As I read more everyday on the progress or setbacks for health care reform, I become more disillusioned. So, why not throw my two cents into the fray.
As a nation, in my lifetime, we have made so many critically bad decisions that continue to come home to roost. Just to mention a couple biggies. Choosing roads and cars over public transportation (increased pollution, damage to the environment from sprawl, destabilization/abandonment of cities, and an annual death toll to which 9/11, Iraq, and Afghanistan combined pale). Criminalizing non-violent drug use (fills our prisons to capacity, our streets with crime, and offers little in treatment for addictions as even Richard Nixon’s administration did). Just as I believe that these social/national choices were shaped and driven by powerful monied interests, so I believe is the health care debate. Our history is replete with repeated examples of unbridled capitalism failing our societies when human avarice trumps moral/ethical concerns for the well being of the majority of our fellow humans. Case in point, a little real estate investment instrument now referred to as a derivative.
What would I prescribe for health care reform?
1) REMOVE THE PROFIT MOTIVE FROM HEALTH CARE. IT IS MORALLY AND ETHICALLY WRONG TO PROFIT FROM HUMAN SUFFERING.
Ah, but the free market people will argue that motivation for innovation and thus better care will suffer if there is no opportunity to obtain great wealth for relieving human suffering. Jonas Salk didn’t think that way (he never patented the polio vaccine).
2) REWARD OUTCOMES AND PREVENTIVE CARE NOT PROCEDURES.
I believe that reasonable people of good faith can see the great potential in this approach for not only improving the overall health in our society, but dramatically reducing long term costs.
That’s it. I believe that from these two prescriptions follow longterm solutions to the current points of contention (availabilty and cost). Will these prescriptions ever be heeded? I can only think of a comment I remember (similar to one made by Samuel Clemens) describing our America as, “A nation of fools led by knaves.”
{ 13 comments… read them below or add one }
“Our history is replete with repeated examples of unbridled capitalism failing our societies when human avarice trumps moral/ethical concerns for the well being of the majority of our fellow humans.”
Well said.
A fascinating recent article in the New Yorker supports your suggestions: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
To the Reverend, thank-you. I’ve long had a love affair with words and I find it deeply rewarding when the words I choose can strike a meaningful chord in another.
Bryan, you were not just whistling dixie when you said that Dr. Gawande’s article was fascinating. I feel ashamed that his ideas/conclusions do not play a larger role in our current national debate. Thank-you for adding to this discussion.
Thanks for the link to the Gawande article. Very nice read.
As the grateful beneficiary of a publicly-funded health care system, I found much of interest in the article.
There strikes me as being several things that will always be true, and which will always pose challenges to whatever configuration of health care a given jurisdiction adopts:
1) Our compassion stretches much farther than our wallet. We will always expect that efforts should be made to extend the lives of individuals, or improve their quality of life. or avoid declines in health. There is simply no way to behave as we do,and spend MUCH less.
2) Our patience often doesn’t stretch nearly as far as our compassion. In Canada, my experience has been that if your life is in danger, your service is quick. If you are *just* in discomfort, your service may be delayed. Small wonder that some of the loudest complaints about waiting times are from seniors whose backs, hips, and knees give them constant aggravation. the run out of patience fast.
3) Our expectations for health, in spite of the many millions who do everything in their power to undermine their own health, are often unrealistically high. That is something I think is true on both sides of the equation, the caregiver, and the care-seeker. Of course, if one spends even a moment looking at the subjective health literature, people tend to be very poor judges of their health.
4) Humans are poor evaluators of their motives. Their judgment is often unconsciously influenced by tacit benefits or penalties of their decisions. As such, it is hard to stop them from being influenced by the possibilities that someone else’s very big wallet offers.
5) In a great many instances, whether health care or some other entirely unrelated context, people are more likely to think about the impact of their actions on themselves, than the impact of their actions on the collective effort. It is unreasonable to expect individual patients to start out their reasoning about their seeking of services in terms of how much it is costing the system and what may be more cost-effective. It is similarly unreasonable to expect doctors to think about how their pattern of services impacts on the overall system. Any “fix” cannot lean to hard on either of these potential sources of support and buy-in. It has to extract preferred behaviour from them in spite of themselves. That being said, one province I lived in issued a tally-for-services each year to provincial residents, showing them what the total billing of their individual health services was to the province that year. Sure made you think twice when you realized what this little visit here, and that little virus there cost the system.
