Thursday, July 31, 2014
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Amerikas Gesundheitswesens: kein Vorbild

TORONTO – Die historische Reform des US-amerikanischen Gesundheitswesens, der Affordable Care Act, von Gegnern als „Obamacare“ verschmäht, liegt dem Obersten US-Gerichtshof zur Entscheidung vor, und das ist Anlass genug, daran zu erinnern, dass die Anzahl der Amerikaner ohne Krankenversicherung 2010, in dem Jahr, in dem das Gesetz erlassen wurde, ein Rekordhoch erreichte. Ungefähr 50 Millionen US-Bürger (ein Sechstel der Bevölkerung) zahlen ihre Arztrechnungen aus eigener Tasche.

Die Rezession von 2008 ist nicht der einzige Grund für diese erstaunliche Zahl, auch langfristige politische Entscheidungen sind dafür verantwortlich. Global, aber besonders für schnell wachsende Volkswirtschaften, ist die Lektion einfach: das amerikanische Modell der privaten Gesundheitsversorgung ist zu vermeiden.

Die USA gehören zu den wenigen Ländern mit hohem Einkommen, die das Gesundheitswesen nicht durch ein öffentliches Versicherungssystem finanzieren. Im Durchschnitt geben die wohlhabenderen Länder ca. 11 Prozent ihres Bruttoinlandsproduktes für das Gesundheitswesen aus, davon sind mehr als 80 Prozent öffentlich finanziert, und nur 14 Prozent der Ausgaben betreffen Leistungen, die von Patienten direkt bezahlt werden. Die öffentliche Finanzierung (bzw. in einigen Fällen staatlich regulierte Versicherungsfonds, die auf eine öffentliche Finanzierung hinauslaufen) deckt die meisten ärztlichen Leistungen ab, die Privatversicherungen tragen nur ergänzend mit minimalen Extraleistungen dazu bei.

Die meisten reichen Länder haben sich aus verschiedenen Gründen für eine öffentliche Gesundheitsversorgung entschieden. Erstens ist eine private Gesundheitsversorgung meistens ungleich und ineffizient. Die Bedürfnisse einzelner Personen sind von erheblichen Unterschieden geprägt, und private Unternehmen sind oft nicht bereit, gerade diejenigen zu versichern, die eine Versicherung am dringendsten benötigen (zum Beispiel Personen, die bereits erkrankt sind oder die an Erkrankungen wie Diabetes leiden, die sie anfällig für weitere Erkrankungen machen). Zudem ist es unwahrscheinlich, dass diejenigen, die Pflegeleistungen kaufen – Versicherer und Patienten – über die notwendigen Informationen verfügen, um die sichersten und effektivsten Behandlungen auszuwählen.

Gleichzeitig bremsen öffentliche Ausgaben die allgemeinen Ausgaben und verhindern eine schnelle Kosteneskalation, zu der Amerikas Privatversicherer beitragen. Die Verwaltung des komplexen und unübersichtlichen Gesundheitswesens kostet die USA jährlich ein Prozent ihres Bruttoinlandsproduktes. Ohne eine Reform der Art, wie sie nun dem Obersten Gerichtshof vorliegt, werden die Gesundheitsausgaben von den aktuellen 16 Prozent des Bruttoinlandproduktes bis 2025 auf 25 Prozent steigen.

Die wirtschaftlichen Auswirkungen des aktuellen Systems sind bereits erheblich. Die letzte Volkszählung in den USA ergab einen deutlichen Anstieg der Amerikaner, die unterhalb der Armutsgrenze leben, eine Tatsache, die eng mit einer fehlenden Gesundheitsversorgung verbunden ist, was wiederum die extreme Abhängigkeit von einer Versicherung durch den Arbeitgeber reflektiert.

Die Regierungen der Schwellenländer sollten fünf Dinge berücksichtigen, wenn sie ein Gesundheitswesen aufbauen wollen. Zunächst bilden Investitionen in Gesundheit ein wichtiges Sicherheitsnetz gegen die Armutsfalle, besonders in schwierigen ökonomischen Zeiten. In Indien zum Beispiel fallen jedes Jahr 37 Millionen nicht versicherte Inder aufgrund von horrenden Gesundheitsausgaben unter die Armutsgrenze (berücksichtig werden normalerweise Ausgaben, die mehr als zehn Prozent der Gesamtausgaben eines Haushalts überschreiten).

