dw2

15 April 2012

Hope for healing healthcare

Filed under: books, change, Economics, healthcare, market failure, medicine, passion — David Wood @ 12:45 am

Within the space of the first few pages of his book “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care“, T.R. Reid had me chuckling at some of his descriptions of healthcare systems around the world. Within these same few pages, he also triggered in me a wave of anger and disbelief. He’s a veteran foreign correspondent for the Washington Post, and his writing skills shine throughout his book. Marshaling personal anecdotes from his experiences during visits to healthcare facilities in ten different countries, with historical accounts of how these healthcare systems came to have their current form, his writing addressed both my head and my heart.

Given the title of the book, it’s no spoiler for me to reveal that the episode in the first few pages that triggered my feeling of anger and disbelief was located in the USA. NY Times journalist Nicholas D. Kristof also read T.R. Reid’s book and had the same reaction as me. He retells the story in his article “The Body Count at Home“:

Nikki White was a slim and athletic college graduate who had health insurance, had worked in health care and knew the system. But she had systemic lupus erythematosus, a chronic inflammatory disease that was diagnosed when she was 21 and gradually left her too sick to work. And once she lost her job, she lost her health insurance.

In any other rich country, Nikki probably would have been fine, notes T. R. Reid in his important and powerful new book, “The Healing of America.” Some 80 percent of lupus patients in the United States live a normal life span. Under a doctor’s care, lupus should be manageable…

As Mr. Reid recounts, Nikki tried everything to get medical care, but no insurance company would accept someone with her pre-existing condition. She spent months painfully writing letters to anyone she thought might be able to help. She fought tenaciously for her life.

Finally, Nikki collapsed at her home in Tennessee and was rushed to a hospital emergency room, which was then required to treat her without payment until her condition stabilized. Since money was no longer an issue, the hospital performed 25 emergency surgeries on Nikki, and she spent six months in critical care.

“When Nikki showed up at the emergency room, she received the best of care, and the hospital spent hundreds of thousands of dollars on her,” her step-father, Tony Deal, told me. “But that’s not when she needed the care.”

By then it was too late. In 2006, Nikki White died at age 32. “Nikki didn’t die from lupus,” her doctor, Amylyn Crawford, told Mr. Reid. “Nikki died from complications of the failing American health care system.”...

Alas, the case of Nikki White is very far from being an exception. Kristof notes the estimates that “18,000 Die a Year for Lack of Insurance” each year in the US. (And numerous online responses to his blog post give other sad personal experiences.)

But here’s what I found really stomach-churning in the opening pages of T.R. Reid’s book:

Many Americans intensely dislike the idea that we might learn useful policy ideas from other countries, particularly in medicine. The leaders of the healthcare industry and the medical profession, not to mention the political establishment, have a single, all-purpose response they fall back on whenever someone suggests that the United States might usefully study foreign healthcare systems: “But it’s socialized medicine!”

This is supposed to end the argument. The contention is that the United States, with its commitment to free markets and low taxes, could never rely on big-government socialism the way other countries do. Americans have learned in school that the private sector can handle things better and more efficiently than government ever could.

In US policy debates, the term “socialized medicine” has been a powerful political weapon…  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 healthcare system. It was a label, at the dawn of the cold war, meant to suggest that anybody advocating universal access to healthcare must be a communist. And the phrase has retained its political power for six decades…

I was reminded of the remarkable claims at the beginning of this year by would-be President Rick Santorum that the “NHS devastated Britain” and caused “the collapse of the British Empire”.

T.R. Reid had been bureau chief for the Washington Post in both London and Tokyo, and had lived in each of these cities for several years with his family. That gave him considerable first-hand experience of the healthcare systems in these two countries. The book arose from a wider set of visits, including France, Germany, Canada, India, Nepal, Switzerland, and Taiwan. He had two reasons for all these visits:

  1. To inquire about possible treatments for a shoulder injury he had sustained many years previously, but which had recently flared up again, becoming increasingly painful and hard to move. As he explained, “I could no longer swing a golf club. I could barely reach up to replace a lightbulb overhead or get the wine-glasses from the top shelf. Yearning for surcease from sorrow, I took that bum shoulder to doctors and clinics… in countries around the world”
  2. To seek, more generally, for “a solution to a much bigger medical problem… a prescription to fix the seriously ailing healthcare system” of the US.