Mark, you bring a wealth of knowledge and perspective to this issue. Certainly a perspective that we in the US do not share. Everything you say makes good sense to me, but in some ways our experiences are quite different.
Here where we do not share the risk/cost of healthcare as a society, many are afraid to seek health care except for dire situations (e.g., need for bypass surgery) because of fear of losing what health insurance we have (insurance premiums can increase beyond affordability if you make use of the policy or if you are labeled as having a pre-existing condition you may be flat-out denied coverage). Of course many in large group plans do not have these concerns and may be iinfluenced as you say, “by the possibilities that someone else’s very big wallet offers” (I like the way you phrase this).
I wholeheartedly agree with you that neither the fox nor the hen can be fully trusted to rebuild the chicken coop (I really don’t mean to reference doctors or patients in pejorative terms, but it is a convenient way to convey my meaning). Not to say that the medical profession and patients cannot contribute to the solution (some more than others), but I do believe that fixes must be imposed on these systems.
Thanks Mark
Fair comments, Tim, and nothing I’d disagree with. Among care-seekers, the biggest complaints in Canada have to do with waiting times, and not with quality of care. Among care-givers, it is the huge demand placed upon them; crowded waiting rooms, etc. Of course, when Canadians pipe up about how much “better” things are under a two-tier system (private+public health-care plans), as found state-side, their chief source of praise is for how quickly they got in to see someone or get a medical imaging procedure done. All of the resources to do those things are available on this side of the border, but the fact that anybody can simply walk up to a hospital or walk-in clinic and get in the line without necessarily being out of pocket personally, or getting bumped from health plan if they lose their job, means that the lines are VERY long. Conversely, when one gets in line in a jurisdiction where a great many are unable to be in line or are reticent to get in line for the reasons you mention, the lineups will be shorter.
I don’t know enough about brain-drain, relative to brain-gain, when it comes to health-care professionals (i.e., how many of ours move south because of what privatized health care can pay, vs how many of yours move north for whatever their reasons may be), so let’s assume the number of health-care providers that each nation has is proportionately equivalent (i.e., with 10x the population, you have 10x as many doctors as us). If an estimated 40% of Americans are uninsured, a many who are insured are reticent to make too many claims, or are in employment circumstances where the nature of their coverage is in question, I think it will be safe to assume that any Canadian with a bit of money to spend will find it easy to locate a lineup that is much shorter, somewhere in the US.
In my own city, as in many others, one of the big problems is families without a family doctor. I imagine the problem is much larger in smaller municipalities, but it is still big here. At least part of it is the need for services in languages other than English. Since recent Canadians are much less likely to have any family connection which assures that the physician who their parents used to take them to will now take on their own kids as patients, they can’t find a family doctor, and they most certainly won’t have an easy time finding one that speaks their first language. And if the heavens part and they do find a doctor that will take them on, there is still the language barrier.
In the absence of a family doctor, emergency rooms tend to take up the slack, and after emergency rooms, walk-in clinics, where the odds of seeing the same physician twice in a row are modest. Some time back,while being admitted for a cardiac “event”, I was asking the nurse about the patient backlog in emergency. She noted that things had been much better after a local tv station reported ER waiting times of 5hrs+. I gather many of those folks sought out walk-in clinics instead.
Again, there is this constant tug of war between the tsunami of care-seeking that comes when people feel they can do so without penalty, and the desire to have speedy service, which ultimately relies on having enough care-providers to serve the lineup. You can’t acquire the care-providers if you offer minimal incentives, but unless you can get the care providers, or impose hurdles to care-seeking, the lineups will continue to be long.
Mark you continue to give me food for thought.