Zweitens erlaubt es die öffentliche Finanzierung des Gesundheitswesens den Armen, ihr Geld für andere Bedürfnisse zu nutzen. In Ländern mit niedrigem Einkommen wird die Hälfte aller Gesundheitsausgaben (ca. 2,5 Prozent des Bruttoinlandsproduktes) aus eigener Tasche bezahlt (verglichen mit zwei Prozent in Ländern mit mittlerem Einkommen). Diese Ausgaben verbrauchen einen großen Teil des Einkommens armer Haushalte, verhindert produktivere Haushaltsinvestitionen, schafft weniger Arbeitsplätze und wird oft nicht versteuert, da Ärzte und Krankenhäuser häufig schwarz bezahlt werden.

Drittens könnte ein öffentlich finanziertes Gesundheitswesen die allgemeine Beschäftigung erhöhen. Die kanadischen Provinzen haben zwischen 1961 und 1975 in verschieden Phasen eine staatliche Krankenversicherung eingeführt. Dort, wo das Programm eingeführt wurde, stiegen Beschäftigung und Löhne, auch wenn die allgemeinen Arbeitszeiten unverändert blieben. Provinzen mit einer hohen Privatversicherungsrate verzeichneten dagegen niedrigere Beschäftigungsraten und ein langsameres Lohnwachstum. Kürzlich gewann Kanada vor den USA eine Ausschreibung für ein neues Werk von Toyota, unter anderem, weil die Kosten der privaten Krankenversicherung in den USA die Produktionskosten eines Fahrzeugs dort um mehrere tausend Dollar teurer gemacht hätten.

Viertens dienen bereits bestehende Gesundheitssysteme in wohlhabenderen Ländern als Vorbild für Schwellenländer, die ähnliche Systeme einführen wollen. Wichtig ist hierbei, dass eine öffentliche Finanzierung nicht heißt, dass die Leistungen durchweg staatlich sein müssen. Privatkrankenhäuser arbeiten unter Umständen effizienter. Taiwan hat 1995 ein Einzelzahlersystem eingeführt, dadurch konnten die Kosten des Gesundheitswesens erheblich verringert und die Lebensqualität der Bevölkerung verbessert werden. Das neue allgemeine Krankenversicherungssystem in Mexiko wurde zuerst in den ärmsten Teilen des Landes eingeführt.

China liefert andererseits ein ernüchterndes Beispiel dafür, was passiert, wenn die staatlich finanzierte Gesundheitsversorgung zurückgezogen wird. Anfang der 1980er Jahre waren nach einer Marktreform circa 100 Millionen Menschen in den ländlichen Gebieten fast von einem Tag auf den anderen nicht mehr versichert. Die direkt gezahlten Kosten schnellten in die Höhe, die Kindersterblichkeitsrate nahm nicht weiter ab, und das Krankheitsüberwachungssystem war geschwächt, was vielleicht zur der SARS-Epidemie 2002-2003 beigetragen hat, die in der ganzen Welt mehr als 900 Millionen Opfer forderte und einen wirtschaftlichen Verlust von ungefähr 60 Milliarden US-Dollar verursachte. Die chinesische Regierung hat anerkannt, dass die Reformen ein Flop waren und sich nun dazu verpflichtet, mehrere Milliarden Dollar in eine staatlich finanzierte Krankenversicherung zu investieren.

Schließlich müssen Regierungen, frei nach dem Prinzip „jeder ist versichert, aber nicht alles”, herausfinden, welche Leistungen am kostengünstigsten sind und welche nicht öffentlich finanziert werden sollten, weil sie teuer und ineffizient sind. Die Liste der versicherten Leistungen kann mit den Einkommen und den staatlichen Einnahmen wachsen. Besonders höhere Tabaksteuern haben gleich einen doppelten Nutzen: sie reduzieren das Rauchen, einer der führenden Ursachen für das Sterben von Erwachsenen und erhöhen die Einnahmen.

