Stuff You Should Know - How Health Care in the United States Works Right Now

Episode Date: September 15, 2009

The United States is abuzz with talk of health care reform, but why does the system need repairs in the first place? Josh and Chuck explore how the current American health care system works (and doesn't) in this episode, the first in a four-part series. Learn more about your ad-choices at https://www.iheartpodcastnetwork.comSee omnystudio.com/listener for privacy information.

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Hey and welcome to the podcast. I'm Josh Clark with me as always is Mr. Charles W. Chuck Bryant. How you doing Chuck? Well, sir. Good. Well, that's a good word. It is for this show. This is Stuff You Should Know and actually this is a special edition of Stuff You Should

Know. Indeed. It's a four part series. Yes. Should I break it? Sure. Healthcare. Healthcare reform.

Everyone seems to be really confused about what lies ahead in the United States and our healthcare system. It's so confusing Chuck that I'm not even certain if healthcare is spelled as one word or two. I don't even know anymore. That's pretty much the level that we're at in understanding of healthcare, let alone healthcare reform. Right?

So we're trying to figure this out along with you guys so maybe you can learn something here. So, I guess let's kick it off. Let's get this ball rolling. Yeah. We're not going to talk about future plans. We're going to talk about how it is today. Yeah.

Well, in this podcast. Right. In this edition. In this edition. Part one of four. Part one of four. Yeah. It's about the current healthcare system in the United States.

Chuck, have you ever gone without health insurance? Oh, yeah. Yeah. How long? Oh, man. I seem to think that after my parents, I think this is the familiar story for everyone. Sometime around after college till I got my first real job, which was at least seven or eight years later.

Yeah. I think I did a decade. Yeah. Same story. And the parents are always on you, you know, like, oh, you know, if you had an accident and I was like, I'm invincible. Yeah. Exactly.

And luckily it worked out. No accident. Same here. I don't think it works out quite so well for everybody. Yeah. Sadly. I think that lead charmed lives. I guess we'll get to the uninsured soon enough.

So Chuck, let's go back to the beginning. 1920s in Texas, a guy named Justin Kimball founded a company named Blue Cross. Still around today, as I understand it. We understand because they have a floor right below us, I believe. That's right. That's where I've heard that name before. Yeah. We share a building.

So he started an insurance program plan where women contributed, I think, teachers specifically contributed 50 cents out of every paycheck toward their eventual maternity needs, right? So when they went to the hospital to have a baby, they were already prepaid. It's not really insurance prepaid plan. Right. Great idea. But there was something that came out of it that really gave birth to the insurance industry in the U.S., if you'll forgive the metaphor.

Sure. Not all of these teachers had kids. Bing, bing. So you could actually make money selling premiums, selling policies to people because not everybody's going to get cancer. Right. And that's how the whole system still works today. It's a gamble.

Yep. You know, Ned Flanders once said on The Simpsons, actually it wasn't Ned, Maude Flanders was explaining Ned's position that they don't have any kind of insurance because Ned considers it a form of gambling. And it really is on one side, you, the insured, are betting that at some point in time, some injury or illness is going to befall you that's going to cost more to treat than you've put in monthly payments toward your policy. I love it.

It is total gambling. The insurance company, on the other hand, is betting that you will be hit by a bus and die immediately, something along those lines where you're not going to need any kind of care. Right. There's no life and nothing happens to you, which is clearly not going to happen. I think the hit by the bus scenario is the absolute best that can happen for an insurance company.

I guess so. But so yeah, it's a form of gambling and you're going head to head with the insurance company and sometimes it pays off, sometimes it doesn't. But for the most part, it's a pretty good system basically speaking. Yeah. And you pay for peace of mind. A lot of times is what a lot of people say. You know?

You sound like a shill. I sound like I'm selling insurance. Yeah, exactly. I believe that was from Barton Fink. Was it? Yeah, John Goodman said that he sells peace of mind. Nice. Well, Chuck, let's fast forward a little bit.