He retells his diverse experiences with good humour and great insight. Along the way, he lists and punctures “Five Myths About Health Care in the Rest of the World” – myths that are widely believed in some parts of the US, but which have limited basis in actual practice:

  1. It’s all socialized medicine out there
  2. Overseas, care is rationed through limited choices or long lines
  3. Foreign health-care systems are inefficient, bloated bureaucracies
  4. Cost controls stifle innovation
  5. Health insurance has to be cruel

For example, on whether cost controls stifle innovation, he notes the following:

The United States is home to groundbreaking medical research, but so are other countries with much lower cost structures. Any American who’s had a hip or knee replacement is standing on French innovation. Deep-brain stimulation to treat depression is a Canadian breakthrough. Many of the wonder drugs promoted endlessly on American television, including Viagra, come from British, Swiss or Japanese labs.

Overseas, strict cost controls actually drive innovation. In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)

And the facts and figures throughout the book are relentless and comprehensive:

  • Average life expectancy at birth in the United States is 77.85 years. “That means the world’s richest country ranks forty-seventh, just ahead of Cyprus and a little behind Bosnia and Herzegovina, in terms of longevity. The United States is among the worst of the industrialized nations on this score; for that matter, the average American can expect a shorter life than people in relatively poor countries like Jordan”
  • “For those Americans who are uninsured or under-insured, any bout with illness can be terrifying on two levels. In addition to the risk of disability or death due to the disease, there’s the risk of financial ruin due to the medical and pharmaceutical bills. This is a uniquely American problem. When I was traveling the world on my quest, I asked the health ministry of each country how many citizens had declared bankruptcy in the past year because of medical bills. Generally, the officials responded to this question with a look of astonishment, as if I had asked how many flying saucers from Mars landed in the ministry’s parking lot last week. How many people go bankrupt because of medical bills? In Britain, zero. In France, zero. In Japan, Germany, the Netherlands, Canada, Switzerland: zero. In the United States, according to a joint study by Harvard Law School and Harvard Medical School, the annual figure is around 700,000”
  • “The one area where the United States unquestionably leads the world is in spending. Even countries with considerably older populations, with more need for medical attention, spend much less than we do. Japan has the oldest population in the world, and the Japanese go to the doctor more than anybody – about fourteen office visits per year, compared with five for the average American. And yet Japan spends about $3,000 per person on health care each year; we burn through $7,000 per person”
  • “When a Harvard Medical School professor working at the World Health Organisation developed a complicated formula to rate the quality and fairness of national healthcare systems around the world, the richest nation on earth ranked thirty-seventh… just behind Dominica and Costa Rica, and just ahead of Slovenia and Cuba…”

(For more about the WHO comparative rankings of healthcare systems, see e.g. Wikipedia’s coverage. T.R. Reid addresses various criticisms of the methodology in an Appendix to his book.)

Rising above the facts and figures, and the various anecdotes, the book provides a handy framework for making sense of the different systems deployed around the world:

“Fortunately, for all the local variations, health care systems tend to follow general patterns. In some models, government is both the provider of health care and the payer. In others, doctors and hospitals are in the private sector but government pays the bills. In still other countries, both the providers and the payers are private.”

There are four basic models:

  1. The Bismarck Model: “Both health care providers and payers are private entities. The model uses private health insurance plans, usually financed jointly by employers and employees through payroll deduction. Unlike the U.S. health insurance industry, though, Bismarck-type plans are basically charities: They cover everybody, and they don’t make a profit”
  2. The Beveridge Model: “Health care is provided and financed by the government, through tax payments. There are no medical bills; rather, medical treatment is a public service, like the fire department or the public library. In Beveridge systems, many (sometimes all) hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge”
  3. The National Health Insurance Model: “The providers of health care are private, but the payer is a government-run insurance program that every citizens pays into. The national, or provincial, insurance plan collects monthly premiums and pays medical bills. Since there’s no need for marketing, no expensive underwriting offices to deny claims, and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style private insurance. As a single payer covering everybody, the national insurance plan tends to have considerable market power to negotiate for lower prices. NHI countries also control costs by limiting the medical services they will pay for or by making patients wait to be treated.”
  4. The Out-of-pocket model: “Most medical care is paid for by the patient, out of pocket, with no insurance or government plan to help”.

Which all these systems apply in the US? The answer, surprisingly, is: All of the above – but not done in an efficient way.

Chapter by chapter, the book highlights ways in which the various medical systems keep costs lower (e.g. through having simpler administration) and deliver generally higher quality than applies in the US.

