Monday, November 24, 2014
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No seguir a Estados Unidos en cuanto a atención de salud

TORONTO - En momentos que la Corte Suprema de Estados Unidos se encuentra a punto de abordar la Ley de Asistencia Asequible (la histórica reforma de salud ridiculizada por sus opositores como "Obamacare"), vale la pena señalar que el número de estadounidenses sin seguro de salud alcanzó un máximo histórico en 2010, su año de promulgación. Alrededor de 50 millones de residentes de Estados Unidos (uno de cada seis) pagan de su bolsillo los gastos médicos en que incurren.

La recesión de 2008 no es la única razón para esta escalofriante cifra; también hay que culpar a políticas y decisiones políticas de larga data. A nivel mundial, pero especialmente para las economías de rápido crecimiento, la lección es simple: evitar el modelo de salud privada de Estados Unidos.

EE.UU. es uno de los pocos países de ingresos altos que no financia la asistencia sanitaria mediante un sistema financiado con fondos públicos de prepago. En promedio, los países más ricos gastan aproximadamente el 11% de su PIB en salud, con una financiación pública de más del 80%; sólo el 14% de los gastos tienen lugar sobre una base de pago por servicio. Las finanzas públicas (o, en algunos casos, fondos de seguros cooperativos regulados por el gobierno que equivalen a financiación pública) cubren la mayoría de los servicios médicos discrecionales; los seguros privados complementan solo servicios adicionales mínimos.

La mayoría de los países ricos opta por financiar su atención de la salud de manera pública por varias razones. En primer lugar, la atención de salud de libre mercado suele ser injusta e ineficiente. Las necesidades individuales varían considerablemente, y las empresas privadas suelen ser reacias a asegurar a las personas que más lo necesitan (como quienes ya están enfermos o sufren de dolencias como la diabetes, que les predisponen a otros problemas de salud). Más aún, es improbable que quienes adquieren la atención - las aseguradoras y los pacientes - tengan la información necesaria para elegir los tratamientos más seguros y eficaces.

Al mismo tiempo, el gasto público actúa como un freno sobre el gasto general, y evita la rápida escalada de costes a la que contribuyen las empresas de seguros privadas de Estados Unidos. El país gasta el 1% de su PIB cada año, simplemente para administrar su complejo y difícil sistema de seguros. Sin una reforma del tipo que tiene ante sí la Corte Suprema de Justicia, el total de los gastos de salud de Estados Unidos aumentará de 16% del PIB hoy al 25% en 2025.

El impacto económico del sistema actual ya es grave. El último censo de EE.UU. mostró un marcado incremento en el número de estadounidenses que viven por debajo del umbral de pobreza, hecho estrechamente relacionado con la falta de seguro de salud, que a su vez refleja el exceso de confianza en la cobertura de seguro provista por los empleadores.

En las economías de los países emergentes, los gobiernos deberían tener en cuenta cinco consideraciones a la hora de diseñar los sistemas de salud. En primer lugar, las inversiones en salud proporcionan una importante red de seguridad contra las trampas de la pobreza, especialmente en tiempos de crisis económica. Por ejemplo, cada año, 37 millones de indios sin seguro caen por debajo del umbral de la pobreza debido a gastos catastróficos en salud (que por lo general se definen como costes superiores al 10%de los gastos totales de un hogar).

En segundo lugar, la financiación pública de la atención sanitaria permite a los pobres usar ese dinero para satisfacer otras necesidades. En países de bajos ingresos, la mitad de todos los gastos de atención de salud (alrededor del 2,5% del PIB) son privados (en comparación con el 2% en países de ingresos medios). Este gasto consume una gran proporción de los ingresos de los hogares más pobres, impide inversiones más productivas en el hogar, crea pocos puestos de trabajo, y con frecuencia permanece sin pagar impuestos, ya que a menudo se paga a los médicos y los hospitales "en negro".

En tercer lugar, financiar la salud con fondos públicos podría aumentar el empleo en general. Las provincias de Canadá fueron integrando de a fases el seguro nacional de salud de 1961 a 1975. El empleo y los salarios aumentaron en las áreas donde se introdujo el programa, a pesar de que el promedio de horas de trabajo se mantuvo sin cambios. Por el contrario, las provincias con altos niveles de cobertura de seguro privado tenían menores tasas de empleo y un más lento crecimiento de los salarios. Más recientemente, Canadá venció a EE.UU. al competir por dónde se crearía una nueva planta de Toyota, en parte porque los costes de seguro privado de salud en EE.UU. suponían añadir varios miles de dólares al coste de fabricación de un coche allí.

En cuarto lugar, los sistemas de salud nacionales existentes en los países más ricos pueden servir como modelos para las economías de mercados emergentes que opten por adoptar sistemas similares. Es importante destacar que las finanzas públicas no tienen por qué significar solamente la provisión pública; los hospitales y clínicas privadas a veces pueden ofrecer servicios con mayor eficacia. Taiwán inició un sistema de pagador único en 1995, frenando significativamente los costes de salud y mejorando la calidad de vida de la población. El nuevo sistema de cobertura universal de México se puso en marcha primero en las zonas más pobres del país.

Por otra parte, China constituye un ejemplo aleccionador de las consecuencias de retirar el seguro de salud financiado públicamente. A principios de la década de 1980, las reformas de mercado dejaron alrededor de 100 millones de ciudadanos rurales sin seguro, casi de la mañana a la noche. Los costes privados se dispararon, las tasas de mortalidad infantil dejaron de disminuir, y se debilitó el sistema de vigilancia de enfermedades, lo cual puede haber contribuido a la epidemia de SARS de 2002-2003, que se cobró más de 900 vidas en todo el mundo y causó pérdidas económicas por un valor estimado de $60 mil millones de dólares. El gobierno chino ha reconocido que las reformas fueron un fracaso, y se ha comprometido a destinar varios miles de millones de dólares a asistencia sanitaria financiada con fondos públicos.

Por último, siguiendo el principio, "todo el mundo está cubierto, pero no todo está cubierto", los gobiernos deben investigar qué servicios son más eficaces en función de los costes y cuáles no deben ser financiados con fondos públicos, debido a que son costosos e ineficaces. La lista de los servicios asegurados siempre puede elevarse en sintonía con las rentas y los ingresos del gobierno. En particular, el aumento de los impuestos del tabaco produce un beneficio doble: reducir el tabaquismo, la principal causa de muerte en adultos, y aumentar los ingresos.

China, India y Sudáfrica se han comprometido a adoptar un seguro nacional de salud. Cuál de estos países lo logre primero no sólo dependerá de sus ingresos, sino también de su voluntad política por superar intereses creados. También de la capacidad de las instituciones para diseñar una atención de salud racional, monitorear la entrega del servicio y valorar correctamente los nuevos tratamientos.

Los costes de salud en EE.UU. son exorbitantes, con escaso valor por el dinero. Solo cabe esperar que el "Obamacare", junto con los modelos que están implementado los futuros competidores de EEUU, le inclinen a adoptar el sistema de atención universal y con financiamiento público que hace mucho debería haber instaurado.

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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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