Mitch Keamy is an anesthesiologist in Las Vegas Nevada
Andy Kofke is a Professor of Neuro-anesthesiology and Critical Care at the University of Pennslvania
Mike O'Connor is Professor of Anesthesiology and Critical Care at the University of Chicago
Rob Dean is a cardiac anesthesiologist in Grand Rapids Michigan, with extensive experience in O.R. administration.
As the election season draws nearer, health care reform continues to vie for position as a leading issue amongst the presidential candidates. Once again, the public should expect to be regaled with stories of the compassion and fairness of such systems, as well as their potential for efficiency. Peer reviewed studies and surveys that portray such systems favorably will be widely quoted.
The recent bill to dramatically expand health insurance for children, vetoed by President Bush, is likely to evolve into a defining campaign issue. Why? Because it is trivially easy to cast opposition to such a well intentioned program for the innocent as mean. Bush, and many of those opposed to the bill, believe that it was another step in the gradual expansion of federal control over health care in the USA. Be certain, the language of this particular bill laid down the scaffolding for the extension of this entitlement by subsequent legislation. Bush may or may not be mean, but he is opposed to nationalized health care.
How are nationalized health care systems doing since I last blogged about them?
Below are a few pointers to interesting stories, and what they mean to me.
Britain's NHS continues to be under-funded to a substantial degree. Like many such organizations, they have shifted resources from longer-term objectives to deal with shorter-term crises. One way this is accomplished is to 'defer' maintenance and replacement activities. The NHS, whose standards for physical plant and equipment are substantially lower than the US's, has done this:
4 Billion pounds - about 8 billion dollars - in a country with about 1/6 the population of the US - would scale up to about $ 48 billion here. Why the backlog? The story makes the reasons obvious:
1. There was a bureaucratic imperative to demonstrate a surplus. They did it by shifting all of their maintenance and capital budget to the future. The shadow health secretary quoted in this article refers to this as 'a sham.' I believe he is being generous.
2. They are so over capacity that they cannot close any substantial structure for renovation without causing serious disruption of service at a regional level.
To be fair, $48 billion dollars is a small amount in US dollars relative to the US health care budget - but it is also enough money to build 48-100 new hospitals…. which is a lot of capacity. The real problem is that they have absolutely no excess capacity in their system, largely as a consequence of previous efforts at 'cost containment.' But parts of England are much poorer than most people realize, with > 20% of the homes in places like Liverpool, Birmingham, Portsmouth, and Leeds not having central heat (or not being able to afford turning it on):
The British spend over $ 3 billion a year helping these people stay warm.
Spin, the modern synonym for propaganda, continues at the political level for Britain's NHS, as demonstrated by these items:
I could be derisive, but it would be hard to surpass the language of the usually sympathetic BBC in these stories. There are several features of nationalized health care systems that are self-evident in these stories:
- progress is announced (sometimes untruthfully) in synchrony with election schedules
- failure is not an option (propaganda can be used to obscure all substantial failings)
- the leadership of such systems are those who are most politically pliable, not the most competent
- this in turn permits fantasy planning, with outrageous under-estimation of the time and expense of major projects (3 years vs 10, 2.4 Bn vs 12.4)
- budgets must conform with legislative allocations (requiring the layoff of a mere 17,000 healthcare workers) and are completely disconnected from demand, and
- politicians can divert vast sums for publicity stunts.
The reduction in personnel is causing a crisis independent of problems related to maintenance:
To me, the most important message of these stories is that there is now profound skepticism, at every level, of all information disseminated by the NHS. A nationalized health care system in the US would likely arrive at a similar relationship with its press and public very, very quickly. The major difference is that the US press would gladly vilify practitioners at the behest of politicians, a practice that the BBC is now too wise to engage in.
While the US press is usually a venue for fluff pieces which portray Britain's NHS quite favorably, the BBC publishes stories that create a completely different impression:
Think about it - less than a third of diabetes receive the testing that the NHS mandates they should. If you read the article, it's clear that the NHS does a lot of things related to diabetes care well, and is making a concerted effort to make almost everything better. Once again, failure is not arising from incompetence or lack of motivation at an individual level, but rather from a system whose resources are generated by coercive taxation and redistributed at the pace of elections and governmental fiscal cycles. The successes and failures here are both arising from the structure of the NHS.
How is the NHS doing? Well, the truth is that it is hard to tell. One thing is certain: medical tourism is thriving and growing in parallel with the NHS, with increasing numbers of Britons willing to pay cash out of their pockets to receive care in dozens of countries (most of which would have been inconceivable as alternatives even 15 years ago).
Ultimately, it may be that our most reliable indicator of how well and nationalized health care system is functioning will be the number of such 'refugees' that it generates. Using this as our metric, it would seem that while its leadership represents that everything is getting better, things in Britain's NHS are in fact getting much worse.
