Rossputin.com: Rational Thinking About Our World

Authored by "The Freak".
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Watching television, here in the UK, I was struck by the numerous advertisements for private health care coverage. It made it amusing because I understand that the NHS is held out by many in the US (I think even Clinton refered to it) as some kind of amazing health care heaven.

Let me set the record straight: I think universal health coverage is a great idea. In fact, I will go even further and state that I am in favor of providing high quality, inexpensive (or free) health care services to every man, woman, and child in the world.

This idea, regrettably, is akin to nuclear energy generation using a controlled fusion reaction: in principle it’s possible (and a great idea), but it’s never been accomplished. In fact, based on data I’ve seen, we’re closer to harnessing fusion than finding a formula for high quality, inexpensive health care.

Before I go on, let me be very clear that I don’t consider the US system (where I’ve also lived many years) to be some kind of nirvana. It is afflicted by many ills: the AMA is a monopoly that controls the market entry of new physicians, insurance companies choke competition, employers warp the market by cornering and limiting insurance opportunities, local regulations eliminate coverage choices, local medical boards prevent meaningful information availability to consumers, etc. Nevertheless the US medical system is distinctively different from most other places I’ve lived; high end extraordinary care is still available if you can find it and pay for it.

For the sake of transparency I’ll mention (as I’ve already stated in other posts over the years) that I’ve lived in many different countries that attempted to realize this elusive health care universal dream. Rather than point out their failures with raw data (it’s been done before and I have no interest in rehashing others’ work) I will discuss 10 traits I’ve observed universally. Just to be clear, the countries where my family and I have lived (for longer or shorter periods of time) include: Greece, Italy, The Netherlands, and the United Kingdom; I’ve also spent lengthy spans of time in France.

The Freak’s 10 characteristics of universal, government regulated health care as implemented in Europe (I would bet in Canada too, but I have no first hand experience):

1. Great basic care. 90% of common ailments that affect the vast majority of healthy people are managed well by these systems. This means that common respiratory ailments and infections, minor traumas, and frequently encountered conditions are treated promptly and in such a way that recovery ensues with a low rate of complications.

2. Inefficient and uncomfortable basic care. No, this statement is not in conflict with #1 above. The care is provided to yield misleading but politically convenient, objectively measurable statistics. For instance, if you’re in the UK and attend an NHS walk-in centre for influenza, you will be told to go home, rest, and drink plenty of fluids. A request for anti-viral medication will not be heeded unless you are in an “at risk” group (I know, I tried and failed). What this means is that the system will deliver recovery from influenza consistently (leading to good politically expedient “outcome” statistics) but also sap the economy of workers. In my example, I was out from work for about a week and a half. When I compare this to other situations (in the US) where I was offered a test (to confirm influenza) and Tamiflu, I was out of the office five days fewer than in the UK. Given my hourly rate, this translates to an economic loss of £4000 (or $8000 if you prefer). So, in this case, the NHS made a decision to skimp on about £120 (or $240) of treatment and thereby robbed the country of approximately £3880 ($7760) in GDP. Not every body is compensated as much as I am, I understand. Nevertheless, by removing economic incentives and trade-offs from the consumer, the UK has eliminated any market force for optimization. The situation is similar in the other countries I listed.

3. Horrible management of uncommon conditions. The way these countries deliver great basic care (see #1 above) is by delegating it to minimally trained professionals (nurse practitioners) who practice without physician supervision. The maxim in medicine is that the world is populated by horses, not zebras. Nevertheless, occasionally a zebra sneaks in and lesser trained observer will call it a horse with disastrous consequences. A friend of mine suffered irreparable harm because malaria was diagnosed as a generic viral condition for 3 visits in a row. When she finally saw a physician, he immediately asked her about travel and realized that malaria was possible given a recent trip to Papua New Guinea. Damage was already done.

4. Downward spiral in quality. In spite of what anybody wishes to believe, policy impacts behaviour. Most European countries had more free-market health care systems not too long ago. When these were taken over, they continued to work as well as they had before – for a while. Then the slide begins.

5. Physicians become scarce or of low quality. We wish physicians would choose their career because they have an aptitude for medicine and enjoy helping people. Some do. Others choose it because they have an aptitude for medicine, enjoy helping people, and like to make some pretty big money, and bigger if they’re better than most and practice some particularly valuable specialty. Take the incentive away and you’re left with the first group – a subset. This subset drives #6, below.

6. Occasional pockets of outstanding all-around care. Smart hospital managers, dedicated individuals, talented professionals tend to attract each other and create pockets of excellence. These examples get studied by all; everybody wants to learn their “secret” to replicate it. The problem is, there is no secret. They’ve succeeded in spite of the system, not because of it. These examples cannot be replicated.

7. Flourishing alternative medical systems (that is, where this is permitted; The Netherlands forbids private medical care). Those who can afford to pay top money, can get first rate care. So in Greece, Italy, and the UK I’ve been to private facilities that are, consistently, as good as any in the world. They cost as much as any in the world as well – my mother had a lung tumor removed in a private hospital in Italy and it cost more than it would have in the US. Of course, this creates a two tier system, a good one for those who can afford it, and a bad one for those who can’t. In some of these countries (Italy comes to mind) the government, in an attempt to cut off its nose to spite its face, forbids private physicians from practicing in public hospitals, thereby assuring that the best leave the public, and those who can’t cut it in private go back to public.

8. A blossoming medical insurance market. Once private systems spring up and public facilities spiral into oblivion, individuals feel they can’t risk to be without coverage. So most people end up paying twice.

9. Delays. Long, long delays. In fact, in this wondrous land of the UK’s NHS (where I’m currently typing this note) an insurance company’s come up with a new product: NHS delay insurance. Check out: http://campaigns.axappphealthcare.co.uk/whichpolicy/assure6choice/page1.php?mode=31&axacmp=Brand/TV/6Week.

10. Slow adoptions of breakthrough new treatments and technology. Enough said.

I could go on, but these 10 characteristics are classic and consistent. I don’t wish them on anybody and hope Americans are smart enough to fix their system rather than break it further. Investing in successful fusion reactors is more likely to pay than effective and efficient government run health care.

Maybe there's a way to deliver universal coverage. I've never seen it -- and I've certainly looked.