Science Vs - Healthcare: How Do We Fix It?

Episode Date: December 13, 2019

American healthcare has big problems. Some say the solution is Medicare For All: one government plan for everybody. But others say government healthcare would be worse than what we already have. Who��s right? And how did things get this bad? We talk to health policy researchers Prof. Harold Pollack and Robin Osborn.  Check out the full transcript here: https://bit.ly/38ye0cY  Selected references:  Paper from last year on why American healthcare spending is so high: https://bit.ly/2t8gkqB  Report from Robin’s group that compares the US, the UK, and many other countries: https://bit.ly/2qRh7vy A WHO report on healthcare cost control: https://bit.ly/38AEHxl Big Lancet report on the health of countries around the world: https://bit.ly/2RLJB4N  Credits: This episode was produced by Rose Rimler with help from Lexi Krupp along with Wendy Zukerman, Michelle Dang, and Meryl Horn. We’re edited by Caitlin Kenney. Fact checking by Michelle Harris. Mix and sound design by Peter Leonard. Music written by Peter Leonard, Emma Munger, Bobby Lord, and Marcus Bagala. Recording assistance from Sofi LaLonde, David DesRoches, Dennis Maler, and James Delahoussaye. A huge thanks to all of the people with diabetes we spoke with-- thanks so much! Also big thanks to Dr. Irene Papanicolas, Prof. Steven Woolf, Dr. Kasia Lipska, Elizabeth Pfiester, Professor Kevin Schulman, Dr. Eric Schneider, Dr. Chris Pope, Cynthia Cox, Lois Rogers, and everyone else we spoke to for this episode. And special thanks to the Zukerman family and Joseph Lavelle Wilson. Learn more about your ad choices. Visit podcastchoices.com/adchoices

What does the AI revolution mean for jobs, for getting things done? Who are the people creating this technology and what do they think? I'm Rana El-Khelyoubi, an AI scientist, entrepreneur, investor, and now host of the new podcast, Pioneers of AI. Think of it as your guide for all things AI, with the most human issues at the center. Join me every Wednesday for Pioneers of AI. And don't forget to subscribe wherever you tune in. It's season three of The Joy of Why, and I still have a lot of questions.

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I'm Steve Strogatz. And this is... Quantum Magazine's podcast, The Joy of Why. New episodes drop every other Thursday, starting February 1st. Hi, I'm Wendy Zuckerman, and you're listening to Science Versus from Gimlet. This is the show that pits facts against free healthcare. On today's show, we're tackling the big mess

that is the US healthcare system. In case you haven't heard, politicians have got it in their crosshairs. This is a broken system and we must fix it. The current healthcare system is not only cruel, it is dysfunctional. Make American healthcare great again. America is pouring money into healthcare, and yet more than a third, one in three Americans, either have no health insurance or insurance that comes with big medical bills that they can't afford.

Politicians and activists are saying this is not good enough. People just want a chance to get their health care without going broke. So we're looking for an America where folks don't die because they got to ration out their insulin? One of the big ideas to fix this is Medicare for all. I wrote the damn bill. That's right. Put everyone on the same government plan. Kind of like what they do in Canada or the UK. It's one Medicare to rule them all. And some police say it's my precious.

That is, it'll fix all our healthcare problems. All out-of-pocket expenses are gone. Medicare for all is the gold standard. But others say, wait a sec. This shall not pass. One Medicare for all, it's dangerous. For the millions of Americans who have good health insurance, this new thing will be worse. It's going to take away the right of

people to choose. They want to take it away and give you lousy health care. It's pretty incredible. And conservative outlets are skeptical too. They're saying, look what's happening in other countries that do this kind of thing, like the UK or Canada. You want healthcare like that? Waiting in the hallways, waiting for a kidney transplant. So I want the millennials who think that they love socialism so much to look at what's going on in the UK and see their own future. So today on the show, are the millennials who love socialism so much deluded?

If they would just put down their TikTok and their avocado toast for one second and look around at the healthcare in the UK, what would they see? We're going to get past the stump speeches and talking heads and look at the data to find out who is to blame for the broken healthcare system in the US and how do we fix it? Is Medicare for All the best way to go? Because when it comes to healthcare, there's lots of millennials who think that they love socialism so much. But then there's science. Science vs Healthcare is coming up just after the break.