While composing this post, I felt like I was shooting fish in a barrel. The bad news about Britain's NHS isn't hard to find. All of the above pointers are to news stories from 2007. Of course, bad news sells, and sells well. The good of the NHS (like its care for the indigent with chronic diseases and cancer) isn't news. Sadly, the thrust of all of the news is that the NHS is failing by almost every measure. This matters, as the British have the greatest experience of any western country operating a nationalized health care system. They know how to do this - they understand the planning, the logistics, the personnel issues, the oversight, and the regulation. On a large scale, this is likely to be as good as it gets. Think about that. Is Bush wrong to reject this? Is he mean? Or is he prescient in supposing that nationalized health care will work about as well as nationalized farming did in the Soviet Union? Only history will know for sure. Mere mortals must make their best guess using the information at hand.
Finally, it is worth mentioning that most of our information about nationalized health care comes from the press of English speaking countries. Why? Because they generate English language documentation and news coverage. Both the good and bad of other nationalized health care systems receive less coverage because of this language barrier. Every once in a while, a story appears that hints at how things might be going in other countries. Take this one from Japan as an example:
I am certain that Japan's system, like England's, has many good features. But, like every system, it's not all good, no matter what its' propagandists and spin doctors say.
What do you think about the Dutch health care system? info here: http://www.rivm.nl/bibliotheek/rapporten/260602002.html
Posted by: Wouter | October 30, 2007 at 02:52 PM
In my post, I mention how hard it is for those of us who read only in the english language to acquire sufficient insight into the health care systems of the non-english speaking world to have an informed opinion. I have no opinion about how the dutch system operates. I would be reluctant to base an opinion on a single document, especially if I have no other insight into the landscape of that world.
As I ponder this, I think back to how utopian the portrayal of Soviet, Communist Chinese, and even Cuban health care systems have been, and how completely discordant the propaganda was with the reality in each of those instances. A free press is not sufficient to have the necessary window into such systems. An ability to critically and independently evaluate the information they disseminate is crucial to understanding the reality of what is happening. If your only source of information is the system itself, you are at their mercy for information. You might have suspicions, but you won't have facts. You'll be able to speculate, but you won't have the necessary context for an informed opinion. In evaluating various sources, it is incredibly helpful to both be in the business and to know people who have worked in these places: it's otherwise difficult or impossible for outsiders to form calibrated opinions.
Similarly, I would not condemn any system on the basis of one unfavorable report, or even a collection of them, while I was otherwise uncalibrated about such a system. So, for example, if my only source of information about either the US or Cuban health care system was a recent 'documentary' about them, I would be reluctant to use it, and the publicity associated with it, as the basis for an opinion. Importantly, you need to read the details of these reports, not just the summaries that are published in the lay press. One recent ranking of health care systems rated the US quite poorly - primarily because it is not a nationalized system (and the murder rate here is high).
Such stuff (reports of bad events) can provoke you to wonder what is indeed going on. The BBC article about the recent problems in Japan is sufficient to make me wonder. I am too ignorant of their system to have an informed opinion or criticize.
Posted by: Mike O'Connor | November 01, 2007 at 08:02 AM
Portugal is a booming market as well.
Posted by: Medical Tourism | December 03, 2007 at 02:27 AM
Most of the industrialized nations with national healthcare have higher life expectancies, lower infant mortality rates and lower obesity than the U.S. Not propaganda, fact. If our healthcare system is so much better than their nationalized systems, why is that?
Posted by: Ronald Cray | May 06, 2009 at 07:08 AM
The short answer is that I don't know, and frankly, neither does anyone else.
1. Obesity. The rest of the world seems to be catching up. Why is there an epidemic of obesity in the USA? There is a massive literature that confronts this question, with many invoking greed, avarice, unchecked desire. Others allege that food is cheap, the US is wealthy, and its citizens are increasingly sedentary. There is little or no evidence that health care can prevent or reduce obesity (unless you count gastric bypass).
2. Infant mortality. Ditto. We know much less about this than most health care experts would like us to believe. A few interesting references:
http://www.arc.org/racewire/030210z_kashef.html
http://www.omhrc.gov/templates/content.aspx?ID=3021
3. Life expectancy. The citizens of wealthy countries have longer life expectancies. Why? Well, no one knows. Citizens of countries with private health care or a patchwork of health care (e.g. Switzerland, USA) have life expectancies comparable to those of countries with completely socialized health care. Socialized medicine may provide outstanding care to the poor, but does not seem to dramatically improve life expectancy. Be clear: even if socialized health care did nothing to improve life expectancy, that alone would not constitute strong evidence against it (it still offers a lot of apparent social good). Life expectancy, like all of the other examples you chose, is more tied to the overall wealth of a society than the nature of its health care system.
Posted by: Mike O'Connor | May 19, 2009 at 03:08 PM