By the 1940s, companies had already begun offering employer-based insurance plans. Yeah, it's a great incentive to get the best and the brightest. Definitely. And actually, still is. Because of this business, which is a sector of U.S. society, obviously part of the economy, which is what I wanted to say, but business is a sector, just like, you know, population is a sector, government is a sector, that kind of thing. Business said, we're going to take the burden of health care on our shoulders.

Yeah, sort of. In 1943, the IRS supported this and encouraged it with a ruling that said employers can pay for these programs, these plans for their employees out of pre-tax dollars, which makes the whole thing really attractive. And all of a sudden, the U.S. has what amounts to a state-sanctioned employer health care system. Right, which still thrives today. Which is good.

Same pre-tax dollars, same deal with the IRS. So the chances are good that you, if you have insurance in the U.S., you have it through an employer. Yeah, most people have insurance through their company and their employer. Not as many people have the more expensive and harder to get individual insurance. Yeah, I think 56% get it through their employer and 30% get it through the government-run program. Medicaid or Medicare?

Right, Medicaid and Medicare were created in, I think, 1965 by the Johnson administration or WJ and the S-CHIP is the other big one for children and that's state-run, like Medicaid. Medicare is for the elderly and the chronically disabled and, particularly, people with kidney failure. Yeah, renal failure. Yeah. Medicaid, as I said, it's state-run, is for other people with disabilities, the poor and pregnant women and then S-CHIP is for kids.

Yes, and that covers uninsured children under the age of 19 whose families earn up to $36,200 per year. Look at you with the stat. I've got a lot of stats. I was going to say, I sense that that's the first of many. And then, actually, there was one more that I don't know if you knew about, the high-risk health insurance pools and these are people that have pre-existing conditions that normally would not be able to get insurance at all and what they do is they group these people

together, same concept as an employee-based deal. Those are the ones you see on little $0.99 signs on the side of the road, like need insurance kind of thing. Yeah. You just get lumped together. Right. So, yeah, you just pointed out one type of insurance, which is group insurance. Most employer plans, probably all employer plans, are group insurance.

Yeah. So, because it is a group, and these are good because you usually don't have to fill out the big questionnaire about your eating habits and your smoking habits. There's no physical exam. Exactly. And pretty much anybody who wants to take part can contribute and be insured. Any employee, I should say, and usually their family, kids, that kind of thing. A very small portion of the U.S. population has individual plans.

And one of the reasons why is because you have to go through a rigorous screening process. It's not cheap. You are found to have a preexisting condition. You can be denied insurance very easily. I imagine pretty heartbreaking. And yeah, it's really expensive. It's an expensive proposition, whether you're an employer or an individual and increasingly an employee.

Right. So, we'll get to that in a minute. What are some of the types of insurance plans that are out there in the U.S. today? There's pretty much two umbrellas, right, as far as models go? I would say so. I think you're talking about the FFS, the fee-for-service model, and then the managed care model. You know me so well.

I know. Which under the managed care is when you hear about HMOs and PPOs and POS, and those are all managed care. Yeah. I guess the main characteristic of fee-for-service is, and this is the original model for insurances. Yeah. Indignity insurance approved is nothing important. You pay your monthly premium, and you're insured.

You come down with the cold. You go to the doctor. The doctor cures you. He gives you a Coke and says, drink this, and you'll be fine. All right. And smoke the cigarette. Right. Yeah.

This is the 1940s. Yeah. And you pay the doctor. You file some paperwork, and your insurance company reimburses you, and you go along your merry way, continuing paying your monthly premiums again. Right. This is kind of the old school model, like what our grandparents probably had. Right.

And then I think in the 80s, the HMOs came about. Managed care became much more popular than the FFS model. And actually, there's some plans that kind of combine the two. But with managed care, with fee for service, the emphasis is on treatment. With managed care, there's more emphasis on prevention, supposedly. And that's where it really, that's one of the big sticking points with this whole mess that we have in this country, is a lot of doctors and a lot of managed care still don't practice enough preventative care, they say.

Right. The center of the managed care model is a primary physician who's supposed to know you, know your family, know your history, know that you eat more donuts than you should, know that you lied on your insurance form when you said you don't smoke, and is saying you're going to get diabetes, you're going to get lung cancer. Somebody who knows you, who you've seen and who you can trust to kind of guide and manage your health. Right.