But two examples are even more important than any mentioned so far. These are the examples of Switzerland and Taiwan. Both of these are countries where significant reforms in the healthcare system have recently taken place – putting the lie to any viewpoint that complicated healthcare systems are incapable of major improvement:

Neither of these countries looks much like the United States of America… Still, both countries have important parallels to the United States. Both are vigorous democracies marked by fierce competition between political parties that look a lot like our Republicans and Democrats. Both have finance and insurance industries that are rich and politically influential. Both are ferociously capitalist places, and both have jumped aboard the digital revolution to build advanced, high-tech economies. Most important, both Taiwan and Switzerland had fragmented and expensive health care, similar to the American system – until they launched their reform campaigns.

In both countries, payment for medical care was dominated by health insurance plans tied to employment; in both significant numbers of people were left with no coverage at all. Even with large numbers of people uninsured, both countries were pouring considerable amounts of money into health care. In both Taiwan and Switzerland, as in the United States…, a growing chorus of voices began demanding universal coverage, arguing that every sick person should have access to a doctor…

In both cases, the results of the reforms have been very positive. To take the case of Taiwan:

Almost overnight, some 11 million Taiwanese who had no medical insurance suddenly had access to doctors and hospitals, with the Bureau of National Health Insurance paying most of the bill. This created a flood of new demand for medical services. The market responded with a flood of new supply: Clinics, hospitals, dentists, optometrists, labs, hostels, and acupuncture centers sprang up everywhere…

The most striking result of Taiwan’s new system is a healthier population with a longer healthy life expectancy and much higher recovery rates from major diseases. This is particularly evident in rural areas, where it was difficult or impossible to see a doctor before the new system took place…

As a system started from scratch, with uniform rules and procedures for every doctor and patient and state-of-the-art paperless record-keeping, Taiwan’s new health insurance system is the most efficient in the world. The 1994 law seemed hopelessly optimistic when it set a limit of 3.5% for administrative costs; in fact, the system has done much better than that, with paperwork, etc. accounting for only 2% of costs most years (and sometimes less). That’s about… one-tenth as high as the administrative burden for America’s private health insurers. As a result, even with explosive growth in the consumption of medical services, national health spending in Taiwan remains at about 6% of gross domestic product (as opposed to about 17% of GDP in the United States). This has kept costs low for patients…

As for the healthcare reforms in the US, under President Obama, T.R. Reid points out that they miss various elements of the reforms undertaken in both Taiwan and Switzerland:

  • Even with the reform in place, there will still be around 23 million Americans without healthcare insurance in 2019
  • American health insurance companies will still be able to get away with various practices (for denying payments to patients) that are banned in every other rich democracy
  • Much of the argumentation in favour of the reform has emphasised economics (not a bad thing in itself), but the moral and ethical drivers which were at the forefront in the debates in Taiwan and Switzerland have had a much lower profile in the US.

The final passage in the main body of the book puts it like this:

The sad truth is that, even with this ambitious reform, the United States will still have the most complicated, the most expensive, and the most inequitable healthcare system of any developed nation. The new law won’t get to the destination all other industrialized democracies have reached: universal healthcare coverage at reasonable cost. To achieve that goal, the United States will still have to take some lessons from the other national healthcare systems described in this book.

I’ll touch on four points in my own conclusion:

1. The moral argument for healthcare reform

The time I’ve spent recently reading Jonathan Haidt’s “The Righteous Mind” and watching him speak at a couple of events in London, has made me more sensitive to the fact that different people have different moral “tastes”, and can assign different priorities to six major dimensions of moral sensibility:

  • care vs. harm
  • fairness vs. cheating
  • liberty vs. oppression
  • loyalty vs. betrayal
  • authority vs.subversion
  • sanctity vs. degradation.

Failure to appreciate this fact leads of lots of bewilderment, as summarised in William Saletan’s New York Times review “Why won’t they listen?” of Haidt’s book. As T.R. Reid highlights, the current US healthcare system may well fail important moral tests on grounds of care vs. harm, and by being “unfair”. However, the arguments of people like Rick Santorum against the reform act build on different moral dimensions – e.g. liberty vs. oppression. These arguments find it particularly objectionable that, under these reforms, many people will be obliged (“oppressed”) into purchasing healthcare insurance. That’s seen as a fundamental denial of liberty.

Another insight from Haidt is that, in these circumstances of conflicting moral intuitions, reasoning often fails. One of his key summary points is as follows:

Moral intuitions come first, strategic reasoning comes second, to justify the intuitions we have already reached.

