The majority of Western democracies are equipped with robust public health systems. The infrastructure is designed to keep costs low and deliver maximum benefit to the citizens. In most cases, the results are quite tangible: lower infant mortality rate, higher life expectancy, reduced burden of preventable disease, and lower morbidity among seniors (i.e. fewer seniors living with 2 or more chronic conditions). These are all despite a general trend--in Europe at least--toward more smoking and alcohol consumption, with varying rates of illicit drug abuse.
In the United States, as anyone who has ever had a serious injury, chronic condition, or unexpected bout of illness can tell you, there is next to no public health infrastructure, unless you are very poor, very old, a veteran, or have certain chronic conditions like asbestosis. Costs are absurdly high and outcomes pale in comparison to our NATO allies. According to the Commonwealth Fund, US expenditure on healthcare as a percentage of GDP topped 17% in 2013, compared to just 12% in France, 11% in Germany, and less than 9% in the UK. And what do we get for all our dollars shelled out? Three fewer years of life than the OECD average, nearly twice the infant mortality and the highest obesity rate by a country mile (an antiquated phrase that basically means “a whole lot”).
“And what do we get for all our dollars shelled out? Three fewer years of life than the OECD average, nearly twice the infant mortality and the highest obesity rate by a country mile (an antiquated phrase that basically means “a whole lot”). ”
When T.R. Reid wrote his comparison of world health systems, The Healing of America, he traveled to France, England, Germany, Japan, and India among other countries to examine healthcare norms and practices. What he found was that, contrary to popular belief, Americans visit the doctor far less than other OECD countries, yet get far more CAT, PET and MRI scans than anywhere else on the planet. Indeed, the Japanese visit a doctor on average once a month, where as we in the USA visit perhaps twice a year, and then only for serious issues. This was a pivotal conclusion: other countries seem to value preventative care far more as a means of halting potentially costly and debilitating disease early. Furthermore, the reduction in mortality from these kind of regular visits was staggering: three times as many people per 1000 citizens die in the US of ischemic heart disease as die in France, and twice as many as in the Netherlands.
So, why then, is there no will to implement a single payer system in the USA?
A frequent claim is that single payer public health systems come with a rash of intolerable problems. These range from long waits for surgery, to subpar care quality, to rationing of resources, to bureaucrats having access to all your personal information, insinuating themselves between you and your doctor. Another oft-repeated refrain is that price controls, such as those in Japan and Norway, stifle innovation and punish medical device and pharmaceutical companies. Then there is a more insidious argument that America would be embracing the dreaded S-word, the one that has led European economies to ruin and spits in the face of American exceptionalism: Socialism. The utterance alone is enough to make the Heritage Foundation shudder and hiss.
“Contrary to popular belief, Americans visit the doctor far less than other OECD countries, yet get far more CAT, PET and MRI scans than anywhere else on the planet.”
These claims have degrees of legitimacy ranging from “meh” to “come on, man.” There are, on average, twice as many doctors per 1000 people in Norway than in the United States, and all the OECD countries from the Commonwealth Fund with the exception of Canada and Japan have more physicians per capita than here. While Canadians do sometimes have to wait for surgery openings, what many Americans perhaps obfuscate with this argument is that so do we. To be fair, urgent coronary procedure waiting times in the US are far lower than in Canada by an average of several days, according to a 1995 report in the Journal of the American College of Cardiology. More recent data is harder to come by. Despite this, mortality and morbidity rates in Canada are much, much lower following open heart surgery. This may also have to do with an economic system that pushes sick workers back into the labor force ASAP.
Regarding subpar healthcare quality, the data speaks for itself. Americans have some of the poorest outcomes in the developed world for a plethora of diseases. One of the areas in which we do triumph is cancer treatment. However, we also suffer higher rates of most cancers than most of the OECD countries, so our priorities are obviously stacked in favor of dealing with such an eminent problem. As far as rationing of care goes, the UK’s National Health Service is frequently held up as the example based on the hypothetical needs of two kidney transplant patients: one in his early 20s, one in his late 90s. In all cases, the early-20s recipient will be given priority for a kidney transplant. It sounds harsh, but then again, the kidney may prolong the 90 year old’s life by a paltry five years, whereas it may bring several decades to the younger patient. Additionally, this is essentially the same protocol used here in the USA for prioritization. Given the prospect of growing organs de novo on washed connective tissue scaffolding, this may be a problem relegated to the past, as well.