China, Indien und Südafrika haben sich alle verpflichtet, eine nationale Krankenversicherung einzuführen. Welches Land sein Ziel zuerst erreichen wird, hängt nicht nur von den Einnahmen ab, sondern auch von dem politischen Willen, etablierte Interessen zu überwinden. Es hängt auch davon ab, ob die Institutionen fähig sind, ein rationales Gesundheitswesen zu entwerfen, die Ausführung zu überwachen und neue Behandlungen korrekt zu beurteilen.

Die Gesundheitskosten in den USA sind exorbitant und haben zudem ein schlechtes Preis-/Leistungsverhältnis. Man kann nur hoffen, dass „Obamacare“, zusammen mit den Modellen, die von den zukünftigen Konkurrenten der USA diese letztlich dazu bewegen wird, ein lange überfälliges, staatlich finanziertes Gesundheitssystem einzuführen.

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  1. CommentedBJ Beard

    This opinion piece does not cite a single source for the claims used to support its arguments, while relying heavily on irrelevant coincidences. It doesn't mention the imploding of the British National Health System, nor the cash profits of Cuba's medical tourism that does not provide adequate minimal care to Cubans excluded from those facilities, nor its profits from renting out its doctors overseas. It doesn't address the long waits for tests and treatments in Canada that are non-existent in the USA. My dog got an MRI within 24 hours of her veterinarian ordering one within 4 miles of home. I can get a CAT scan within 2 miles of my house within one hour if I need it. I personally have met hundreds of "snowbirds' who purposely come to my state annually for world-class healthcare they can afford here but can't get in their home Province. Some facts about American healthcare that eviscerate the author's over-generalized unresearched premise and conclusion: 1. The decline in Americans carrying health insurance since the start of the Obama Recession correlates to unemployment reaching and sustaining Great Depression levels of 9% officially registered and 17-21% when self-employed ineligible for benefits, entry level young people who have not worked enough yet to get benefits and be countede cannot enter the workforce, those who have been unemployed so long they no longer receive benefits, and those who began collecting government disability income when unemployment benefits ran out are counted. 2. A percentage of low-risk Americans have always chosen to forego health insurance premiums - healthy young adults just out of school working in entry level jobs paying all their own living expenses for the first time, buying cars, taking vacations, retiring student loans, then saving for a first home. Upon marriage and family responsibilities they prudently begin to carry health and life insurance. It is a matter of personal priorities and choices. Many self-employed do not carry health insurance during the early years of building their business, and add it later when they have a few employees for whom they wish to offer the benefit with wages. At that point the small group coverage became an affordable business expense - which will disappear under the new healthcare law, forcing people into "pools." The ability to choose how to respond to a variety of life's risks, and to run one's own life is the essence of America, and seems to have served the country well over the long haul. 3. "Poor" people tend to be covered by Medicaid (state health insurance for the poor), also paid for through federal taxes, and almost exclusively provided at government facilities by government employees, are: the Armed Forces Health Services, caring for military and their dependents, Veterans Healthcare (federally funded The Obama Administration released its FY2011 budget on February 1, 2010. It requests $48.8 billion for VHA for FY2011, an increase of $3.7 billion over the enacted amount in FY2010. Furthermore, the Administration is requesting $50.6 billion in advance appropriations for FY2012 for the three medical care appropriations: medical services, medical support and compliance, and medical facilities. The majority of veterans who qualify for VA care prefer private healthcare service and can get it. Anyone like me who has considerable personal experience with both private and VA healthcare facilities and service can instantly see the glaring differences in favor of private and "would give their eye teeth" to avoid using the VA. Thank goodness the majority of us DO still have the CHOICE. Bureau of Indian Affairs Health System (federally funded Population Served: Members of 565 federally recognized Tribes
    2 million American Indians and Alaska Natives residing on or near reservations Annual Patient Services (Tribal and IHS facilities):Inpatient Admissions: 50,349
    Outpatient visits: 11,778,527 Dental Services: 3,568,201
    FY 2010 IHS budget appropriation: $4.05 billion Total IHS employees: 16,159 (70% are American Indian/Alaska Native) Includes about 900 Physicians, 2700 Nurses, 350 Physician Assistants/Nurse Practitioners, 300 Dentists, 650 Pharmacists, and 650 Engineers/Sanitarians. The remaining 10, 609 65.65% are bureaucrats.) Additionally, the FY 2009 budget included several proposals affecting the State Children's Health Insurance Program (SCHIP): Reauthorizes SCHIP through FY 2013 (at a cost of $19.7 billion over 5 years);
    Limits coverage to children at or below 200 percent of the Federal poverty level, which was, according to the budget materials, what the program "originally intended";
    Establishes outreach grants to support enrollment initiatives (a cost of $50 million in FY 2009 and $100 million in each of FYs 2010 - 2014; and Clarifies what counts as "income" when determining enrollment eligibility According to the budget materials, the SCHIP proposal would cover 5.6 million low-income children by FY 2013 and nearly nine million at some time during the year. Note that the US Health and Human Services definition of "poverty" is more generous than the Census Bureau's for determining eligibility, and does not include the value of other government subsidies for housing, aid to dependent children, food stamps, or disability benefits. For fiscal 2011 it is: 2011 HHS Poverty Guidelines Persons in Family 48 Contiguous
    States and D.C. Alaska Hawaii
    1 $10,890 $13,600 $12,540
    2 14,710 18,380 16,930
    3 18,530 23,160 21,320
    4 22,350 27,940 25,710
    So 200% for a family of 4 is an income of $44,700. The federal minimum wage is $7.25/hr or $15,080/yr - most states have enacted higher minimum wage laws.