Welcome back. Today we're asking, is Medicare for All the dream that will solve America's healthcare woes? Currently, the US spends $3.6 trillion on healthcare. Trillions, with a T. It's about 18% of our GDP. It's huge. And when you compare it to other wealthy countries, the US is forking out about twice as much per person. So tons of money is being poured into this system that doesn't manage to cover everyone. To know how to fix it, the first thing we want to do is to take a close look at that big pile of money. Where is it going? It's very, very clear that we are overpaying the United

States dramatically. That's Professor Harold Pollack, a healthcare expert at the University of Chicago. And he says our price tags for basically everything are just too high. That's true for hospital care. It's true for pharmaceuticals. It's true for pretty much everything. So, for example, the exact same cholesterol-lowering drug, exact same, costs $66 more in the U.S. per month than in France. An MRI, on average, costs $300 more in the US compared to the UK. Pacemakers cost thousands of dollars more in the US compared to Germany. Over and over again, academics have found that things are just more expensive in the US. A famous economist asked, why is healthcare so expensive in the US? His answer, quote,

it's the prices, stupid. Okay, so why is America getting shafted on prices? Well, if you got off Tic Tac and started reading The Economist instead, you would know of a little thing called the free market. To be more specific, in the US, we've got the manufacturers like drug companies, the service providers like doctors and hospitals, and the insurance companies. They're in the middle. The insurance companies negotiate with these other two, the hospitals and the doctors, to set the prices that they're willing to pay. And here's what's been happening. Say you're an insurance company about to go into a pricing battle with a hospital.

So, you know, imagine that I'm Blue Cross Blue Shield of someplace and I go to the fancy hospital. You walk up to that really nice hospital, cutting-edge treatment, amazing doctors, beautiful lobby, and you start your negotiation. You ask, OK, so how much is your liver cancer treatment? The hospital tells you... It's $72,000.

And you say... Gee, you know, your liver cancer treatment seems awfully expensive. And, you know, we really want to pay less. The hospital can say back, well, I'm sorry, $72, we really want to pay less, the hospital can say back, well, I'm sorry, $72,000 is our price. If you don't want to pay it, that's fine. You can explain to your members that they can go down to the county hospital

and get liver cancer care. They'll be a lot cheaper. And it's very, very hard for the private insurers to say, okay, you know, we're going to walk away. The insurance company here is in a bit of a bind. Either they suck it up and pay the high prices or risk losing business because their plans don't cover this fancy treatment. And the hospitals can afford to negotiate this way because they are fast becoming the

only game in town. You see, over the last few decades, large hospitals have been merging. They've been gobbling up mum and pup private practices as well as other hospitals. And that means in many places, hospitals have become a kind of monopoly. According to a survey from 2016, more than 100 million people in the US live in places with, quote, moderate to highly

concentrated hospital markets. And that is giving these hospitals a disturbing amount of market power and that allows them to charge awfully high prices. Some of them are essentially the size of a Fortune 500 company. And we don't think of them as a, you know, as a major corporation. But in many ways, that's that's what they are and that's the way they behave. Hospitals already tend to be more expensive than private practices, and research has found that as hospitals gobble up things, they jack up the prices even more. So, for example, studies have found that prices generally increase by around 10% after a merger. And hospitals aren't the only bad guy here.

If insurance companies do get a bad deal, studies have found they don't suck it up. They often pass the bucks along to their customers. And there are other players here, too. We're kind of getting gouged left, right and center. Drug company manufacturers, doctors, everybody who sells a Band-Aid. So, you know, there are many villains to this piece in terms of why the costs are so high. And there is one more villain that's worth talking about here. And that villain... ..paperwork.

A big chunk of that, not all of that, but a big chunk of that is stupid, annoying stuff that is very wasteful. With all these different groups haggling with each other and haggling with you, it's a lot of time and money and dumb letters promising to explain your benefits. And a study from last year found that all of that crap really adds up to more than $200 billion. That's right. 8% of what we spend on healthcare is spent on administration. That is way more than other wealthy countries. Okay, so now we know why America's healthcare is so expensive. Time to talk about how to fix it. And this, some politicians say,

is where Medicare for All comes in. When it comes to solving the cost problem, here's one way that Medicare for All could fix it. If you want to take power away from hospitals and pharmaceutical companies to set the prices, you could replace all these insurance companies with one big badass, a government health plan. So imagine that scenario you heard before.

