Tuesday, May 22, 2007

Mandate for change?

With thanks to Dr. Brian Jarman for sending this along, here is the latest Commonwealth Fund report comparing health care in several countries. The main conclusion:

Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries.

Here is the chartpack with all the slides summarizing the data.

No doubt many will argue that this is proof of the need for a national health plan like those found in the comparison countries -- Australia, Canada, New Zealand, the UK, German, France, the Netherlands, or Japan.

Personally, I think it argues for broader insurance coverage in the US, perhaps along the lines recently enacted in Massachusetts. Plus, it argues for better reimbursement in the US for primary care physicians. Plus, it clearly argues for greater emphasis by US hospitals and physicians for more systematic implementation of quality control, perhaps with more than gentle nudging by government and private payers. (See chart #50 for the percentage of primary care doctors who report any financial incentive for quality improvement: The US is lowest at 30%).

But I recognize that many disagree, and my point here is not to get into that debate. (I have done that elsewhere.) Instead, I want to raise the question of whether there is broad political support in the US for a major change. Notwithstanding similar data for years and lots of speeches on the subject, there has not been movement along these lines. Why have there not been votes for passage?

Hidden away in these charts might be indications of why the national health plan idea has been politically unpopular in the United States. Chart #60 shows the percentage of "sicker adults" who had to wait more than four weeks to see a specialist: Germany 22; US 23; NZ 40; Australia 46; Canada 57; UK 60. Chart #61 shows the percent of physicians who feel that their patients often have long waits for diagnostic tests: Australia 6; Germany 8; US 9; Netherlands 26; NZ 28; Canada 51; UK 57. And chart #62 shows the percentage of people who waited four weeks or more for needed non-emergency or elective surgery: Germany 6; US 8; Australia 19; NZ 20; Canada 33; UK 41.

So, if you think about things in purely political terms, because of proximity and/or language, the US public is most likely to hear about the experience of Canadian and British citizens with regard to these aspects of care. "Everyone" has a story about a friend of a friend from Canada who choose to fly to the US for elective surgery because he or she would have had to wait months for that treatment in Toronto. In the US, there is an expectation that when you need or want treatment, you get it quickly.

In addition, chart #97 presents a fascinating story, the percentage of people above average income in the Australia, Canada, NZ, and the UK who have chosen to buy private insurance to gain access to care not provided by their national health plan -- 63, 81, 57, and 35 percent, respectively. This factor gives yet another indication that the rationing of care provided under the national plans is not viewed positively by those of better economic means.

Finally, charts #126 and #127 give an indication of physician dissatisfaction with their country's health system and their own practices. The numbers are all over the place, with no clear mandate for change in the US among physicians -- or at least no clear distinction on this point with those in other countries.

For years, the Democrats have pushed the health care agenda, citing the equity and access reasons inherent in this report. For years, the Republicans have not, citing the issues of personal choice and government rationing. While many polls have showed public interest in major change, those same polls have often showed that there is less interest among people who vote. Have the Republicans been politically astute by not pushing this agenda, or have the Democrats locked onto an issue that will finally have traction?


Anonymous said...

Oh, boy. This post may exceed your possible record # of comments in the "take pride" post. (BTW, what IS the post receiving the most comments so far?) I look forward to this one.
My own opinion is that frustrations with health care will eventually reach enough of the voting U.S. population that there will be a mandate for change. But I remember reading somewhere that there isn't a country in the world which is entirely satisfied with its health care system - it may be impossible to achieve.

Anonymous said...

Hi Paul,

This is a great question to be asking prior to the release of Michael Moore's "Sicko"!

As a Canadian, I am having a bit of trouble with your interpretation of chart #97. Yes, 81% of Canadians have insurance coverage for dental, out-of-hospital pharmaceuticals, massage, etc..., however, this doesn't mean that Canadians are not happy with government rationing. Please note that Canadians are not able to purchase insurance for core-services.

Insurance for non-core services is a common benefit offered to employees (and their families), students, the elderly, and those on social assistance. Very few individuals seek out this coverage in order to mitigate their own risk. Self-employed individuals, for example, physicians and small business owners are mostly uninsured!