    Those who aren't covered by a state or federal program simply haven't applied for it, despite the government spending millions annually to "recruit" them. The total number of people who do not have health insurance or government care is, by Health and Human Services' own calculation, 11 million out of 310 million people, a total population that includes 15 million non-citizen residents. 4. American hospitals have been legally required for 60 years to treat all regardless of ability to pay. Since 50% of those hospitals are non-profit charitably or religiously funded, most were doing so anyway. For example The Shriners Hospitals for Children are world-class and all treatment is free and funded by private donation. Everyone in the USA has access to quality healthcare. 5. The single largest driver of healthcare cost increases since 1960 has been Medicare - the artificially low-cost federal insurance program for seniors. Because it covers so much for our highest-cost users of the system, but pays so much below market price for services, providers must make up the difference by raising fees on the other patients, and thus their insurance - somebody has to pay. Health insurance premiums thus outpaced inflation in increases every single year. Further, the bureaucratic overhead, in paperwork to process claims, government reporting, and government employees required to administer federal healthcare (Medicare, Veterans, Indian, and State Medicaid) skyrocketed, due to lack of market accountability, efficiency, and patient interest in controlling expenses - the government workers and the recipients are all on an anonymous someone else's dime. Corruption and fraud to the tune of millions of dollars in claims in the government systems have been aided by the very ponderous bureacracy, which had no incentive to catch and stop it. In a suburb of my town, a fellow signing people up for motorized wheelchairs and "scooters" for the $6,000 apiece to be paid by Medicare filed thousands of fraudlent claims and pocketed over a million dollars before a whistleblower caused investigation in 2009. Public spending on healthcare is crippling state budgets. In my state: In order to cover Arizona’s large deficit, Gov. Jan Brewer and other Arizona lawmakers approved a budget earlier this year that cut Arizona’s Medicaid program, also known as the Arizona Health Care Cost Containment System or AHCCCS. The current AHCCCS program covers 1.3 million people in Arizona. That is 20 percent of the entire population as well as 20 percent of the patients treated by each private hospital system, and over 70 percent of the patients treated at county and state hospitals and university teaching hospitals.

