As many of you know, I am a family physician. I have been taking care of families for over 20 years. I love my work treating health and illness and nudging my patients and families towards health. It is deeply gratifying. Over the last couple of years however I have found myself more and more frustrated about the broken system in which i practice. I've been raising the question, "Isn't there a better way"?
This is a comparative analysis of various health care systems in the modern world. It is well written and factual. I learned a a lot and became intrigued. I would like to write about some of the highlights of this book.
There is a fundamental question that was raised in every country . Should health care be a human right?
There is a paradox. The US, at the beginning of the 21st century was the most powerful, innovative and richest nation on earth. Our health care system however falls tragically short. Our system does not cover everybody. All the other developed countries consider that every person has a right to health care. When the World Health Organization rated the national health care systems of 191 countries in terms of "fairness" the US ranked 54th, just ahead of Rwanda.
How many people go bankrupt because of medical bills? In Britain, France,Japan, Germany, the Netherlands, Canada, Switzerland: zero. In the US, according to a study by the Harvard Law and Medical schools, the annual figure is around 700,000. The US spends more on health care than any other country and our outcomes on many measures are worse than those countries who spend much less. Quality in the US is mediocre by global standards.
The US is the only developed country that relies on profit-making insurance companies to pay for essential and elective care. American health insurance differs from other countries on the question of "guaranteed issue". In other developed countries, health insurance plans are required by law to guarantee coverage for anybody. American firms, though, are allowed to pick and choose their customers. They cherry pick. There is another essential term "individual mandate" This is a mandate that requires everybody to pay for coverage either privately or through a government program. If insurance companies have to cover everybody who applies, they need to have every body in the insurance pool to cover costs. All other developed nations require both "guaranteed issue " and "individual mandate". In the 2010 healthcare reform act, Congress followed this model which received intense political strife. What is standard in other successful nations is greatly resisted here. This mandate remains an unsettled issue in the US. In the rest of the world there is no debate on this point.
US insurance companies deny about 30% of all claims. In our country 22,000 people die each year from treatable diseases. Average life expectancy in the US is 77.85. This means that the richest country in the world ranks 47th, just ahead of Cyprus and just behind Bosnia in terms of longevity.
France: the Vital Card. The care of life contains the patients entire medical record. This is a card that is the same size as a credit card. It has in it a memory chip. France rates near the top in terms of health care systems. There are no paper or electronic charts in a French doctor's office. The patient brings with him his "card" which holds all of his medical history. The doctor opens it up on his computer, does his evaluation, adds his recommendations and treatment plans and it is then there for the patient to take to his next appointment. All billing is also done on this card at the time of service. As a physician, I can not imagine how this would simplify my work. In France it is law that insurance claims may not be refused and must be paid within 3 days. France spends $3165 per capita each year for a health insurance system that covers everybody. The US spends $7000 per capita and leaves tens of millions without coverage. A study by Bank of America in 2006 concluded that if we could get our health care spending down to the French level - say 10% of GDP- we would save 600 billion annually, enough to cover every American.
Is the US to big to change? Every other wealthy country in the world have made the essential moral decision that every person shall have access to health care when needed. Every other country studied in this book provide high quality, universal health care and they spend far less than we do in the US.
As democratic countries, Switzerland and Taiwan carried out fundamental reform of their health care systems despite significant political opposition, They both made a national commitment to provide health care to all. There are many ways that these two countries differ from the US but they both had highly fragmented and expensive care similar to the US system. Both of these countries developed new health care systems in 1994, the same year that Clinton's efforts were squashed. Taiwan hired Professor William Hsiao, a health care economist from Harvard to study health care systems around the world with the goal to give Taiwan a 21st century health care system. They took a hard look at the US health care system. They concluded that American health care is not a system at all. Its a market. In a market, people with money can buy what they want and many people are left out. We want a real system, something that covers everybody and doesn't depend on how much money you have. Taiwan's plan was designed primarily after the Canadian system. Today Taiwan's system covers physical, mental, dental and optical treatments as well as organ transplants, acupuncture, Chinese massage, drugs, traditional herbal medicine and long-term care. Almost overnight , 11 million Taiwanese who had no medical insurance had access to care. The system grew explosively and national health spending in Taiwan remains at about 6% of of gross domestic product ( as opposed to 17% in the US) . The monthly payment for an entire family's health insurance averages $150 or so.
In Switzerland, the "right to medical care" is not a political argument but is a basic truth of modern life. President Couchepin, a leading figure in the Christian -Democratic party ( the European version of America's republican party) reported, "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 health system- the basic needs of the people- must be handled with a high degree of equality. It is a profound need for people to be sure, if they are struck by the stroke of destiny, they have a good health care system. Our society must meet that need."
These countries all have universal care. There are many models. Universal health care does not equal socialism. Some are government run and some are private. One of the major insurers in Switzerland Group Mutuel, promises to pay every claim within 5 days. If it misses that deadline, the next months premium is free.
Which inequalities will society tolerate. Is it acceptable that some people are left to die because they can't afford to see a doctor when they get sick? Is health care a human right? The fundamental question that needs to be answered is, Is Medicine a right as is the right to think, to pray as you like, to be educated and to vote? Or is medicine a commodity to be bought and sold like a car, a computer or a camera? Every developed country except for the US has decided that every human being has a basic right to health care. Once this question is answered, we can then tackle the complicated details of transforming a system and we can draw on a world of ideas and experiences from health care systems in other industrialized democracies. Are we too proud to learn from our neighbors?
All other developed countries have decided to use one system of healthcare that applies to everybody. Young or old, employed or unemployed, military or civilian, sick or well, aboriginal or immigrant, citizen or prime minister, newborn or about to die- everyone is in the same system and covered by a single set of rules. They find a single system is much easier to administer with one set of forms to fill out, one book of rues, one price list. This is a powerful cost for cost control. It has been shown that without a revised health care system, we can not address the economical issues facing this country. This is not to say that other countries don't face challenges. Doctors do make less many in most of the other countries. They also have less medical school debt. Yes, Canadians wait for health care.
I long to live in a country where these questions can be debated with open minds. I long to live in a place where moral decisions hold the same value as economic decisions. I long to practice in a simpler and fairer system. Call me an idealist if you wish....
Now i will go paint.
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