“Bureaucrats already have access to your health information, and if you have a health insurance provider with a strict in-network coverage policy, your choices are already being interfered with. ”
Bureaucrats already have access to your health information, and if you have a health insurance provider with a strict in-network coverage policy, your choices are already being interfered with. Because of the labyrinth of coverage providers and networks, we spend up to five times as much as our allies on the bureaucracy part of healthcare each year, money that could easily be put towards, I don’t know, actually providing healthcare. And price controls? Well, it would certainly be good for the consumers, but how about the providers? Doctors in this country are usually in the upper tier of income, and around the world that is not exactly the case. They are well off, but by no means, as Reid put it, part of the country club set. But in most other countries in this comparison, those doctors paid no money to go to medical school, other than books and housing. Reid also found that in Japan, when the government instituted rigorous price controls, it stimulated demand from providers for better, cheaper, more effective and efficient medical devices that could conform to the new models. Honda, Mitsubishi, Yamaha and various other daihatsu were happy to oblige.
As far as socialism in the medical field goes, allow me to push the bold question: so what? At the heart of socialism is the idea that the society functions well when its members are cared for. Isn’t that sort of at the heart of medicine as well? But, I digress.
“While Japan, Norway, Germany and France are, by and large, ethnically homogenous populations which cluster for the same diseases, and have populations ranging from 1%-25% of the United States, the USA is an immense, multicultural, young nation.”
There is one perfectly legitimate argument against a comprehensive single-payer system. While Japan, Norway, Germany and France are, by and large, ethnically homogenous populations which cluster for the same diseases, and have populations ranging from 1%-25% of the United States, the USA is an immense, multicultural, young nation. It is difficult to provide a framework for the treatment of ALL the diseases that significantly affect Americans, because the population genetics, environments, and cultural norms are incredibly disparate in many cases. To boot, insurance companies in the USA are for-profit corporations, and thus have a vested interest in trying to minimize the amount of money paid out in care each year. If that seems confusing, infuriating, or downright dastardly, then you’re feeling a completely normal emotional response and you should sit down and write your Senator today that you think it’s bogus.
I propose a compromise on the front of single payer insurance. We cannot simply copy and paste any nation’s public health infrastructure, but we can learn a lot from our allies. We could create a suite of services that are covered through general taxation, folding parts of Medicaid, Medicare, the VA and SCHIP into a single comprehensive unit and then expanding it to cover all citizens for a variety of procedures, treatments, and provider visits. This could include immunizations, yearly checkups, X-rays, MRIs, CT scans, mammograms, prostate exams, mental health counseling, diabetes prevention, neonatal and maternal care, just to name a few. The approaches must be data driven and evidence based, and incentive payments for patient survivorship and comorbidity could be awarded to physicians to encourage best practices. Patients could contribute small copays to avoid abuse, with the bulk of cost both negotiated and covered by federal, state, and local government partnerships. Collective bargaining for drugs and medical devices could significantly drive down costs of treatment. For special diseases not covered by the plan, supplemental nonprofit private insurance companies could step in and fill the gaps, again driving competitive pricing models by offering suites of services for specialized care. Another idea is drastically reducing the cost of attending medical school, but I don’t have a well-thought out framework for how to accomplish that. Finally, grants for experimental treatments and novel approaches could be made available to physicians and researchers alike.
“We cannot simply copy and paste any nation’s public health infrastructure, but we can learn a lot from our allies. ”
Of course, if CRISPR and other gene editing tools take off as predicted, and if Watson and his ilk supplant traditional physicians, all of these points may be moot, as we’ll all be superhumans being cared for by AI doctors with the collected knowledge of thousands of human physicians.
That seems like a long way off, though, so let’s keep pushing for solutions to present problems.