    The first change to this program came on May 1 when enrollment for the AHCCCS “spend down” program was frozen. This program covers people who normally would not qualify for AHCCCS, but who have sustained medical expenses that reduced their income to below 40 percent of the federal poverty level. Without medical expenses, these people's income would not qualify as "poor." Taxpayers receive a tax deduction of 100% on annual medical expenses at or above 6% of their income.

    The next set of changes to the AHCCCS program will go into effect on July 1st. These changes include:

    •The elimination of enrollment for childless adults.
    •The elimination of enrollment for parents earning 100 percent of federal poverty level. (The children themselves are still covered 100% by the federal SCHIP program.)
    •The elimination of Federal Emergency Services (for non-qualified aliens, of which the poor economy has reduced our state's numbers from 500,000 to 360,000).
    •Current enrollees will be required to have eligibility redetermined in 6 months. (Thousands have been kept on the benefit rolls for years after no longer qualifying, enabling them to opt out of enrolling in coverage offered by their employers.)
    •There will be more mandatory co-payments. (More than 70% of services presently have no co-payment. Typical co-payments for privately insured citizens are $5 to $15 until a maximum annual figure is reached.)
    •And there will be new benefit limits, such as for emergency room visits and inpatient days. (The typical government-subsidized patient uses emergency services at a rate six times that of non-government subsidized patients.)
    Then on Oct. 1st, there is yet another change. AHCCCS will cut the payments to health care providers by five percent. This reduction of payment is in addition to the previous deduction of five percent that occurred on April 1st. ( Physicians estimate they will need to cut back on the number of AHCCS paid patients they see as a result. Due to government regulation and paperwork, in addition to their own insurance, equipment, and staff costs these patients cost more to treat than private payors or privately insured patients. One such additional expense, embedded in the 2008 "Stimulus" Bill to begin preparation for "Obamacare" was a requirement that all physicians report all treatment of all patients to the federal government electronically - not just any treatment for an infectious disease or condition the Center for Disease Control wants to study. That alone added $20 to the cost of every doctor visit. State aid healthcare patients also tend to sue service providers at a rate seven times higher than non-government subsidized patients. Law firms that specialize in this abound.)
    The statement "In particular, higher tobacco taxes yield a double benefit: they reduce smoking, a leading cause of adult death, and raise revenue." is a half-truth at best. Tobacco taxes pour millions into American healthcare and education systems annually, but is not spent on care for smokers. The leading cause of death in the US is not smoking (users are 20% more likely to develop cancer than non-users) but rather heart disease and other deadly ailments caused significantly by diabetes, obesity, and, golly, aging!
    This assertion by the authors would be right if turned on its head "At the same time, public spending acts as a brake on overall spending, and prevents the rapid cost escalation to which America’s private insurance companies contribute. The US spends 1% of its GDP annually simply to administer its complex, unwieldy insurance system. Without reform of the type now before the Supreme Court, total US health expenditures will rise from 16% of GDP today to 25% by 2025." It SHOULD READ "America's private system ENJOYS a 1% administrative cost, compared to a 25% administrative cost for its government healthcare, which does not have to account for costs of capital expenditures and numerous other line items ordinarily included in business budgets. This benefits research and development, and service delivery. For the last 50 years, public spending on healthcare has driven up costs at double or triple the inflation rate, whereas before public spending, health care cost increases remained in line, or were below general inflation, due to continued improvements in diagnostics, treatment, and private sector efficiencies responding to market needs. Also by the government's own estimates, DUE TO OBAMACARE, the percentage of the GDP that will be sucked up by healthcare instead of productive industry will rise from 16% to 25%, and its costs will be 400% higher in the first decade than what was claimed to the American taxpayer when it was rammed through Congress unread by the legislators. America is dedicated in its charter to personal liberty, which Obamacare violates with an unconstitutional tax requiring personal participation in public healthcare with a requirement to purchase it, despite heavy taxation for it already. To implement it, a majority need to be persuaded it trumps freedom enough to fundamentally change our national Constitution. The majority are not even remotely persuaded to forsake freedom for inferior medical care at a higher cost.
    The authors can prefer public healthcare on ideological grounds, but are disingenuous at best in their attempt to defend it on economic or quality terms when using America as their bogeyman.


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