Healing America - Part I

This last year, T. R. Reid, author of The Healing of America (July 09), traveled the world to examine how other countries deliver health care, in comparison to USA’s. I’ll, in part, use this book’s information to probe debatable propositions that my friends (Virgil and Staton, my brother-in-law) offered in response to “A Damascus Experience.” Each of their comments is posted on Critical Actions: (click to read) Virgil’s ADE Response and Staton’s ADE Response. Part II, forthcoming, will address the political aspect of their debate. For that, I’ll in part use Sam Tanenhaus’ latest book (July 09) as counterpoint. Tanenhaus puts in historical context, giving reflective, retrospective understanding of movement conservatism (alongside moderate to more liberalist) over the last forty-to-fifty-some years. (Forward, quotation marks will enclose exact quotes from the Reid’s book.)
Reid dedicated The Healing of America to General-President Dwight D. Eisenhower. The Supreme Allied Commander during WWII discovered the German autobahn expressway system built in the 1930s. To great advantage military trucks, tanks, and troop carriers moved much faster than Ike had planned. As a classical-conservative Republican, when elected President of USA in 1952 (1953-1961) and was presented with rather timid plans for a two-lane highway network across America, he trashed the plan for (if you will for a Nazis idea) comparative-German-master-plan USA Interstate system. Today, we have 47,000 miles, 55,500 bridges, 14,500 interchanges, and zero stop-lights. When many hubristic Americans think there is nothing to be learned from other nations, Reid has defined and shown examples of health care that may benefit Americans if we’re only willing to take a look, concede we don’t have all the best answers.
“Contrary to conventional American wisdom, most developed countries manage health care without resorting to ‘socialized medicine.’” “The term was popularized by a public relations firm working for the American Medical Association in 1947 to disparage President Truman’s proposal for a national health care system.” Reid describes four basic health-care models used around the world:
1) Bismarck (named for Prussian Chancellor Otto von Bismarck) is in Germany, France, Belgium, Switzerland, Japan (Japan is the most prodigious consumers of HC; on average a visit to doctor 14.5 times annually, three times as many as an American.), and to a degree in Latin America. France, Germany, Taiwan, and maybe some others use a digital health card, carried in your pocket like a credit card; it knows all your cares, medical records, your doctor visits, pharmacy needs, your payment coverage; it eliminates all the paper work and filing cabinets.
2) Beveridge (named for William Beveridge a social reformer; a plan he viewed as “a program of applied Christianity.”) – countries that use this model or a variation of it, include its birthplace, Great Briton, as well as Italy, Spain, most of Scandinavia, and Hong Kong with its version of Beveridge Style (“The Beveridge Model, with the government holding almost all the cards, is probably what Americans have in mind when they talk about ‘socialized medicine.’” This welfare-state approach, seemingly thoroughly European, is the purest examples of the Beveridge Model or “socialized medicine,” and is in Cuba and the U. S. Department of Veterans Affairs, where health care professionals work for government in government-owned facilities. The patients receive no bills.
3) National Health Insurance has elements of Bismarck and Beveridge. NHI is Canada’s. Some newly industrialized countries, Taiwan and South Korea have adopted variations on the NHI.
4) Out-Of-Pocket is in undeveloped nations. (Only about 40 countries, industrialized-developed nations, have any established health-care payment systems.) If personally wealthy enough to pay, and care is available or can travel outside country, health needs are met. Otherwise, many of the poor stay sick or die; hundreds of millions of people in countries’ rural regions such as Africa, India, and South American never see a physician in their lifetime. Except, maybe a village healer using home-brewed remedies! Luckily some may get help from an international health organization.
America has elements of all of these models in our convoluted national-health-care apparatus. But “The United States is the only developed country that relies on profit-making-health-insurance companies to pay for essential and elective care.” All other developed nations have necessarily, out of fiscal responsibility, decided that basic health insurance must be a nonprofit operation, which may be run by government or by private entities that exist only to pay people’s medical bills. It is not to provide dividends to investors. (When an America’s private health-insurance company pays a bill to doctor, hospital, or pharmacy it is considered a “medical loss.” The “loss ratio,” borrowed from fire and casualty business, is the measure closely watched by health insurers to make sure actual medical payments don’t eat too deeply into administrative cost and profits. Accordingly, ten of the larger health insurers’ combined profits during the past decade has risen 428 %. “U.S. insurance companies deny about 30% of all claims, although some of these are eventually paid through appeal process.”) In today’s N&O, a group of Duke and UNC Hospital doctors say, “Our current system is broken and unsustainable;” they argue for a strong public option. No other developed nation allows there citizens to go bankrupt because of medical bills; a joint study by Harvard Law and Harvard Medical Schools says around 700,000 annually in the USA go bankrupt because of medical bills.