Anonymous said...

I am looking forward to see Sicko - a movie by Michael Moore to be released in June...it addresses the same topic -- "If people ask, we tell them 'Sicko' is a comedy about 45 million people with no health care in the richest country on Earth."

Anonymous said...

Thanks, Erik. Please explain a bit more about what is core and what is non-core if you wouldn't mind.

Anonymous said...

Paul -

I agree with you regarding this one. Indeed, based on the information you presented the data supports it: people want a better minimum healthcare coverage for all, supplemented by payment for higher degrees of service for those who can pay for it. I drive a 2006 Lexus, while someone across town may drive a 1993 Chevy (bad example, let's say a 1993 Toyota since the former is unlikely to still be on the road), because I can afford to pay more for my car. I live in Newton and am afforded better public schools while those in Roslindale need to figure out another solution for this extremely important issue. (I bring up the latter because education is typically viewed to be more of a "right" than a privilege, as is certainly perceived to be the case with healthcare). By providing a minimal accepted coverage and allowing us to supplement it based on means, we would undoubtedly bring up the completely exposed rear (who are responsible for our dismal world rankings, and yes, that pun was intended) and keep those of us who are fortunate enough to afford it still living with greater coverage. Think about auto insurance: one can play with one's deductibles to get to a point they can afford, whether or not they consciously realize they could be ruined if they total their car, hit another expensive one, and can't afford the deductible.

The point is that everything is rationalized in the U.S., whether we want to admit it or not. It's just that healthcare has been held out unfairly as an example of where this shouldn't occur, much in the same way that we are viewed to be failing in our battle for a "cure for cancer" while endocrinologists have been secretly losing their "cure for diabetes" for diabetes, despite the fact that the latter arguably causes as much morbidity/mortality, yet we're oddly okay with disease modification and mitigation of symptoms as opposed to complete eradication of the disease as we expect with cancer.

The bigger issue to me, and it complements your data regarding how long we wait for care, is that Americans don't accept death as an outcome. To us, the scorecard is simple and binary: we live or we die. To others, they realize there is such a thing as a quality of life low enough that it is not worth living. Based on that metric, we overfund the "living" goal with the purposes of achieving the unachievable (or at least the undesirable from a environmental perspective!) - immortality. Anything less is not acceptable and "failure." Given this uniquely American perspective, we therefore foot the bill - we pay more for all branded medicines, for clinical development, etc. in order to pay for pharmaceutical and medical device innovation. We also employ it much more frequently, and at greater cost. We DEMAND it. These demands for innovation comes with a price, however. We either have to lower that (culturally unlikely) and better share the costs, or accept that these costs will elude payment by the poor, our overall health will suffer, and economic polarity will continue to move forward the point that we might as well rename ourselves "New India".

In the meantime, let's call a spade a spade and stop being so hypocritical. All human beings are created equal, but from the moment they take their first breath the divide begins, from access to the top obstetrical services (versus a public hospital) to how long they get to stay there to the car ride home (Lexus or Chevy?) to the degree to which one of their parents can stay home (supplemental nannies or going it alone?) to preschool selection to. . . everything except our acceptance that what doctor we see or what care we receive may also vary - in fact WILL also vary - based on our socioeconomic backgrounds. We are kidding ourselves too much these days (don't get me started on the way that kids can no longer be cut from Little League or that it's hard to tell who's the birthday boy at a party these days because all attendants receive a goodie bag): Americans need to be less disingenuous, more honest, and simply be blunt when the task calls for it. Indeed, if I could import one thing from any of the other countries mentioned in your post, Paul, it would not be their healthcare system, but rather their logical and straightforward communication patterns. Without that, we'll continue to divide ourselves between the hopelessly liberal and the deliriously capitalist.



Anonymous said...

Although the system in the U.S. is not perfect, competition is still the best motivator for providers. Equality was never the foundation of this country, freedom is. We do need a system that can assure necessary, emergent care to everyone; and we aren't that far from that. It would be a shame to see the government take over and ruin just one more area of the economy.

Anonymous said...