They're kind of a dying breed, too, sadly. Definitely. And there's a good reason why, Chuck, you read that CNN article. Yeah, that was distressing. Actually, it was an editorial by Dr. Vance Harris, I believe. Yes. And he basically gave a rundown of why the primary care physician is becoming a dinosaur, right?

Yeah, it was pretty depressing, actually. So he was saying that for every several thousand dollars, he saves the healthcare industry by using his medical training to actually make diagnoses, rather than really expensive screenings like MRIs. Treatment as opposed to procedure. He said that for every several thousand dollars he saves the industry, he makes 50 bucks. Yeah. 75 bucks.

I know. So primary care physicians are not making a lot of money. What's more, there's a lot of issues surrounding malpractice. On one hand, you can say, well, the very fact that there's malpractice lawsuits out there, and they often add up to astronomical amounts of money being paid out to people who are found to have been the victim of malpractice, doctors are a little nervous about relying on their medical training to make a diagnosis. When there's an MRI machine in the next room, that they can just say, this is going to solve

it one way or another, I'll know for a fact. And then at the very least, even if I miss it, I could say, well, the MRI manufacturer screwed up. There's a lot of passing the buck because of that supposedly, but there's another way of looking at that, correct? Well, medical malpractice is, you hear a lot about doctors saying, that's driving us out of business. We can't afford the premiums.

We have too many patients. We haven't a squeeze in patients that come in for, you know, because they're worried. I know CyberCondria feeds into it. People read on the internet. I've got reflux. They need to get an endoscopy and they go in there and demand one. Which I mean, really, it's there. It's your right.

You're a patient and you want to make sure that you have a healthy body. It's tricky business though. It is because what did you call it, CyberCondria? Yeah. Excellent. It's an argument that's often used against pharmaceutical companies advertising on television. You get the impression that they are educating the consumer to say, hey, here's the words you use when you talk to your doctor to get our pill.

You know, I mean, how much of an effect has that had on over prescription? I'm sure a bunch and there's so much information out there now. That's the first thing I do. I diagnose myself on the internet all the time and I know a lot of people do that. Do you really? Oh yeah, man. What do you have? I like that reflux.

Do you? Huh? Big time. You're not much of a complainer, Chuck. Oh, shut up. No, really. I had no idea you had reflux. Like a bad reflux, dude.

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the future of transportation. Let's take it back to, can we talk about malpractice again real quick? Oh yeah. I do have a study. Please. Let's talk about how those costs are driving doctors out of business. I'm not saying one way or the other, I'm just going to throw this study out. The Americans for Insurance Reform, they are a coalition made up of Consumer Federation

of America, ConsumerWatchDog.org, and 100 other public interest groups. They released a study this week, actually, that found that malpractice premiums are down and at the lowest they've been in 30 years. Malpractice claims are down 45% since 2000. In states where the states have limited the consumer's ability to sue for malpractice, premiums are about the same as in other states. So I'm not saying they're not paying a lot and it's not putting a dent, but they do say that malpractice claims only constitute one-fifth of 1% of annual health care costs

in the United States. So that's kind of an obsolete argument these days. Well, it may be a little overblown. I mean, of course, tell the doctor that has to pay a lot of money, but from what I read, it's not the central problem, like some people say. Like it needs reform, it needs to be controlled by the government, who knows. I'm just here to report the facts. And you did an excellent job of it.

Let's go back to talking about where you get your insurance, right? We talked about employer-based plans. We talked about people who get their insurance individually. People who get it from the state. And then there's another group known as the Uninsured. Yeah. And this is where it gets really hinky. The number of the uninsured is kind of all over the map right now.

