Al Tanner
The US health care system is a mess. Ask anyone in the health care profession. Doctors fight insurance companies for their pay, many only getting paid 30 cents on the dollar. Frivolous malpractice suits drive up insurance not only for doctors, but for patients as well. Patients fight with insurance companies for certain benefits. A significant portion of the population struggle even to find insurance that is affordable. There exists a disparity in access to health care. The problems with the health care system go on and on. And yet the United States has the best health care in the world—the world looks to the United States for its innovation, research and cures for illnesses. The best doctors are in the US. The best researchers are in the US. The best medicines, technology and procedures are in the US. But is there another system which works better? Will changing the system destroy the best health care in the history of the world? Can Government do a better job than the current system? These are trillion dollar questions, and I submit that the burden of proof lies at the feet of those proposing change.
Let’s break this down further and ask some more questions.
How much is spent on health care?
The US spends more than UK on health care as measured by %GDP in 2006: Canada: 10%, Japan 7.9%, Germany 10.4%, UK 8.4%, US 15.3%a. Approximately 70-80% of this is by the government in foreign countries, and 45% of expenditures in health care in the US is by the US government. Government expenditures on health care as a percentage of GDP are calculated: Canada 6.9%, Japan 6.7%, Germany 8.2%, UK 7.1%, US 6.8% h. If the US government spends approximately the same percentage of it’s GDP on health care, yet does not provide universal coverage, how does it reason that giving more responsibility to the US government will lower costs once universal coverage is in place? Doesn’t it seem to reason the opposite? An inefficient institution will continue to be inefficient.
Who are the major players in medicine?
US health care consumers—the patients are the most important in this debate. Lives depend on access to and quality of health care. Health care workers, those that train to provide these services, are number two: doctors, nurses, PAs, social workers, mental health workers, dentistry workers, etc. Also important are the innovators: pharmaceutical workers, health device researchers and manufacturers, medical and biological science researchers. Also, like it or not, insurance companies and trial lawyers have a place in the debate. There are many players, but we can simply state correctly that all those involved in medicine should be there for the benefit of the patient. So let’s focus on the patients health interests.
How do we measure health?
Mr. Eastman shared two ways: average life expectancy (ALE) and infant mortality rates (IMR). ALE is the average number of years that a newborn is expected to live if current mortality rates continue to applyb. IMR is not a rate but a probability of death derived from a life table and expressed as rate per 1000 live birthsc. The World Health Organization keeps track these statistics world wide. These numbers are based on individual governments which release their own health information. In countries that do not have such resources, a best guess is made by WHO. There are other measures of disease such as prevalence of cancer, heart disease, diabetes, hypertention, etc.
Is there a statistically significant difference between the US and wealthy nations with socialized medicine?
Let’s first talk about statistics. The ALE and IMR are calculated statistics based on life tables, and as such, there involves a standard of error with calculationsd. Conventionally, science accepts any value for the calculated statistics within a confidence interval—2 standard deviations (2σ) above and below the meane. For example, WHO publishes yearly the ALE and IMR by countrya. I’ll give a few (in years): US: 78, UK: 79, Canada: 81, Germany: 81 Japan: 83. Let’s suppose that σ = 1 year for the calculation of these statistics. The accepted ALE for an American would fall between 77 and 80. Only Japan would have a statistically significant difference from the US, for the accepted values of Canada (79-83), Germany (79-83) and the UK (77would overlap. But what if σ = 2? There would be no statistical significance between any of the five countries. See the importance? The same holds for IMR (deaths between birth and 1 year of age per 1000): Japan: 3, Germany: 4, UK: 5, Canada: 5, US: 7.
So is there a statistically significant difference in these statistics between countries? I don’t know, after hours of searching for the sources that WHO based their calculations. (for further work in this area, WHO uses a modified logit life table). Without knowing the error, nobody can correctly say that there is a statistically significant difference. Let’s find another measurement.
ALE and IMR are affected any condition which is detrimental to a persons health, such as disease (congenital, acquired), nutrition, sexual health, substance abuse, sanitation and access to caref. The statistic is also influenced by cultural, religious and political decisions to report deathf. It is inaccurate to state that government controlled health care directly correlates with changes in ALE and IMR alone. It is known that there is a difference between health status between the US and other countries.