I'm a Republican and normally I'm a believer in competition and the free enterprise system. However, I'm not a believer when it comes to the health insurance industry. I'm a physician practice manager and have been fortunate to have the opportunity to see and compare payment methodologies and practices of the federal/state governments and commercial insurance companies. The federal and state governments are by far more reliable and honest. I'm sick of all of the tactics that insurance companies utilize to NOT PAY hospitals and providers (downcoding services, losing applications, claiming services were not approved, etc.). I'm afraid the health insurance industry, in general, is populated with individuals whose priorities are not aligned with the care of people.

Anonymous said...

It's telling that you had to look that far into the report to find something nice about the US system, and even then the evidence isn't exactly great. Another interpretation of the same charts is that it's possible to reduce US waiting times by moving to a socialized health care system along the lines of Germany while cutting expenditures by 50%.

If Canada, Germany, France or any of the other countries in the report maintained the same structure of their systems but doubled spending to match US levels, imagine what they could achieve.

Anonymous said...

Amplifying on one of the charts from the study, this graphic shows the percentage of the population over 15 years old in various countries with a Body Mass Index (BMI) greater than 30. The U.S. is in a class by itself on this measure while other English speaking countries have higher rates of obesity than other countries in Europe and Asia.

I believe the very high U.S. obesity rate (and associated diabetes) has a lot more to do with lifestyle, diet, culture and, perhaps, poverty rates than with the healthcare system or the percentage of the population that lacks health insurance. The U.S. also has much higher rates of heart disease for the same reasons with at least some of it connected with diabetes. On the other hand, the U.S. now has the second lowest percentage of the population who smoke (after Canada) which I attribute to the steep increase in cigarette taxes implemented in recent years. I think that is an example of both good tax policy and good health policy.

Both diabetes and heart disease can go undetected for years until a major event like a diabetic coma or heart attack occurs. I recall having surgery in a NYC Academic Medical Center in 2004. My roommate was a young guy in his 20's who qualified for Medicaid. He went into a diabetic coma and had to have his foot amputated. He never presented himself to a healthcare provider until it was too late even though he had insurance and NYC has plenty of good hospitals that serve the poor. I wonder to what extent these adverse outcomes among people with diabetes and heart disease relate to this issue of waiting until it's too late to seek care. This could be another instance where poverty and ignorance are more important factors than anything to do with the healthcare system.

With respect to cancer of all types, there seems to be much less difference in the number of cases per 100,000 population from country to country. With the exception of lung cancer, diet and culture appear to be less important factors, though preventive care plays an important role in catching at least some types of cancer early when they are much easier to treat.

Bottom line: we may be attributing too much of the difference in diabetes and heart disease related outcomes among countries to differences in the healthcare system and not enough to variances in diet, lifestyle, culture and poverty rates.

Anonymous said...

Hello, I'm a relatively new reader to your with no connection to the medical community, just reading along for interest. I'm from a country with cradle-to-grave healthcare (though not one of those in your comparisons), so I know the up- and downsides of such a system. To answer your question, I think at least part of the growing support for universal healthcare in the US comes from people like me or my husband, who have had no or inadequate coverage for most of our adult lives. I don't think we're atypical among our age group. If I remember correctly, the statistics that drove Mass. to enact its law showed that a significant number of the uninsured were young people without employer-paid insurance programs.

My husband held a series of contract-type jobs with no health insurance. Even with a city program for lower-income families, we could not afford to purchase coverage for him. I'm a graduate student and was forced to purchase expensive health coverage through my university. It was cheaper than paying out-of-pocket, but still ate up about 30% of my fellowship. (Also, I could only go to a doctor about 2 hours from where I actually live, and the wait for a dentist was usually 6 months.) Now, at 30, my husband finally has a job with a terrific healthcare package. We couldn't start a family without this. We are both educated, working people - I can't imagine what those in far worse situations do. I think that's where the support comes from.

Anonymous said...

Yes, David Williams, but that wasn't my point in mentioning those charts. I was trying to give hints as to why there has not been political support for the kind of change you suggest would be better for Americans, and which Anon 3:55 argues would not be better for Americans.

AnnEM, RN said...