Well, yeah. And also, it's one of the central foci of the insurance or health care reform debates. Well, it has to be. That there's 45, actually, as far as August 2009 Census Bureau figures, 45.6 million uninsured Americans, that if you are a person who believes that health care is a human right, you think that these people should be covered in some form or fashion, right? Right. And they're really nitpicking this number because this number, the number of uninsured

is largely what a lot of the financing is going to be based on. Yeah. They're trying to project a decade into the future. And if they don't get that number right, the money doesn't work out, then that's when you're really screwed. Well, sure. We were saying that not everybody's on the same page with who the uninsured are, how many there are.

There's a guy named Michael D. Tanner of the Cato Institute. I mean, he pointed out that- Our favorite think tank, right? Actually, I'm more of a Brookings Institute fan. Oh, man. Cato's pretty good. It used to be all about Cato. I was. I'm still am I, but I like Brookings these days.

You've changed. And so Tanner points out that about 12 million of the 45.6 million people who are uninsured in the U.S. are eligible for Medicaid or S-Chip. They just haven't signed up. True. Well, maybe true. It's a really good point. Yeah.

He also points out that if they ever go in for treatment, that should pop up in whatever patient data that the administrator takes in and they'll be automatically enrolled in whatever program suits them. Right. Right? So that takes care of 12 million. One of the ones I don't necessarily agree with, and I think people who think that healthcare is a universal human right would disagree with very much, is he points out that about

10 million of these people who are uninsured in America aren't Americans. Right. If you're a legal- It depends on- When you start looking at these numbers, I started looking around. People are throwing all kinds of numbers around. Everybody's got a number for this. Just because it's hard to count and account for these people, they're generally illegal immigrants aren't going to step forward and say, you know, count me on your report.

Right. So that's one reason. But Tanner also makes one last point that you and I are kind of anomalies, Chuck, in having gone several years without insurance when we were younger men. About 50% of the uninsured in the U.S. go six months or less without insurance. Right. Because 45.6 million Americans, even if the number remains the same, who makes up this population is changing constantly.

Right. It's a snapshot, basically. That's all is one person put it in one of the articles you sent me. So yeah, exactly how many uninsured people there are and who they are is kind of a big part of this debate about whether, you know, healthcare needs reform. Actually, let me correct myself. I haven't run across anybody who says that healthcare doesn't need reforming, have you? No.

No. Everybody agrees that there's something wrong with that. That it's broken. And the World Health Organization would probably agree with that stuff. Well, hold on. First, let's talk about some of the different arguments. There's some people who say that public healthcare is nothing more than just a weak part of the American welfare state and why should my taxes pay for some other guy's health insurance

when I'm paying through the nose. You could say that competition might ease this, giving people vouchers to go buy their own insurance might make them a little more penny-wise with how they spend their money. Really ultimately, what seems to be agreed upon by everybody is that the American healthcare system is too expensive for what it provides. Big time. So let's talk about this. You mentioned the World Health Organization.

This was huge. And this still, the study was from 2000. And it remains a real piece of ammunition that's used many different ways in the debate on healthcare reform. Yeah. It was a groundbreaking study. And like you said, we are the most expensive. We spend more money on healthcare than anyone in the world.

When we spent 16 in 2008, we spent 16.6% of our GDP on healthcare. Not just government spending, but just across the board, 16.6 of the market, 16.6% of the market value of the United States in that year was spent just on healthcare. That's more than defense, buddy. I know. So do we. We were in Iraq and Afghanistan at that time. If you give me a number like that, I would say in response, Josh, that of the 191 countries

you say study, then that probably means that we're at the top of the list then for what you get for your dollar. You would think we should be since we have the most expensive and technologically sophisticated healthcare system in the world. Top 10. I would say top 20 at least. You would think. Oh, where we should be?

Yeah. I mean, I'm not going to go easy. Yeah. But I'm going to give you some leeway and say top 10. Okay. What is it really? Where did we write? 37.

37. In the world. Out of 191 countries. Do you know who is just above us? Costa Rica. Awesome. You know who is just below us? Who?

Slovenia. Wow. Yeah. That's where the U.S. ranks. If this were the Olympics, we would be ashamed. Nothing against Slovenia, but yeah, since we have the most expensive healthcare system in the entire world on the planet, we should by proxy have the best healthcare system is rated by the World Health Organization.