Looking at the US and the UK, The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancerg. Other differences exist between countries as well. Look at percentage of years lost due to injuries: Canada: 15%, Japan 16%, Germany 10%, UK 9%, US 17%a. US demographics differs quite a bit than UK, Germany, Japan, and Canadai,j k,l m. Diabetes, hypertension, heart disease, myocardial infarctions, stroke, lung disease and cancer are multifactorial diseases affected by genetics and cultural differences.
What about the higher US IMR? Genetics and environment are strong players here as well—the most common causes of IMR are congenital anomalies (genetics is huge here), short gestation/low birth weight (genetics & environment), SIDs (known to be more prevalent in the AA population and recently genetic defects have been identified), Maternal complications, and Infant Respiratory distress (related to genetics and short gestation). What else could increase the IMR in the US? What is the earliest that a baby has been delivered in the US? Do high risk pregnancies fly to Europe or Japan to be treated? Where is the best care for premature infants? What about attitudes in the US toward abortion? It is a well known fact that this country is much more religious and conservative than Europe when it comes to abortion. Do mothers with babies with birth defects carry their baby to term more in the US than in other countries? I think the answer would be yes. Such infants would increase the US IMR.
So what other examples of socialized systems are there? Canada, England. Go look at their system. What is the wait for care when compared to the wait in the US? What about the wait for elective surgeries? What options do patients have about second opinions? What if you get stuck with a primary care physician that graduated last in his class at The Cancun School of Medicine and Binge Drinking? Can you go somewhere else under a socialized system? What about new experimental treatments? Can you do something that you think is right for you and your health when there are government enforced guidelines concerning your treatment? Do you get arrested for choosing alternative treatments? If you are thinking: “Ridiculous! This would never happen!” just remember that this has happened do our friend Darren Jensen in a private system!! What about end of life issues? When the government is footing the bill, what happens to the Terri Shiavos? These cases will be decided in court, so remember we’re the country that let the Juice loose, and awarded $2.9 million to Liebeck for spilling her hot McD’s coffee in her lap! Once government starts regulating your health care, what happens to your basic human right to make decisions concerning your health and your life?
What about medical innovations, drugs, research—those institutions that have DOUBLED the US ALE within the last century? As the government controls access and regulates procedures, what will happen to these institutions—the future of our health care? We are entering a genetic era. Treatments at the end of my life time will be radically different than those we are using today. Genetic sequencing of each patient will give the risks they face in life. Drugs will be customized to each patient and their specific disease! GATTACA is in the not too distant future. But what will government controlled spending in these fields lead to? What is the R & D in the socialized countries compared to that going on in the US? Who is leading the way? Each part—research, technology, and pharm play a vital role in this expanding field. Will government controlled health care destroy this? Hard questions. Just let the same people that run UDOT delve into these problems!
I will go on the record that the health care is much better in the United States than in any other country in the world—in the history of the world. Is the system a pain to get through? Yes. Are there disparities? Yes. Is there enough of a problem that the entire system be changed? Do we really want elected officials making decisions about your health and the future of medicine in this country?
For those of you voting for McCain, think of Obama making the decisions; for those of you voting for Obama, think of McCain making the decisions. Finding answers to these many questions is not and easy task, but it must be done before we go about advocating change in a system that could affect our lives, the lives of our children and grandchildren. As we well know from Social Security once an institution is put in place that provides some care for the individual, neither party is willing to fix the it regardless of the ominous collapse looming on the horizon. Do we dare to place our health in the same hands?
I don’t. But that is just my opinion.
Don’t belittle my wife again.
References:
a) http://www.who.int/whosis/en/
b) http://www.who.int/whosis/indicators/compendium/2008/2let/en/
c)http://www.who.int/whosis/indicators/compendium/2008/3mr5/en/
d) http://www.who.int/healthinfo/paper39.pdf
e) http://en.wikipedia.org/wiki/Margin_of_error
f) http://www.who.int/whr/2002/en/whr02_ch4.pdf
g)http://jama.ama-assn.org/cgi/reprint/295/17/2037
h) http://www.who.int/whosis/whostat/EN_WHS08_Table4_HSR.pdf
i) http://en.wikipedia.org/wiki/Racial_and_ethnic_demographics_of_the_United_States
j) http://en.wikipedia.org/wiki/Demographics_of_the_United_Kingdom#Ethnicity
k) http://en.wikipedia.org/wiki/Demographics_of_germany
l) http://en.wikipedia.org/wiki/Demographics_of_Japan
m) http://en.wikipedia.org/wiki/Canada#Demographics
8 comments:
The superscript annotation did not transcribe into the blogger format. Occasionally you will see a letter at the end of a statement. This correlates to the source at the end of the post.