No doubt, America is the most innovative country ever known; it has the best-educated doctors, nurses, medical technicians; best-equipped hospitals, research laboratories; sets global standard in developing miracle drugs and advanced medical technology. The country of Singapore, about as far as you can get from Durham NC, sought out Duke University Medical School to operate its sparkling new state-of-the-art hospital. While most of us think of hands-on medicine as top-notch, there are some defying statistics. “In 2000, when a Harvard Medical School professor working at the World Health Organization (WHO) developed a complicated formula to rate the quality and fairness of national health care systems around the world, the richest nation on earth ranked thirty-seventh.” France ranked 1st. Among nineteen wealthy nations: “A 2008 report by the Commonwealth Fund (CF), ‘Deaths Before Age 75 from Conditions That Are at Least Modifiable with Effective Medical Care,’ concluded the united States ranked nineteenth in curing people who could be cured with decent care.” A study by CF of nine developed nations, e.g., showed Americans with diabetes or asthma die younger; after a kidney transplant Americans have worst survival rate. “Among those nine rich nations, the per-capita rate of ‘Deaths Due to Surgical or medical Mishaps’ was the highest by far in the USA.” Could this a drawback to TORT Reform? Is the high-malpractice insurance that doctors have to pay justified? Is the reported additional 1% extra cost, of all-of-medical-care expense, attributed to malpractice settlements justifiable? A person, or parent of child, whose simple-operation procedure has been botched could better answer this question. There is some evidence that doctor’s excessive testing may not be the direct overriding cause of excessive medical cost. Reference: Medicare spends twice as much on similar patients in some parts of the country as in others. Texas in June 2003 put limits on malpractice payments; malpractice insurance is lower but there is no evidence of consumer savings.
Common of all developed nations that rely on health insurance, except America, is a “personal mandate,” every individual must be signed up for HC. It is considered an element of personal responsibility. What the individual pays is not a tax but a “national insurance premium,” it’s a product: your 100 % inevitable need in a lifetime, “prenatal to grave.” The USA does not allow you to drive your automobile, or other vehicle of your privileged ride, on an American highway without liability insurance; in the USA health liability, 1/6th of national GDP, exceeds automotive liability. In Switzerland, the “right to medical care” is not a political argument by left-wing parties. But President Couchepin, a corporate executive, who became a leading figure in the Christian-Democratic Party (European version of American Republicans) expounded: “A society cannot have complete equality. It is not possible. You can earn more money than your neighbor; that is not society’s business. But a good railway system, a good school system, a good heath system – the basic needs of the people – must be handled with a high degree of equality.” Prior to 1994 Switzerland had been operating with profit-making insurance (same as USA), and their national GDP cost was second to USA (It still is 2nd, at 11% of GDP; improving now with equity in the system.), 5% of their population was uninsured and otherwise an inequitable system. To correct the problem they went with the Bismarck Model, relying on private but nonprofit health insurance plans. (Without getting political, factually speaking, what some call a rush to health care reform: The sixty-year rush? Defeated in 93, revived again after 16 years! As the Swiss equivalent Republican leadership took the initiative as described above, so could have the US Republicans of 2001-2006, six years with full control. But then privatizing social security and a 1.3 trillion tax cut prioritization debarred, apparently, unwanted reform that could have been fashioned to their liking.)
An MRI scan in the U.S. cost $1,000 to $1,400; Japan fixed price is $105. That’s all a fee schedule allows; however, they do a lot of scans, dirt cheap. They got Toshiba to build an MRI scanner for $150,000 without all the bells and whistles, about 1/10 cost of bigger machines used in USA. Japan’s “Dr. Kono emerged from medical school with no student debt; the tuition was only $1,500 per year, and the local government helped pay it.” Most doctors in developed nations have free education, no debt at graduation, and very low malpractice insurance to pay, if any. Many doctors Reid met liked to complain about too low a compensation but very few ever give their profession up for another line of work. Throughout they are dedicated professionals, as we know our American doctors are, who on average don’t match pay (some do) of America’s contemporary --- but have unmatched benefits otherwise.
Regardless of the country, consumers of HC around the world have complaints but the vast majority of citizens in each country like their health care. Margaret Thatcher, the conservative-iron-lady reformer never dared to take on Briton’s NHS. Briton admittedly has some waiting for elective procedures, per NHS, even though in the last 15 years it has improved. Of recent Blair and Brown have poured larger sums of money in the system. America too has copied Briton’s NHS to provide free, no bills, HC to tens of millions of Native American, military personal, dependents, and veterans; all with government doctors in government facilities, dispensing government drugs. (Is this un-American?)