This issue boils down to two elements: money and power. Who has it and who wants to keep it and who doesn't have it and suffers horribly because of that sorry fact in our "civilized democracy".

Healthcare is not a commodity and should not be subject to the greed of "the marketplace". Our political process is largely controlled by corporate special interests resulting in the Faux Reform that we are living through -- and paying through the nose for -- here in Massachusetts.

Healthcare is a public good and a human service and should be treated as such, as is done in the rest of the industrialized world.

I am ashamed to be an American, for the Iraq war and for U.S. Healthcare, to name a couple of reasons.

And I am ashamed to be a health professional (RN, MSN) in this country due to our inhumane greed-driven obscenely expensive, wasteful and largely ineffective healthcare non-system system that causes the premature deaths of tens of thousands of people every year (see IOM reoprt "Consequences of Uninsurance").

Please learn more about ongoing work for health justice at http://www.DefendHealth.org


Sign the Petition opposing the new Mass. health reform law's inadequate unaffordable health insurance plans at http://www.Mass.PNHP.org

Thank you.

Anonymous said...

Dear Paul,

I love reading your blog, (from not-so-sunny Melbourne, in Australia). I just wanted to point out the issues of just comparing raw data between countries, as some sort of a league table, without any knowledge of how the data was collected or the context of what the data means. I understand that you were talking about why, politically, in the US there is not a call for a national health system, but it doesn't give the whole picture. Eg. waiting lists don't necessarily measure the illness/ waiting/dissatisfaction in the community (ie in Australia, waiting lists can be "closed", or for dental people don't even get onto them, due too lack of money to pay for care, or too much money to qualify for subsidised care and I imagine in the US, if you can't afford to see a specialist then you also may not get on the list). I think that the difference in the stats between those who believe healthcare is an issue, and those who vote and think health care is an issue is really interesting, and possibly says a lot about the more advantaged people who are more likely to vote, and be happy with the healthcare system. In Australia it is compulsory to vote, so a completely different situation.

Anonymous said...

Hi Paul,

Non-core services differ among the provinces, but generally include dental, basic vision tests, out-patient pharmaceuticals (unless prohibitively expensive) and cosmetic surgery.

If the public system provides the service, then you cannot buy insurance for it. That said, this is likely to change in the province of Quebec (the home of for-profit medicine in Canada).


Anonymous said...

You're right, Paul. I meant to imply that supporters of nationalized care should be able to rebut this almost universal objection by pointing out: 1) we have waiting lists here, too and they're worse than socialized Germany, 2) the problem in other countries isn't socialism, it's lack of funding.

Anonymous said...

I'm told that the AARP and, perhaps, others have done studies in the past that show that approximately 50% of all healthcare spending in the U.S. is attributable to the 65 and older population. Spending includes payments by Medicare, Medicaid (mainly nursing home costs for the poor), supplemental insurance policies purchased by individual seniors and their employers or former employers, and out-of-pocket payments.

Since we already have universal coverage for this population in the U.S., the uninsured can be removed as an issue in comparing healthcare spending on behalf of this population across countries. How does the percentage of GDP spent on the 65 and older population compare? To what extent are the differences attributable to defensive medicine, presence or absence of electronic medical records, and very different approaches to healthcare (and utilization) at the end of life? How much of the difference in life expectancy (beyond age 65) is due to differences in diet, culture, lifestyle, etc. as opposed to the quality of doctors and hospitals and wait times for services? How much relates to differences in what medical personnel are paid and the price of brand name drugs in different countries?

The bottom line is that this is a complex subject, and glib calls for the imposition of a single payer system, universal coverage and getting rid of for profit private insurance companies is unlikely to result in either significantly lower costs or better health outcomes.

Anonymous said...

Very thoughtful presentation of that question, BC. Anybody out there have responses on the over 65 issue?

Anonymous said...

Regarding over 65, I do not know the answer, but Mathew Holt's blog "The Health Care Blog" has debated these types of issues ad nauseum, if bc is not already aware of that blog.
It may be there (I can't remember) that I read a spoof about an insurance company offering people excellent rates if they agreed to humane euthanasia at 65 years of age, or something along those lines.