Also, you will note that as the post went on, I stopped finding references and began answering more questions. This is because I based this post on a similar post that was placed on the old Citizen Post. I also became more tired and did not want to waste more time on finding facts to satisfy everyone. I encourage you to find the facts yourself and present them here.
Your opinion is welcome too.
-Al
Thanks for all of the work you put into this, it was very informative.
What still bothers me, though, is that we often talk about the amount of money our government spends on health care, but it is often left out that much of this spending is done by paying private HMOs to do the work of providing this care, especially through the Medicare program. I don't think that we can use our current government spending on health care as a measure of the true cost of universal care, since the government usually provides this care through a for-profit company.
In the end, I don't care if socialized medicine costs more than market-based care, at least it will be more fair. In a market based system, more money is spent on research for the most profitable drugs and treatments, not the most necessary: there is a pill for restless leg syndrome, but not for cancer. Cancer research still depends upon government grants. Why isn't the market providing its own National Cancer Institute? Because it wouldn't be profitable.
And I do not agree that our government is inefficient. For what I pay in taxes, I get enormous benefit. While a privately run fire department, etc. might cost me less in the long run, I will always have a distrust of an organization designed around the idea of profiting from providing me with safety. Somehow, I don't think the shareholders will care if I live or die.
Sorry I don't have any facts to back up my beliefs. Perhaps I could cite the recent financial crisis as evidence that pleasing the shareholders isn't necessarily good for society.
In your reply you stated that government expenditure on health care as a percent of GDP is not a valid measurement of what the government will spend on health care. You failed, however, to offer suggestions on what we can use. Why does the government contract out its care? Is it cheaper? Do the make greater profit? Will socialized medicine remove HMOs from the picture?
You don’t understand medical research. The pill for restless leg syndrome was not developed to market to the masses. It was noted that the use of dopamine agonists, medication1 developed for the treatment of PARKINSON’S DISEASE, was useful in the treatment of this unnerving condition. Sure it is marketed on TV. Is that bad? If you have restless leg syndrome but do not realize that you even have such a disorder, would not the news that a medication that disturbs your sleep nightly be of great comfort to you? Might that prompt you to see a doctor, who can then evaluate to see whether or not you might have restless leg, iron deficiency, or have sever peripheral vascular disease that may require surgery? Don’t allow your arrogance to lead you to believe medicine and big pharma are evil profiteers.
And concerning cancer, plenty of ‘incentive’ exists to find a cure. It only the 2nd leading cause of death in the US according to the CDC. Cancer is a much more difficult disease than restless leg syndrome. There exist over 30,000 genes in the human cell. An unknown number of them can experience a mutation leading to either a gain of function or loss of function. This leads to uncontrolled cell growth. The trick is to target the unhealthy malfunctioning cells without killing the healthy cells. It is very, very, very complex. I cannot believe anyone would attribute motivation to find a cure for any illness by medicine and big pharma to be based solely to be monetary gains2,3,4,5,6. I’ve stood at the bedside of patients with terminal cancer. I’m not their for monetary reasons. Neither are the plethora of PRIVATE AND PUBLIC ORGANIZATIONS working on cures for cancer.7
You have not answered my questions concerning the cost of socialized medicine in regards to what is best for the patient, THE SOLE SHAREHOLDER CONSIDERED IN THE ABOVE POST. Rather you have said you don’t care if “socialized medicine costs more than market-based care, at least it will be more fair.” IS THIS REGARDLESS OF COST?! I will not vote for a system that I believe will bring worse health care for everyone. I just don’t have it in my soul to do that.
1) http://en.wikipedia.org/wiki/Restless_legs_syndrome
2) http://www.jnj.com/connect/caring/corporate-giving/?flash=true
3) http://www.pfizer.com/files/responsibility/values_commitments/pfizer_us_grants_cc_q2_2008.pdf
4) http://www.research.bayer.com/edition-19/19th_edition.aspx
5) http://www.gsk.com/community/public_health_programmes.htm
6) http://www.novartis.com/newsroom/news/feature-stories.shtml
7) http://www.cancer.gov/researchandfunding/organizations
PS I have finished the difficult part of 4th year medical school and my application for general surgery residency is complete. I have quite a bit of free time in the next few months, and look forward to having good discussions about heath care. Also, sorry about the deleted comments. There doesn't seem to be a good edit feature for posts so I find errors and have to repost with corrections.