Fancy Hospital says, OK, buckaroo, it's $72,000 for liver cancer treatment. Government says, hey, we pay 50. That's what we pay. And that's a fundamentally different position. And so you're using the leverage, the tremendous marketing power on the demand side of the federal government, all the millions and millions of people that would be in one plan to really squeeze those prices.

And we know that the U.S. government can squeeze those prices because they already do it. Right now, the government runs a Medicare program that covers around 60 million Americans, and they end up paying less than private insurers for all kinds of things. For example, a private health insurer, on average, pays nearly $20,000 for a hospital stay.

Medicare pays only about half of that. And Harold's like, if we had all of America under Medicare? The federal government has a health care pay, which is now a 600-pound gorilla. You'd be making it into a 900-pound gorilla, and it could really wrestle down a lot of the prices that we're paying.

Three big economic analyses of Medicare for All agreed that this King Kong of a system would get us lower prices. Also, this King Kong would slay the paperwork Godzilla because if everyone had the same coverage and was paying the same fees, everything would be more streamlined. So there are good reasons that economists think

switching to Medicare for All could save money. But on the flip side, there is an obvious reason to think that healthcare spending could go up if we switched. If the some 30 million people who don't have any health insurance right now in the US suddenly got health insurance, they'd probably go to the doctor more. And as a country, we'd have to pay for that.

The nitty-gritty of who will pay for what, how, and how much it'll cost you as an individual in, say, taxes. Well, that's all being argued about right now. And, of course, the devil will be in the details. OK, we've talked about cost, but what would Medicare for All actually look like? Like, if you got sick and had to go to the doctor, what would it be like? Because now the government would be in charge of everyone's health care.

And that is scary to some folks. Harold totally gets it. He actually likes his health care plan. His employer pays for most of it. It covers his whole family. And this Medicare for All is basically saying, You know, Professor Pollack, you know that $21,000 insurance policy that you were just talking about that basically works really well for your family? We're going to replace that

with some government thing. And the people that couldn't get the Obamacare website to work are going to actually run it. And it's going to be great. I love that you said government as if it was a four-letter word. Yes. Fair enough. Yeah, well, Americans are distrustful of having government control huge sectors of our economy. Should we be distrustful? We hear tales of government-run health care in other countries where people have to wait in long lines for outdated treatments. When we come back, we're asking, will Medicare for All actually be crappy care for all?

That's coming up after the break. Welcome back. We've just learnt that the US has really expensive healthcare basically because everyone is charging up the wazoo. And Medicare for All could put a stop to that. But a big thing that people are worried about is what will happen to the quality of care. A lot of people actually like their healthcare plan in the US. A survey of almost 5,000 Americans found that 50% of them were

very satisfied with their current health insurance. So would things get worse for them if we had one Medicare to rule them all? Well, we don't have Gandalf to cast a spell and show us an alternate reality. So the best thing we can do is head to a place that has a healthcare system that's pretty close to Medicare for all and to see how it's going. So let's go on an adventure to the Shire. Over in England, everyone gets a second breakfast.

They have healthcare, it's paid for through taxes, and it's run by the government. And so now, we're going to compare the two systems. We made some phone calls to people in the UK... Hello. Hello. Hello. Hello. ..and in the US. Hello. Hello. How are you? Good. How are you? They were so stoked to hear from us. And in the US. They were so stoked to hear from us.

These aren't just any old schmoes. They're schmoes who have type 1 diabetes. It's a chronic disease and it's a huge part of their lives. So much so that people we spoke to on both sides of the Atlantic remembered the moment they were diagnosed. And I dropped a big casserole dish and it shattered. Went to the hospital and they were like, oh, he's got diabetes. Yeah, so people call it your diversity. Definitely a turning point when all of a sudden you have this life-threatening disorder.

To stay healthy, these diabetics have to test their blood sugar levels and inject themselves with insulin daily. They also check in with their doctors quite often. So this all makes type 1 diabetes a really good disease to follow if you want to know how well a healthcare system works. So we wanted to see up close, what is it like to be living with a chronic illness in the UK and the US? Sounds interesting. The first and most obvious difference became clear when we talked to them about getting the medicine they needed.