Taiwan undertook a comprehensive study of developed nations’ HC systems and decided to follow the Canadian model. “In 1965 when the U. S. Congress decided to guarantee health care to any American over sixty-five, the Americans adopted both the National Health Insurance model – that is, private providers and public financing – and the name Tommy Douglas gave it, Medicare.” “Douglas came into the ken of J. S. Woodsworth, a Methodist Minister and a fiery populist who preached the ‘social gospel,’ the idea that the church must be concerned not only about the next world but also about injustice and equality in this one.” As Premier (governor) of Saskatchewan, in 1944, Douglas’ successful government-run, single-payer (Technically inaccurate, because Canada really has ten provinces and three territories which operate their own Medicare Plan.) health-care system was adopted by Canada’s federal government in 1961. It covers all medical and psychiatric care, in or out of hospital. It will not pay for Viagra, Botox treatment, or to circumcise your baby. Private insurance may be purchased for these. Reid says Canada’s universal-coverage system is a source of pride, but it’s also a national concern, it’s limping along. The system still records a high level of satisfaction. The “race to south” for care is mainly fictional. Statistically, Canada’s care exceeds USA at a cost of about ½ the per capita of America’s. So far, Canadians have been willing to wait, providing urgent procedures are met and if the rich and poor have to wait about the same amount of time.
My friend’s (Virgil) proposition that American Insurance companies currently have over “1900 mandates” is something I’ve never heard. So far I’ve not been able to confirm or refute, but it sounds like a stretch. Coverage of massage therapy, cosmetic surgery, etc., should be covered if bodily injury/deformity occurs in an accident. But I don’t think my wife’s Blue Cross will cover her face-lift. We know Medicare Supplement Plans, e.g. an election of Plan “F,” must pay same across different companies. But other health-care policies vary to a great extent, in many cases the patient and neither the insurer can readily figure out. It is the mishmash in all these supposedly competitive free-market policies that many buyers find frustratingly complex, which must be rectified if the insurance model continues. Competition across state lines, a familiar mantra, sounds like a good thing; I haven’t heard discussion of its ramification on “states rights.” We do know “state rights” is the political shield for various issues, and it is used when convenient or advantageous. (Some of our health-policy sales representatives, on this list, may have some thoughts on this.) To open competition and give responsibility to all states, on Oct. 1st U.S. Senator Maria Cantwell’s (D-WA) sponsored and the Senate Finance Committee passed an amendment to the America’s Healthy Futures Act of 2009 that will for the first time provide states with the ability to negotiate with health insurers in order to provide high quality health care coverage at a lower cost. Let’s see where this goes!
With insurance, an emphatic exception I take to my friend’s propositions is that Health Insurance companies are encumbered by too many regulations. If it’s going to be for-profit insurance, no improvement in care delivered or cost reduction will result until regulations are applied and enforced. Can we depend on their disciplined morality any more than the behemoth-financial-institutions management’s debacle that cost our nation about a trillion dollars in TARP rescue? Remarkably absent has been the moral, ethical aspect of the health-care debate. In addition, a distraction of flagrant enmities picked from the disparagement-basket has diluted an honest debate: Congressmen’s slackness; excessively paged bill! Surely a congressman’s staff and/or others have assisted in its scrutinizing nitty-gritty. I was satisfied with my congressman’s performance the two times I attended his meetings. How possibly small a bill? It’s to unwind over sixty years of mixed-up complexities unabated? Of course none of the bills are final; yet, much to be hashed out; so let’s lend our civility and call down those who show much disrespect; of course everyone is entitle to free speech and should join a rational discussion.
Regarding “employee coverage” by the employer, tax benefits, etc., I think there may be some problem convincing many people that “individual policies” are cheaper, apple for apple. (The ins-and-outs on this remains open for debate, depending on potential tax-law revision.) Insurance experts say on average a customer stays with company less than six years. Change/lose job; lose or change HC companies! So an insurance executive, with his eye on bottom line, has little financial incentive to pay for long-term preventions. The employers/employee sharing insurance premium is the common practice in countries where HC insurance is the primary payer. Irrespective, in developed nations if a change or loss of job occurs, the individual still has health coverage. Somewhat miss-stated: American auto makers pay HC for employees where as foreign countries do not. “In fact, Japanese companies often build and run hospitals for their workers; Toyota has several of them in Toyota City, just outside Nagoya.” It is a country’s overall-lower-medical cost that gives the foreigner manufacture the advantage (and some would insert USA’s labor cost). But also some profitable American companies such as SAS, a large software company based in Cary, NC finds onsite, convenient, health care good for the company.