You want to hear something else chilling? Well, Americans' life expectancy is lower than Canada, half of the Caribbean, including Puerto Rico and Cuba, Chile, all of Western Europe, some of Eastern Europe, Israel, Jordan, Singapore, Hong Kong, Japan, Australia, and New Zealand. Our life expectancy is lower than all of those countries. Wow. And I'm not necessarily saying that definitely means that their healthcare system is so much better, but it probably lends itself to that argument.

I know the article you're referring to, Chuck, and it references a study from the New England Journal of Medicine from about 10 years ago that showed that the average black man in Harlem was less likely to reach age 65 than a man in a Bangladesh. That is messed up. That's not supposed to be. No. Not when you're spending the... And we're not saying because America is so much better, it's because we spend the kind

of money we spend. Right. You expect better results. There are a lot of people who have agreed on it. The other point to this is, by the way, we spent $2.4 trillion in 2008 on healthcare, right? Healthcare spending and costs continue to increase, but as someone else pointed out, in 1996, our mortality rate flattened.

It hasn't gotten better since then. So in short, the U.S. is not getting enough bang for its buck as far as its healthcare system is. We're happier, but we're certainly spending more money. What's going on? You're ready to travel in 2023 and since 1981, Gate One Travel has been providing more of the world for less. Let Gate One handle the planning for you with affordable escorted tours and European

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called crowdfunding? Less than 15 years ago, a mechanism like this wasn't available, making it difficult for common people to get in on early game-changing ideas in companies like Apple or Tesla. Today, crowdfunding gives you the chance to contribute to small companies you believe in and make a difference in the world. One company using this method of fundraising, Apptera Motors, is accepting investments to produce one of the world's first never-charged solar electric vehicles. With its integrated solar package and unique aerodynamic shape, Apptera requires no charging

for most daily use. That's in addition to its 1,000-mile range battery pack. To invest.apptera.us, that's invest.apptera.us to get in on the investment opportunity that's creating a future free from the gas pump and the charging station. With as little as $1,000, you can join over 15,000 investors to help Apptera transform the future of transportation. Well, I mean, there's a, jeez, there's a lot of reasons. I know one thing a lot of people point at is the aging baby boomers and out the age

where they need a lot of care in the hospitals and by doctors. There are fewer and fewer doctors and nurses, so they're not getting as good a care and there's more, I think they just call them medical errors in the article I read because of understaffing. That's one reason. What you're talking about could actually be considered symptoms. And we should probably say just for COA that if you put Jerry and Matt in here, you would get a totally different podcast with all the same research.

There are so many ways of looking at this issue that all you and I can do here, Chuck, is try to get to the central focus of it without leaning into partisan politics or anything like that. Right, right. It seems to me from what I saw come up time and time again from sources on both the left and the right, pro-business, pro-labor is that the American healthcare system is too sophisticated. It's too advanced and patients have too much access to it, too much, you could say frivolous access to it.

So that MRI scan we were talking about, the ones that a patient might demand. The patient demands it because that money that goes toward your employer-based insurance policy comes out of your paycheck. And so right there, this is money you haven't even seen. It comes out before your paycheck is deposited into your account. Secondly, it's relatively cheap and when you go to the doctor, you're not actually shelling out money. No, you're co-pay.

Right. So you have no real incentive to be cheap. What was the Simpsons episode you were talking about? Do you remember the one where Homer and Lisa go into isolation tanks, which by the way I did recently and it was cool. And Homer's isolation tank is repossessed while he's in there. And one of the laborers who's repossessing this thing tells the other one to lift with his knees and the other guy goes, screw it, I've got health insurance.

And that's kind of the attitude some people take is I'm paying for this, I'm going to get my money's worth out of it. Exactly. And I'm going to go demand the camera down the throat instead of trying to treat it and see if they're not eat chocolate and red wine right for you. That's the other thing that it betrays is that we aren't taking responsibility for our own health as Americans we don't. And that's where it has to start, buddy.

Definitely. And part of that is putting that focus back on prevention again rather than treatment because consider this. If you have an advanced disease, how much more rigorous is your treatment going to be? How many more doctors visits does that entail? How many more scans does that MRI scan does that entail? How much more medication? Right.