-Al
To your question about how socialized medicine works in England, "What if you get stuck with a primary care physician that graduated last in his class at The Cancun School of Medicine and Binge Drinking? Can you go somewhere else under a socialized system?" The answer is, yes, you can go somewhere else. Choice is a key principle of the NHS.
To your question " Do we really want elected officials making decisions about your health and the future of medicine in this country?" I would answer that yes, I would rather have someone working in the public interest making decisions about what is covered or not than have executives at insurance companies with only a profit motive making those decisions. But I think your question is a bit misleading. Elected officials (i.e. politicians) don't make those decisions in countries with national health care systems. The state appoints panels of experts to determine what should or should not be covered by the national system. And when that body decides that cosmetic surgery shouldn't be covered under the national system, that doesn't prevent citizens from getting cosmetic surgery and paying for it themselves.
While I think this discussion is interesting and informative, I hope we all acknowledge that talk of socialized medicine has little relevance to this election. Obama isn't proposing a socialized health care system. He's offering incentives for individuals, families, and employers to ensure that more people get private health insurance.
Al;
Well thought out post and you make valid and thoughtful arguments.
I understand your feeling that government screws up everything it touches but I have to disagree.
I trained and worked in Navy Medicine for six years. Military medicine is "socialized" medicine 100% funded by taxpayer $ and 100% administered by the US government. I also spent time working in the VA system during residency.
Both of these institutions are well run and efficient. They have their problems and you would not struggle to find people who complain vociferously about both systems. Those people use many of the arguments that you did.
Those systems also have their strengths and they are profound strengths. I never fought with insurance companies who wanted to deny care or coverage. If my patient needed a medicine they got it. I had to make choices that were within coverage limits but those choices were clear. Now when I prescribe a medicine it's a total crap shoot as to whether it will be covered by my patients unique formulary benefit. This one problem leads to mountains of paperwork on my desk every day.
If my patient needed a Cardiologist, Oncologist, Surgeon, whatever, they got it. The difference is, all those decisions were made by me, their primary care doctor. They were not made by their insurance company or anyone else. Only by me. If a patient "wanted" to see a Cardiologist they had to come see me first. 9 times out of 10 I could care for their problem very well, avoiding the time and expense of a specialist.
You see, in our country specialists and procedures are king. This is where the money is. Primary care is an afterthought. This leads to low wait times for spinal fusions and hip replacements, but it also leads to shortages of primary care doctors which leads to untreated hypertension, diabetes, mental illness, and a host of other problems.
The US government gives EVERY soldier, sailor, airmen, and marine and his/her family access to quality care. As a doctor in that system I was privileged to give that care and I felt that we were great at keeping our troops and their families healthy.
The health care system will not implode as the government becomes more involved, and Senator Obama has never proposed "socialized" medicine. As the US government takes on a more active role the balance will shift more to where I think it should be - more health care access for more people, more emphasis on primary care, less emphasis on specialty care.
You mentioned the uninsured man getting $20k worth of stents. I've been on the other side of that story caring for that man afterward. I have just such a patient. He came to me one day complaining of chest pain. I did a treadmill test on him which was not normal. He ended up with 3 vessel bypass surgery. He credits me with saving his life. He's been depressed ever since, to no small degree because of the enormous financial burden. He told me once he'll be paying on those bills for the rest of his life. At least he's still alive right? But maybe, if he'd had health insurance and regular visits with a primary doctor all of that could have been avoided. I'm confident it could have been.
A couple of months ago I saw a 35 year old man who came in with anxiety and chest pain. He was insured, had access, came in early. His father died of a heart attack in his late 40s and he was scared. We did tests. We discovered diabetes, high cholesterol, early signs of blockages in his coronary arteries. Mostly using standard, inexpensive measurements. He's since dramatically changed his life. He eats better, exercises, controls his stress. His blood sugar and cholesterol are better. I can makes those blockages in his heart start to go away with an inexpensive cholesterol medicine. All this with good primary care. No $20k stents, just a few office visits and about $20 a month on pills.