It is true “America’s unusually high rate of homicide is one reason we die younger than the Japanese, the Canadians, or the Greeks.” Add to that, auto-accident deaths caused by cells, texting, drugs, and drinking --- gun irresponsibility and smoking --- is not only life-shorting and a health-problem in itself, many times resulting in incarceration, a crippling-national-financial burden. For California it’s a cost of $49,000 per inmate annually. The USA has the highest incarceration rate of any country, 738 per 100,000; next highest is the Russian Federation, 607. The fact that 10s of million Americans don’t have health care and/or have a health-harmful lifestyle, diet, tobacco use; lack preventive medicine; poorest mothers without insurance and prenatal care, all add to a shorter life. No other industrialized democratic country allows people to dies from treatable diseases because they can’t afford the doctors bill. A formula devised by National Academy of Sciences says, people who are uninsured are 25% more likely to die of treatable diseases than people of same age cohort who have insurance. Institute of Medicine says, people without insurance are more likely to die of disease and accidents; 37% greater in US if hit by an automobile; 30 to 50% for various cancers. If these issues were dealt with effectively, perhaps America could be “number one” on the nations’ life expectancy chart.
Health-care economists, and statisticians at WHO, have come up with a range of measures to give a more meaningful rating of countries’ “life expectancy at birth.” The DALE (Disability-adjusted Life Expectancy); sometimes it’s called HALE (Health-Adjusted Life Expectancy). How long can you expect to live a meaningful life without a chronic disease, heart disease, back pain, rheumatoid arthritis, blindness, hearing loss, Alzheimer’s, painful cancer, etc.? A high ranking on this scale means a nation’s population has good health habits and the country provides good health access, for both prevention and cure of disease. Top ranking 1-5: Japan, Australia, France, Sweden, and Spain. To the surprise of Christopher Murray, a doctor and health economist at Harvard, America, the richest country, ranked twenty-fourth. If you want to feel good about America’s health, compare it to China’s: Under Mao’s Cooperative Medical System (Poor man’s version of Briton’s Beveridge Model), spartan but essentially free, from 1952 to 1982, life expectancy increased from thirty-five to sixty-eight and many contagious diseases were controlled. In 1980 the government-run system essentially shut down; China reverted to the Out-of-Pocket Model for most of its 1.3 billion people. Child mortality rates increased, so far life expectancy is same, but epidemical, infectious diseases are occurring, not seen in decades.
Cost control as an imperative before universal coverage? Reid says, “At first blush it might seem logical to go after health-care cost first; once cost are under control, we could more easily afford universal coverage. But everywhere I went on my global quest, I was told that this approach gets things backward. Universal coverage is an essential tool to control cost and maintain the overall quality of a nation’s health.” “All developed nations except the united States have decided that every human has a basic right to health care.” The myths about nations’ health care are: it’s all socialized medicine; they ration care with waiting list and limited choice; they are wasteful systems run by bloated bureaucracies; health insurance companies have to be cruel; those system are too foreign to work in USA; and perhaps the greatest misconception is that all foreign systems are the same.
Is health-care reform politically hopeless? “There are hundreds of companies with a multi-billion-dollar stake in the status quo; those firms and their backers on Wall Street are fiercely resistant to any change that might cut off the gravy train.” I’ve heard there are six or more health lobbyist in DC for every congressman; $1.4 million daily spent on lobbyist. “The USA is the only nation that lets insurance companies extract profits from basic health coverage.” “If you are a senior, a soldier, a veteran, a Native American, a member of congress, or a renal-failure victim, or if you are scratching by on an income below the designated rate of poverty, government will help you obtain health care. (30% of population) It may be possible to provide fair and cost-effective health care for all while maintaining these separate systems, but no country has ever made it work. An essential building block for every wealthy country except the USA is the principle that financing health care must be a nonprofit endeavor. That doesn’t mean people can’t work for a living in a private nonprofit health-insurance industry.
Obviously, to give every citizen the right to the full range of testing, treatment, surgery, and medication afforded by state-of-the-art contemporary medicine would likely lead to bankruptcy. Although, if we are the moralist people some claim and if not, we must work together to gain that rectitude; only then can we answer the basic question other developed, free countries have answered: Should we guarantee medical treatment to everyone who needs it? Or do we continue to default to the secondary question as we have for many years: In a land where all are created equal, which inequalities are we willing to accept? Now we must get serious to answer the first question. And, if the answer is “yes,” then we must do at least what other developed nations have done: provide a floor for basic health care and a ceiling below prudent-commonsense, excessive cost. Citizens with the means to buy expensive-private insurance or have wealth for unlimited treatment are not deterred: state-of-the-art care will be available as long as it doesn’t depress the ‘ceiling’ of those less fortunate.
Can we cure the hubris, be a classical Ike; can America take the first “small step” toward healing America?