In their case, insulin. In the US, even the people we spoke to who had health insurance weren't always guaranteed to have insulin. I randomly go to the pharmacy one day and they were like, we keep running it, but it's still saying it's going to be over $1,000. And I was like, well, I don't have $1,000. I called the insurance company. I'm crying. If I break a bottle of insulin, if I drop it or something, my insurance company won't allow me to get another one without paying out of pocket for it.

Insulin costs like $300 a bottle. It's pretty terrible. In fact, studies have found that in the US, about a quarter of people with diabetes said that they used less insulin than they should to make their supply last longer. A quarter. And this is really risky. But in the comfort of the Shire, it's an entirely different reality. I have a fridge drawer full of spare insulin. Should I need it? I've never, ever, ever, ever had to worry about

where my next vial of insulin was coming from. Yeah, it's entirely free. We don't pay anything. Yeah, I mean, obviously, like,'t pay anything. Yeah, I mean, obviously, like I pay for car parking at the hospital, but like, that's no biggie. I've never had an issue with getting insulin or anything. So access to as much insulin as they need. That's one way that UK diabetics have it better. They also never lose access to their doctor. But over in the US, if people lose their job, they lose their insurance,

and then it can be difficult and expensive to get on a new plan. Like one guy we spoke to, Jim, who got diagnosed after he shattered the casserole dish, well, he got laid off after the big housing crash. When, like, all the jobs in my industry just, like, dried up and disappeared, I was, like, working crappy part-time jobs for a while. And during that time, because I wasn't seeing the doctor like as much as I normally would, like my control got really bad. And I started to get like really bad retinopathy. That's a diabetes complication where blood vessels in the eye start to leak.

So Jim's vision started to go blurry. It was scary. How am I going to do? How am I going to live? And this, of course, isn't just happening to Jim. Serious complications from diabetes are more likely to happen in the US compared to the UK. So, for example, a diabetic in the US

is more than twice as likely to wind up in the hospital. And just in general, people trying to manage a chronic illness, like chronic kidney disease and heart disease, they tend to do worse in the US. That's according to a report from the Lancet. Okay, so it's looking like the US can be pretty crap if you have a chronic illness. But there are some ways that the US is better. So sticking with diabetes just for the moment, a huge part of being diabetic is managing your blood sugar and giving yourself insulin. And a lot of people told us about some tech

that can make all of that way easier. So Jim, for example, uses a blood sugar monitor. In the old days, he'd have to prick his finger several times a day. But this thing is great. You poke yourself once and it lasts for like 10 days. I can't believe that there are probably diabetics out there still using the finger stick thing when this exists because it is so much better.

There's also a fancy insulin device that people with diabetes can use. And overall, a lot more Americans with diabetes get these gadgets compared to the Brits. So why are people with diabetes in the UK getting shafted when it comes to these fancy gadgets? Well, it's because in the UK, decisions about what kind of medical stuff people get is made by a group called NICE. No, really, that is their name. NICE stands for the National Institute for Health and Care Excellence. They look at the data on how much a new type of treatment can help people and then they look at the price tag and ultimately ask,

is it worth it? And when NICE looked at these diabetes gadgets, they basically said, we can't just hand them out like candy. We're only going to cover people who we think really need it. Not so nice after all. It didn't help when former Prime Minister Theresa May, who has type 1 diabetes,

was pictured wearing one of these fancy blood sugar monitors. That was a little bit of a sore point, I guess. That wasn't nice to see. But, you know, I guess you did have Brexit to deal with, so we can't be too hard on the poor old tea. Now, we'd heard stories that because the US doesn't have these government gatekeepers, that Americans tend to get a lot of cool gadgets and meds

that Brits don't. But other than with diabetes, we actually couldn't find convincing evidence that this was part of a trend. And that might be because in the US, insurance companies are often the gatekeepers. They might choose not to cover something or only cover a bit of it, making it so expensive that you can't afford it. So there isn't a big difference between the kinds of gadgets and medicines that you can get in the UK and the US,

and the UK does better when it comes to managing diabetes and chronic conditions. Away from that stuff, though, the US does win in some other areas. To find out more, we said goodbye to our people with diabetes. Bye. Bye. Bye. And called up Robin Osborne, a senior advisor at the Commonwealth Fund.