Here's a video of a good panel discussion about the issue put on by the Harvard School of Public Health and the New England Journal of Medicine. http://www.nejm.org/perspective/health-care-reform-video/
Wow, Al, maybe you should tone it down a bit before you start calling other people arrogant. Pharmaceutical companies are in the business of making profit. This is not an opinion, it is a fact. If they do some good, it is a fortunate byproduct of increasing shareholder value. I don’t think it is arrogant of me to think this is true.
Please don’t take my thinking as a personal attack. I really believe that you want to be a doctor to help people. That is why it bothers me that there will be times when you will be pressured by pharmaceutical companies and HMOs. You should be left alone to make decisions based on good science, not good business.
My belief in universal health care (and I believe Obama's proposal is at least a step in that direction) is that I think that access to health care should be a human right, not something you get only if you have money. And I think that our government can do this, and do it well. I can understand why the last 8 years have given you reason to believe that your government is incompetent, but it can improve. I don’t think that our government will encourage doctors to go to medical school in Cancun, and I don’t think that the people from UDOT will be slated to run our health care system.
And the doctors of the Physicians for a National Health Program agree with me. I am not a doctor, so I will leave it to them to explain it. Here is the link:
http://www.pnhp.org/publications/proposal_of_the_physicians_working_group_for_singlepayer_national_health_insurance.php?page=1
Your many facts and figures suggest that universal health care wouldn’t dramatically change the overall health of Americans. To me, that says that universal care is just as effective as our current system. Why not let everyone have access to it? You said, “I will not vote for a system that I believe will bring worse health care for everyone.” I think it might bring worse health care only for those that can currently afford to have it. Shouldn't health care be a basic human right?
Alex, thanks for your comments.
I’ve addressed the fact that this article is not about the current situation. It is a good point, and all should be aware.
Most socialized health care systems allow for individuals to purchase and use private health insurance as well. But to work within a system, you have to follow their rules. In the UK, the NHS allows for this as you pointed out. In Canada, it is less so, but you can always drive south. In the Navy it sounds like you have to go to your assigned PCP first. Since there has been no institution of socialized medicine in the US, we can’t accurately answer that question. It was rhetorical. I was hoping others would see my point that once a system is in place, you are bound by its restrictions.
I don’t want panels of experts deciding what my care should be either. I’d rather that be between my doctor and I. But that is my choice, and you are entitled to yours.
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Matt, thank you for serving in the armed services. I have a great respect for individuals who dedicate their time to serving our country.
Your observations are insightful on how a well run system should work. I completely agree with you that individuals seeking care from specialists before seeing a PCP is ridiculous. Most insurance providers, however, require individuals to see their PCP before they will pay for visits to specialists.
I have some questions for you, and would appreciate your insight from serving in the VA system.
Why is the VA system outsourcing more and more of its care? Is it a funding issue or an effectiveness issue? How many of active service men are dual-users of insurance? How many of retired veterans are dual users?
The VA is not a closed medical system. Many individuals qualify for Tricare (VA health care) as well as Medicare and Medicaid, as well as have the options of private insurance. Many medical studies from the VA are confounded by the fact that there exist this population that will get some care within the system and without.
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Josh, sorry. I did through it in your face pretty hard.
You are correct that Big Pharma is in business to make money. So are hospitals, doctors, nurses, and even the cleaning personel. Money isn’t the only motivation, or perhaps even the biggest, in most cases. I am sorry you are so soured on Big Pharma and my resources could not convince you that they are not just working to increase shareholder value. The products they create save lives, and they donate quite a bit to other organizations to find cures.
Honestly I don’t feel pressured by Big Pharma and HMOs to make choices. If anything I feel a lack of pressure. If I knew which drugs were available to my patients in their plans, I could pick more effectively which would work the best and be affordable at the same time.
Doctors know the science well and are rarely pressured to make the wrong choice scientifically. Often they embarrass drug reps with this:
My favorite is from my family med preceptor: some rep was pushing an ARB as a 1st line treatment for HTN, the doc got fed up with it and said, “why wasn’t it in the JNC VII then?” The rep replied, “Jane who?” (Matt you’ll appreciate the humor)
The only pressure I feel is to eat their free lunch without having to talk to their reps.
As to whether or not I feel that medical care is a right, I do think that every individual should have access to care. I don’t think that means that the government should socialize medicine.
-Al
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