By James G. Kahn, M.D., M.P.H.
Sunday night’s CNN special narrated by journalist Fareed Zakaria titled “Global Lessons — The GPS Road Map for Saving Heath Care” was interesting and initially promising, but ultimately disappointing.
It started out with superb references to other countries, then became illogical and gutless. In the end, the “solutions” offered by Zakaria to cure our broken health care system didn’t flow from the evidence presented earlier in the program. Remarkably, the U.S. implications of successful single-payer models were ignored.
Zakaria started out with a reasonable report on Britain’s single-payer National Health Service: its good quality, universal access and low cost. He also gave a fair account of the evidence-based, evaluative work of the National Institute for Health and Clinical Excellence, NICE (which is being undermined now, something he failed to mention).
He interjected a few comments about long wait times in Britain for non-urgent care, and raised the bogey of high taxes as the price one has to pay for such a system. But on balance the account was generally favorable.
Taiwan’s adoption of single-payer national health insurance was treated next. Zakaria noted that with Taiwan’s shift to a single-payer system in 1995, the proportion of the country’s uninsured dropped from 41 percent to 8 percent within a year. He also described other positive aspects of the Taiwanese health system. Overall, this segment was quite favorable and accurate.
Then came Switzerland. Here he gave a reasonable report about the country’s system of highly regulated private insurers (who can’t profit from selling basic health insurance policies and must offer insurance to all comers). He was incorrect, however, in equating the Swiss reform with the Affordable Care Act in the U.S.
Then the logical connections fell apart.
Zakaria proceeded directly to a segment on “consumer-driven care,” interviewing a corporate CEO who recently wrote in praise of free-market medicine in The Atlantic. Here Zakaria at least pointed out that there’s no evidence that a free-market approach will control costs, saying that the only evidence of competition working is for elective procedures like Lasik surgery, whereas most health care costs arise unpredictably or stem from chronic disease.
He then looked at ACOs, accountable care organizations, in the form of an uncritical interview with Dr. Atul Gawande, the surgeon and writer for The New Yorker. Gawande emphasized how uncoordinated and excessive care contribute importantly to our nation’s high health care costs. Zakaria noted that there are ACO experiments, but failed to emphasize the lack of evidence that we can scale up ACOs.
Next was also an uncritical, indeed quite favorable, report on efforts in Camden, N.J., to provide case management care for high utilizers in “hot spots.” Zakaria glossed over the lack of solid evaluation data on the Camden experiment.
In his wrap-up, Zakaria offered his own views. He endorsed individual mandates (noting that they were first proposed by the Heritage Foundation). He said the ACA won’t control costs, and said we need a “cost control board” to decide what’s covered and what isn’t.
He explicitly rejected a pure market solution as inappropriate to health care, noting we’re not buying cars, we’re buying something for which we have little choice when it’s needed. The pure market solution won’t control costs and will leave many without care, he said.
Inexplicably, Zakaria failed to point out the implications for the U.S. of the successful British and Taiwan experiences, and instead said that we need to “acknowledge what’s on the ground” in the U.S. (read: path dependence), and thus need to fix the current “messy mixed model” we currently have.
As I said at the beginning: promising opening, but ultimately disappointing in acceptance of our current structurally defective health care financing system. Viewers deserve a more coherent and brave progression from evidence to action.
Dr. James G. Kahn is a professor at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. Dr. Kahn is an expert in policy modeling in health care, cost-effectiveness analysis, evidence-based medicine, and administrative costs in U.S. health care. He is also a board member and immediate past president of Physicians for a National Health Program – California.