It's Robin's job to compare the health care of different countries. And she says that when it comes to the U.S., it's not all bad news. The U.S. has some of the most outstanding health care in the world. And we certainly have exemplars. A big report by Robin's team found that if you have a stroke in the U.S., you're two and a half times more likely to be alive after 30 days compared with the U.K. And that's not all. In terms of like breast cancer outcomes, the U.S. does really well.

American patients are more likely to survive breast cancer and colorectal cancer compared to the UK. It's not clear why, but there is evidence that the US provides more screening and more treatment. So there's some wins for the US system. And finally, we asked Robin to walk us through one of the big fears that people have about Medicare for All, and one that gets a lot of attention.

It's the idea that people in the UK have to wait in long lines for their medical care. Over and over again, news is wafting across the Atlantic about this. And it sounds bad. The NHS in England is under intense pressure as patient numbers rise year by year. The total number of people waiting for routine operations is now nearly 4.5 million.

Stephen's mother died after her heart surgery was postponed. Waiting in line for surgeries? These stories sound scary. So we asked Robin, what's really going on over there? Is it as bad as it sounds? So wait times have been a challenge in the NHS. We do a survey every year and we survey the population in 11 countries about their healthcare experiences. Through these large surveys over the years, Robyn and her team have found this. Wait times for seeing a GP or family doctor

are actually a little better in the UK. But in the UK, on average, you do have to wait longer to see a specialist, like a neurologist. And it's become worse over the last decade or so, since the country has really put the squeeze on the NHS budget. And as a result, the wait times started to creep up. For example, in Robyn's latest survey, one in five people in the UK said they had to wait a couple of months to get an appointment with a specialist. In the US, it was way less.

Only about one in 15 people had to wait that long. Brits also had to wait longer for other stuff, like surgery. And we see this in other countries with a national health plan, like Norway and Sweden. So, yes, people on Medicare for All-type plans are more likely to wait for some things. So where does all this leave us? Well, if America were to go for a Medicare for all type system

like they have in the UK, Americans wouldn't have to worry about losing their healthcare or being able to afford medicine like insulin if they needed. And it's this that makes the Brits really proud of the system they've put together. So proud, in fact, that Robin says that when the Olympic Games were held in London a few years ago... The opening ceremony featured the NHS.

Do you remember what the ceremony was? Did the NHS have like a giant stethoscope or like... I'm trying to picture that. No, I think they... As I remember, I think it was a whole display of hospital beds and nurses and nurses and doctors, you know, sort of in a formation. That's our producer Rose Rimler talking to Robin. But even though no one in the U.S. is putting on coordinated dance routines to celebrate the American health system, it does have some good bits that really are worth keeping.

Shorter wait times, better treatment for certain diseases. And if we switch to Medicare for all, we might lose some of those things. And Harold, who you heard from at the beginning of the show, told us there's another concern with switching to Medicare for all. He says the US is just so politically divided right now that the idea of healthcare coming down from the government, it can make people a little tetchy. Imagine that if you're talking to someone who's super progressive,

say who's very pro-choice, and you say, well, you know, what do you think about the idea of having President Trump operating a national Medicare system, and that's the only source of health care for women? I think a lot of Americans would say, you know, that makes me a little nervous. So if we don't like America's health care system the way it is now and Medicare for all isn't a utopia, what should we do? Well, Harold says, don't fret. I think there's a lot of things we could do to tinker with our current system that would improve it. If we want to stay away from having just one big national health plan,

but still give everyone affordable health care, there's so many countries we can look to. I mean, it's rarely a talking point, but even the UK has a private option. Yeah, you think Kate Middleton had her babies at Babington Hospital in Derby? Anyway, there's also Australia to look to, Japan, Singapore, but also Switzerland, France, Germany. You know, Western Europe actually exists. It's a place. Okay, so let's zoom in on this so-called Western Europe. Countries like France and Germany get just about all of their citizens covered with the help of private insurers. And how do they get there?