I’ve personally adopted the view that money is not important as long as you have enough to live decently. Of course “decently” is quite relative isn’t it? As a young boy I lived in a bungalow without central heat or hot water and shared a hallway “bedroom” with three siblings. Still we always had good nutritious food on the table, a clean, dry place to live and sleep, and the oil-burning stove kept us warm in winter. I might have been the first to wear an article of clothing only a handful of times through my single digit years. Yet, I have never felt deprived or ashamed of these circumstances. I still think they were quite adequate and not untypical of the era. However, I have a sibling who, to this day, feels terribly cheated by and ashamed of these circumstances.
So, from my perspective, I think those in the medical profession should be rewarded with “decent” lives. Comfortable housing, a reasonable work-life balance, sufficient resources to provide their children with higher educational opportunities, etc. But , I do not think that a medical degree should be a ticket to becoming wealthier than god.
Having got all that out of my system, it will be interesting to see how health care changes (if any of consequence should occur) in the US impact the Canadian system. After all, we are all Americans sharing proximity on one continent (many of my fellow citizens fail to realize that the United States of- is only one nation/state on the continent called America). I too am not familiar with what may be happening relative to brain drain/gain between our two nations in medical professionals. How would this issue be affected if the US instated the socialized approach employed in Canada (I can’t imagine this happening in my life time, but we can suppose)? Further, as it appears that the US is one of or the last “developed ” nation to move in this direction, where would health professionals then seek greater rewards? Would the problem then become simply attracting capable people to the field at all (a pipeline dribbling instead of flowing)?
I can only hope that much of the motivation for those to enter and remain in the health field is not about becoming wealthier/more powerful than most in our societies, but about the satisfaction of being able to do the job well. This of course means providing the tools and circumstances so that these aspirations can be achieved. I think you address some of these shortcomings in your system. Still, I know the grass is always greener…, I could be tempted to adopt your system in a heartbeat if I had the power and I didn’t know that prevalent free marketers here would crucify me….. very slowly.
More food for thought…
One of the overlooked impacts of the health care systems in Canada vs the US is on labour law. That’s right, labour law. Because so many Americans receive their health coverage through their employer, American employers have been able to insist on certain conditions of employment as BFORs because the impact on their health care premiums could be considered an undue hardship. In other words, if my premiums, as employer, would go up dramatically by not filtering out hires who have a risk of lung cancer or smoking-related respiratory health costs, I can make it such that insistence on applicants being certifiably non-smokers, whether on the job or off, is a defensible limit on their employment. I can create “snitch-lines” as has been the case in some jurisdictions.
If, on the other hand, the health care costs of my employees are covered through taxes, then there is really no impact to me, as an employer, if my employees are smokers or not, with the possible exception of absenteeism and sick days. Consequently, the sorts of smoking-related employment restrictions one sees in the US are nearly absent in Canada. Doesn’t mean we like smoking any more than you. We just integrate it into law and health differently. Insomuch as health care is an *employer cost*, rather than a *state cost*, one should expect labour law and jurisprudence to factor in the financial impact of health care costs on employers.
From a public health perspective, it is probably a good thing that employers can say “If you expect to ever work here, smoking cannot be a part of your life…ever”. From a workers’ rights perspective, the incursion of employers into the off-site lives of its employees is a bad thing. Pick your poison.
It is also worth suggesting that the litigious society we live in these days is also a partial result of the difference between health care systems. The motivation to sue for large sums following injury or trauma is partly driven by the need to assure that continuing care can be afforded, particularly when the individual is deprived of employment, or their employer’s health plan declines to cover the injury. When continuing care CAN be afforded, because it is provided by the state, would the size of suits (by fair-minded people not eager to make such a suit into a lottery windfall) decrease? One wonders.
Tim,
Your comment about your sibling being ashamed of said circumstances is incorrect! I only noted that the circumstances were uncommon for the time.
Mark,
At a recent meeting, I was told that Canada is currently developing more fully the private health care system and that in a few years there should be a fully functioning parallel health care system?
I don’t know that what you were told is true. What IS true is that either the current, or the current and previous presidents of the Canadian Medical Association are pushing for what some call a “two-tiered” system that would allow for more expedient private delivery of services that are already covered by public health care. Note that the extent of the “second tier” depends on the province. Some provinces are more moneyed and populated than others, such that offering a for-fee service is more viable in some places than others, and one sees some of the stronger push for privatization in those places. Alberta, with its huge infux of petro-dollars, and legions of affluent middle-agers who fly off to US clinics for fast service, also pushes much harder than the Maritime provinces.