That’s not to say further discussion is pointless. As William Saletan puts it:

Haidt believes in the power of reason, but the reasoning has to be interactive. It has to be other people’s reason engaging yours. We’re lousy at challenging our own beliefs, but we’re good at challenging each other’s. Haidt compares us to neurons in a giant brain, capable of “producing good reasoning as an emergent property of the social system.”

Our task, then, is to organize society so that reason and intuition interact in healthy ways. Haidt’s research suggests several broad guidelines. First, we need to help citizens develop sympathetic relationships so that they seek to understand one another instead of using reason to parry opposing views. Second, we need to create time for contemplation. Research shows that two minutes of reflection on a good argument can change a person’s mind. Third, we need to break up our ideological segregation. From 1976 to 2008, the proportion of Americans living in highly partisan counties increased from 27% to 48%. The Internet exacerbates this problem by helping each user find evidence that supports his views…

2. A surprisingly effective example of lower-cost healthcare

So, what happened to T.R. Reid’s shoulder? Out of the all the recommendations from different doctors around the world, which was the best?

Doctors in several countries – including the US – recommended expensive, invasive, reconstructive surgery – even though all these doctors noted that there was no guarantee the surgery would be successful.

But the advice T.R. Reid ultimately found most useful involved a very different kind of technology, with roots going far back into time. That treatment was in India, and was based on Ayurdveda – which, like yoga, is derived from ancient Hindu scripture. It included

  • Eating only bland food (lentils and rice, primarily) during the course of the treatment, on the theory that the body should be under minimal strain during treatment
  • Daily massages involving hot oils and powerful hand movements (“to smooth the bodily routes that the prana needs to follow”)
  • Six times each day, imbibing “a vile assortment of herbal medicines, most of which tasted like spoiled greens or aging mud”
  • Attending a temple within the hospital grounds, “to perform poojah, or reverence, tot he Hindu god of healing”
  • Undertaking various yogic exercises
  • Accepting advice to “relax, and to forget whatever stresses and worries”
  • Reading one of the key Hindu scriptures, the Bhagavad Gita.

After several weeks of this treatment, the results were unmistakable. The shoulder had a much greater range of movement than before, and the pains were much reduced:

To this day, I don’t know why it happened. Was it the massage, the medication, the meditation…? In any case, the timing was definitely propitious. Ayurveda worked for me. I didn’t have a miracle cure; my shoulder was not completely healed. But my pain decreased, my range of motion increased, and I was definitely better – and all without the trouble or cost of a total shoulder arthoplasty…

Note that the book also describes some alternative medical treatments that were not successful – including other herbal medicines in Nepal, and acupuncture in Taiwan. And as mentioned, the Ayurveda did not provide “complete” healing. What’s more, Ayurvedic clinics increasingly incorporate x-ray machines, stethoscopes, and other western tools. But this section of the book was an intriguing reminder to me that I’d love to dig more deeply into material such as William Broad’s “The science of yoga: the risks and the rewards“.

3. Every healthcare system is under increasing financial strain

Despite the many successes of healthcare systems covered in the book, T.R. Reid was clear that all these systems are under increasing financial stress. He quotes the (somewhat tongue-in-cheek) “Universal Laws of Healthcare Systems” as articulated by economist Tsung-Mei Cheng:

  1. No matter how good the health care in a particular country, people will complain about it.
  2. No matter how much money is spent on health care, the doctors and hospitals will argue it is not enough.
  3. The last reform always failed.

As the author states,

All national health systems, even those that do their job well, are fighting a desperate battle these days against rising costs.

We live in a technological age, and technology – in the form of new miracle drugs, new medical devices (e.g. man-made shoulders) and new procedures – plays a huge role in modern medicine. This is unquestionably a good thing… but it is also an expensive thing.

But good technology, wisely applied, can reduce healthcare costs, rather than simply make them more expensive. For example, as T.R. Reid points out, suitable early tests can do wonders in preventive medicine. One place I’ve covered this topic before is in “Smartphone technology, super-convergence, and the great inflection of medicine“.

4. The good news in American medicine

Lest it be thought that T.R. Reid, the author of “The healing of America”, is unduly negative about America, or unpatriotic, let me draw attention to a 53 minute PBS documentary he has recently released: “The good news in American medicine“.

Whereas “The healing of America” gathers inspiring examples of best practice from around the globe, “The good news in American medicine” gathers inspiring examples of best practice from around the US – and draws out some important economic and moral principles along the way. (Quote: “A whole lot of this is about doing the right thing“.) Just as I recommend the book, I also recommend the video.

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