Well, the government tells everyone to get insurance. And then they do a bunch of things to make sure it's affordable. Like they help people out using subsidies. Or they set caps on how much people pay out of pocket. They have private insurers and people get subsidies when they can't afford to buy their insurance. Works very well, achieves universal coverage. And what about those stubbornly high prices

for things like prescription drugs and hospital services? How did Germany and France deal with that? Well, governments there take an active role to keep costs down. They negotiate directly with big pharma and hospitals to set prices for drugs and treatments. And Harold says this is key. Yes. Yeah, there's no other way to do it. We're using the massive bargaining power of government

to really leverage, you know, to pay a reasonable price. I think that's essential in one way or another. I view that as absolutely essential. Some U.S. politicians, including the president, are looking at different ways that the government can get involved in drug pricing. And many academics agree that getting the government to start throwing its weight around would help to make prices cheaper in the U.S. Now, Harold told us that obviously there is a limit in how low you can go with prices. Let's say you're setting the price for a drug company, someone that makes insulin. You can't go so low that they can't stay in

business. It can't be ridiculously low. Otherwise, either no one will supply insulin, but it'll be a heck of a lot lower than what we're paying right now. And it is really contentious just how low we can go without squeezing the system too much. But finding the balance is possible. Other countries do it. And Robin from the Commonwealth Fund told us they don't lose out on quality or wait times.

We're not the only one that can ensure people get in to see specialists and have surgery quickly. Yeah, put it all together and a huge review in The Lancet that ranked the health and healthcare of many countries all around the world out of 100 gave the US 89, our mates in the UK 90, while France and Germany got 92. So they beat America and they paid way less for it. So when it comes to health care in the US, is Medicare for All a dream or a nightmare? Is it the answer to our problems? We've gone on a journey to the Shire to see if one Medicare can truly rule them all.

And it can. It's not crazy. They basically do it in the UK and it works totally fine. But there are trade-offs, and people with really good health care now, they may lose out a bit. But that's not the only way to go here. There's a fellowship of countries who get more of their citizens covered and cut prices

without losing quality. One thing that's clear is there's a journey ahead of the US. But as a philosopher of our time once told us, it's a dangerous business going out your door, you step onto the road, and if you don't keep your feet, there's no knowing where you might be swept off to. You might just end up with a better healthcare system.

That's Science Versus. Next week, asteroids. Are we in trouble? How are we going to explain to the world that we did not see this coming? Hello, hello, hello. Hi. Hi, Rose Rimla, producer at Science Versus. Hi, I'm Wendy Zuckerman, host and executive producer of Science Versus.

Wow, we're very formal today. How many citations in this week's episode? This week, 168. 168. Yep. Is that a top? Is that a record? It's up there, man.

It's got to be up there. Whoa. Healthcare. Who would have thought? Who would have thought healthcare would be so complicated? And if people want these citations, where should they go? The citations are all in our transcript, which they can access by clicking on the link in our show notes

or going to our website, which is scienceverses.show. Thanks, Rose. Thanks, Wendy. Hey, while you're here, can we have a look at the Olympic Games opening with the NHS? Yeah. Olympic Games, London, NHS. Oh, wow.

Wait a sec here. There they are yeah first they're all doing like something akin to the robot but then it like morphs into like

acrobatic kind of display and look they look kind of look like they're reanimated corpses which is a bad look

for a bunch of doctors and nurses. This episode was produced by Rose Rimler, with help from Lexi Krupp, along with me, Wendy Zuckerman, Michelle Dang and Meryl Horn. We're edited by Caitlin Kenney. Fact-checking by Michelle Harris.

Mix and sound design by Peter Leonard. Music written by Peter Leonard, Emma Munger, Bobby Lord and Marcus Begala. Recording assistants from Sophie Lalonde, David DeRoach, Dennis Mailer and James Delahousie. A huge thanks to all of the people with diabetes who we spoke to. Thank you so much. Also a big thanks to Dr. Irene Papanikolas, Professor Stephen Wolfe, Dr. Kassia Lipska, Elizabeth Feister, Professor Kevin Schulman, Dr. Schneider, Dr Chris Pope, Cynthia Cox, Lois Rogers and everyone else we spoke to for this episode.

And a special thanks to the Zuckerman family and Joseph Lavelle Wilson. I'm Wendy Zuckerman. Back to you next time.