergency room and fail to pay their bill, who do you think is covering those costs? We all are - through government subsidies (your tax dollars) or through higher medical premiums (your paycheck). What we are missing are the low hanging fruit which would help lower health care costs - preventive medicine. It's much cheaper to treat a common cold then to have an uninsured wait for it to develop into a full blown case of pneumonia that requires a hospital stay.

So if we get past the spurious and erroneous argument that we have the best healthcare in the world, and accept that our system needs improvement we need to look at how to best achieve this. The first step is to try to get a better return on what we already spend. A couple of ideas:

1. In previous blog posts I've attempted to address the insurance problem and its solutions (The Insurance Problem). Getting everyone included in insurance (even if it is high deductible insurance) will ensure that people aren't afraid of the medical system and seek appropriate help in a timely manner.
2. Create continuity with healthcare through a central repository for healthcare data. Too often one doctor will needlessly repeat tests and request repetitive information already done by another doctor. Patients are hurt or killed when prescriptions by multiple doctors result in unintended reactions. At a minimum the government needs to devise the standards for security and exchange of this information, and more likely will have to act as the clearinghouse for this information.
3. Establish metrics for the industry. Without understanding the true costs in the industry, it is impossible to begin to identify and fix inefficiencies in our system. In our schools, despite all the flaws of "No Child Left Behind", it does create some metrics and (uncomfortably) puts into the spotlight some flaws in our system. Such a system needs to be put in our medical system. Like "No Child Left Behind" it may take years of trial and error to find the correct metrics to track, and the corrective action that can be taken - but we must start today to head off an exploding healthcare crisis.
4. Make the industry responsible. In every group there are bad apples. Doctors are human too - prone to addiction, debt, stress, laziness, and the like. We have doctors that lose their license in one state and then practicing in another. If the industry is unable or unwilling to self police, the government will need to do it for them. In exchange, the government should limit medical lawsuits, and create reasonable medical insurance pools.

There is one more action, one that is very tough to take but ultimately must be made. In 1970 the US spent 7.2% of its Gross Domestic Product (GDP) on healthcare. Today we spend 15.3% of our GDP on healthcare and the Centers for Medicare and Medicaid Services (CMS) expects this to rise to 19.6% of our GDP in 2016. Keep in mind this growth isn't in absolute terms - that number is much higher. Rather for every percentage point in growth that goes towards healthcare, that's a proportionally less amount of other items we create to consume. America, as a collective society needs to determine if, and potentially how, we should ration healthcare. A classic economists' "guns or butter" problem (what mix of economic output should be produced for defense vs. domestic consumption?). Do we, as a society, allow healthcare costs to increase to meet the needs of everyone? This is an especially important question as we are all living longer and baby boomers move into retirement. Or do we as a society, find a way to ration healthcare? This raises the important question of who decides what medical procedures should or shouldn't be done and in what situations? This is a very emotional and personal issue. With the Kaiser Family Foundation estimating that the top 5% consume almost half all America's healthcare resources and the top 1% consumed almost a quarter of all health care spending (22.5%) - one has to ask if this is the most efficient use of resources? A coldhearted and impersonal analysis might say that reprioritizing this spending and spreading it out among the entire US population may provide greater public good than keeping alive this small group of very sick people. However, I also understand the other argument - that if it were me or my loved one in the hospital that I'd want everything possible done - regardless of cost or chance of success. The problem is that if we fail to address this problem intelligently and upfront, it will be decided for us. The most likely solution, bereft of steering, will be a continuation of the current trends: insurance companies will charge more and cover less, and the medical community will cater to those who can afford it. The public won’t allow 'dying rooms' (akin to those in the classic movie All Quiet on the Western Front) where uninsured go to die - but only the most extreme cases will be dealt with. Those with treatable illnesses will be denied coverage until in the most extreme need, and then only provided comfort to die. Clearly, what is economically expedient is not always in society's best interest. Allowing those that are vibrant contributors to America's economic success to die because they are in the unfortunate few unable to afford preventive medicine, while allowing sickly, but rich, patrons to consume an extraordinary portion of resources is not in the long term best interest of America.

We must not allow healthcare to take the path of least resistance, rather address the problem head-on. While the nation debates the thorny and tough problem of rationing who should have access to what healthcare - let's begin with the easier parts: admit we need to fix healthcare; fix the insurance problem and get everyone insured; create a national database for individual's medical information; establish metrics to allow us to pick the low hanging fruit to create more value for the dollars we already spend; and, finally, create more responsibility within the industry itself. America is a great country and deserves the best healthcare system - it is about time that we rise to the occasion and make it happen.