Also note that what is envisioned is the delivery of highly specialized services (e.g., places that specialize in ONLY hip/knee replacement, or ONLY medical imaging services), and not privately-insured hospitals. Still, there are many who refer to this derisively as “queue-jumping”.
Realistically speaking, health services currently exist in a sort of two-tier and 3P (public-private partnership) version. Many services are not insured in most provinces, such that people have to pay for them out of pocket or through private health insurance. Some provinces will cover chiropractor visits (to a point), but few cover psychological services. Doctors, of course, operate as if they were practicing in the private sector, except that billing is to the health plan rather than the patient. There is, however, a great deal of public and political resistance to the general idea of greater privatization. Not because we are “Soviet Canuckistan” (as Pat Buchanan called us), but rather because there is legitimate fear that any gains made in the private sector would *necessarily* be at the expense of the public system. That is, those who rely on publically-funded services would get progressively worse and worse service because of the migration and bifurcation of the health industry.
Understand that medicare came in largely due to the efforts of Kiefer Sutherland’s grandfather, Tommy Douglas ( http://www.cbc.ca/greatest/top_ten/nominee/douglas-tommy.html ), and was part of his overall fight on behalf of the little guy. His approach has become engrained in the Canadian psyche, to the point that the very notion that someone would be too poor to have medical aid is simply unconscienable to us at this point in history. Certainly one of the big fears is that medical services for the nonurban areas, like the small towns and the north, will be sapped, and that the better physicians will be drawn to the private sector, leaving a gap in the public sector’s capacity to respond. So equal access to decent care for all regions is part and parcel of the package. I think that not only Americans, but many Canadians too, forget just how far away from a major urban centre (and medical care) so many parts of the country are. The idea that someone might have to fly 800-1000 miles just to be able to have a baby, or have their cancer looked at, is completely foreign to the American context (except for maybe parts of Alaska). Insomuch as the people who live in those far-flung places are essential to maintaining Canadian sovereignty and stewardship over that territory, one cannot permit health care to migrate to the densely-populated zones where the profits live.
There is also the huge huge challenge of the role that federal transfer funds play in the political fabric of the nation. Keep in mind that a) with publically-funded health care services 100% nation-wide (with instant transferability to other provinces for the citizen; i.e., I present my Ontario health plan card to a hospital or walk-in clinic anywhere else in canada, and they simply serve me and bill things to my home province), and b) with health dollars coming from federal taxes largely via transfer funds to the provinces earmarked specifically for medicare, the public health-care system is also a vehicle for maintaining central control over the provinces. Reducing the amount of say that Ottawa has over the provinces, by devolving more health care to local private interests, starts to turn us into a different sort of nation, and I doubt that federalists would ever permit that to happen.
So, to try and answer your query more succinctly, Dennis, yes there are currently all manner of uninsured specialized clinic services operating in parallel with hospitals, walk-in clinics and family physicians. But if my brilliant college-graduate son goes on a camping trip with his drunken engineer buddies and slips on some rocks and busts up his hand, I take him to any hospital anywhere in the country, he shows his health card, and they do his X-rays and patching up, all on the public nickel. That will not change any time soon.
Short addendum: http://www.cbc.ca/health/story/2009/07/31/medicare-ad-exaggeration523.html
Certainly, as I asserted in the original blog posting here, monied interests are at work attempting to shape the debate toward outcomes in their interest. And sensationalism abounds on both sides of the debate. Just to add a little more fuel to this fire, here are a couple more links:
http://www.michaelmoore.com/
This is the website of the fellow who made the documentary “SiCKO.” As much bad press as this movie has received, I found it informative and entertaining, yet some do not agree.
http://www.pbs.org/moyers/journal/07312009/watch.html
This one leads to the recent PBS Bill Moyer’s Journal program where former health insurance executive Wendell Potter describes among many other ploys, the industry’s fairly successful attempt at suppressing and discrediting “SiCKO.”