On another note, I am anon 0845, who predicted a large number of comments on this post and asked which of Paul's posts had the most comments. Looks like I was dead wrong on the first point, perhaps proving the statistic that people who vote are not wholly engaged with this issue.
Since I had always wanted to read the back posts before I discovered the blog in January anyway, I reviewed all the posts for highest # of comments. And the winner is..... a tie, at 52 comments each, between the recent gay pride post and the one of Oct. 20, 2006 in which Paul asked "How am I doing?"
Next was the Da Vinci robot at 40, "the future is in primary care" at 38, and several tied at 37, including the famous one "Am I paid too much?"
I don't guarantee these results since my 17 yr old was arguing with me about money while I was trying to review them, but here they are. What does it all mean? (:

Anonymous said...

I have noticed the same phenomenon on John McDonough's excellent Health Care for All blog. When this topic is covered, there are often no comments. I have no idea what that means.

Anonymous said...

I think it means most people who vote are still covered by a reasonable employer-sponsored plan and have no worries. As a retired self-employed person, I have an HSA with catastrophic backup coverage and $6000 deductible. Just getting Dr's office employees to understand what this is and how I will pay for my bi- yearly colonoscopies is a challenge. (They categorize me "self-pay", the medical euphemism for uninsured.)
Just wait 5 yrs till all the employers bail.

Anonymous said...

I'm very aware of Matthew Holt's blog. While general healthcare issues and differences across countries have been debated extensively on THCB, none of the debates have focused purely on the sub-set of the population that is 65 and older, perhaps because good data is hard to come by.

I suspect that a very significant percentage of the higher costs in the U.S. are due to (1) more heroic services provided at the end of life, (2) defensive medicine, (3) higher compensation for medical personnel (especially doctors), (4) higher costs for brand name prescription drugs and (5) less use of electronic records leading to more duplicate testing and adverse drug interactions.

Interestingly, none of those factors would change with a different health insurance financing scheme even if we manage to achieve universal coverage.

Anonymous said...

Yep, I'm an MD and I agree with all 5 of your factors. I would add a 6th, that of high demand for healthcare among the populace. I know people that go to the doctor every single time they contract the common cold. I wonder if there's any data on this aspect in other countries?
I also agree with your last paragraph. Interestingly, the commenters at Mathew's blog once told me that defensive medicine didn't exist (never mind, I practiced it), and poo-pooed my contention that one must reform the delivery system before reforming the insurance system, for affordability's sake. I think YOU should run the committee that changes the U.S. healthcare system. (seriously. That's a compliment.) (:

Anonymous said...

With apologies for possible plagarism, below is the opening statement from an abstracted article regarding the Medicare program in the New England J. of Medicine, 2005. I have previously expressed in this blog my irritation that such material cannot be read by anyone without a subscription, so that we all can learn about these issues and debate them.

"The Medicare program has been a notable holdout in the global movement toward the use of cost-effectiveness analysis to inform health care decisions. Unlike the reimbursement authorities in Canada and Australia, and in many countries in Europe, Medicare officials do not formally consider cost-effectiveness when determining the coverage of new medical interventions, even as they also confront ever-growing worries about the program's fiscal solvency."

Unless something has changed since 2005, perhaps this gives a window of insight into the U.S. attitude toward paying for medical care over 65 vs. other countries, a question raised by bc.

Anonymous said...

And by the way, bc, I'm not trying to 'out' you or anything, but might you be Barry Carol? I have noticed his comments on THCB have a particular lucidity which resembles bc's here. If so, I want you to run the committee even more. (:

Anonymous said...

anon 9:59,

Yes, Barry Carol and bc are the same person. I comment mostly on THCB, Running a Hospital, Charlie Baker's blog, Ezra Klein's, DB's Medical Rants and a couple of others. Thanks for the compliments.

Anonymous said...


Along the lines of your post, I'm sure you saw today's (5/30) WSJ article entitled "Why health care no longer makes politicians leery."

Anonymous said...


as the Kaiser Family Foundation reports:


80% of the costs are spent by 20% of the population. They don't break it down by age, but it's something to think about whenever you're talking about universal coverage. It will always be a transfer from the healthy 80% to the sick 20%.