And don't get me started on the pharmaceutical companies. Yeah, that's a different podcast. How much more time and effort and just cost is it going to take to treat an advanced disease than it's going to be to prevent it or treat it early on? Exactly. This is like when they recommend I think 40 or so for women to start getting your mammogram and for men to get the old how's your father treatment from your doctor. These kind of things.

My poor dad. People avoid this stuff. And then all of a sudden you have, like you said, holy cow, got a tumor that's in an advanced stage because I haven't taken care of myself and I haven't done the regular checkups like I need to and it costs a lot more. So this infrastructure that we're talking about, the health system infrastructure, it keeps growing and growing. It costs a lot to manufacture an MRI machine and I keep using that but it's just such an

easy example. And as a result of just not just the MRI machine but all of these different external factors and possibly corporate greed from 2004 to 2009, the average cost on health care premiums increased four times faster than the average wage in the U.S. So all of a sudden health care is just getting more and more and more expensive and not just for you or me, Chuck. We are premium from 1999 to 2009. The employee contribution went from an average of $1543 to $3,354.

That's just our contribution. This isn't including employers' contributions which is affecting their bottom line and as health care costs rise, they're losing a competitive edge in the global market in an increasingly globalized world. And all businesses have budgets. They work on budgets that also might affect the raise you might or might not get because of the budget and how much they're having to spend. I know my father-in-law has a small business and dude, he has a really small business.

He only has a handful of employees but he has a health insurance program. And one of the ladies that works with him is one of these people that does not take care of herself. She has like three or four surgeries a year and it's driving him out of business, dude. This one lady. Yeah. And let me tell you something else. What?

Buddy. The organization estimates that between 19 and 24% of the total dollars spent on health care here is spent on administrative costs. Wow. Administrative costs. Yeah. And another reason that it's so expensive is there's been a big shift, I don't know if you've noticed, in for-profit hospitals as opposed to the old non-profit model.

The community model. And that's kind of helped drive up prices too, so they say. Well sure, not only that but the uninsured drive up prices. And the Medicaid and Medicare are notoriously terrible on paying out billing to physicians. Hospitals have started to use something called balance billing where they start billing patients for procedures they didn't know they weren't covered for. And the insurance company is refusing to pay and all of a sudden you've got a collection agent all over you because the hospital didn't say, oh by the way, this doctor right here

who you're about to see is out of your network so you're going to have to pay for him out of pocket. There's just, there's, we have big problems here. Yeah. No kidding. So Chuck, how do we solve this? I have no idea. Other people do.

Thank heavens for that. Well, one of those people is a man named Mr. Barack Obama, you may know him as President Obama. Sure. He's got a plan for healthcare reform and we're going to cover that in the next installment of the podcast, Barack Obama's healthcare reform plan soup to nuts. Yes. So again, this is kind of a weighty topic and we're going to need some help.

So we're going to recruit Molly Edmonds, right? Molly Edmonds of Stuff Mom Never Told You, popular sister podcast and our healthcare writer. Well, yeah, she's been completely submerged in healthcare for the last three weeks. Health in general. She's our health writer. She is, but she's been studiously studying healthcare reform. So she's going to come in for the next few podcasts to help us sort through things.

We can rely on her a little bit and we also spoke to Dr. Michael Royson, who is the chief wellness officer of the Cleveland Clinic. Yes. And more famously known as co-author of the you, the owner's manual series of books. With Dr. Oz. We got him on the phone. Yeah. He was awesome.

So it's going to be like a whiz bang, super big healthcare reform podcast and hopefully by the end you will know as much as Molly Edmonds, which is substantial. So stay tuned for the second episode, which will be out in a week. And in the meanwhile, you can go to howstuffworks.com, type in healthcare in our handy search bar and you're going to find a slew of really thoroughly researched and well written articles by Molly Edmonds. And if you want to send us an email about healthcare or anything else, you can shoot that to stuffpodcast at howstuffworks.com for more on this and thousands of other topics.

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