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By Jim Edwards
Business Insider, Jan. 29, 2015

I’ve spent half my life in the US and half of it in the UK, so I’m used to both countries’ healthcare systems. I recently returned to London after 20 years in America, and after a few doctors’ appointments I’ve come to see the NHS through American eyes.

The National Health Service is, as all Americans know and fear, a completely public “socialized medicine” system. It’s dramatically different from the US’s patchwork system of private providers and insurance companies.

My story isn’t representative, of course. Healthcare delivery is different in the UK depending on where you live and which doctors and hospitals you use — just as it is in the US. But I’ve now used both systems for about two decades each, so I feel I have a pretty good handle on the main contrasts.

‘This Rolls Royce isn’t moving fast enough!’

The context here is that the NHS just released its most recent stats on accident and emergency room waiting times. The headline number is that 84% of patients are seen within four hours. In the UK, this is regarded as a huge failure — the standard the NHS is supposed to meet is 95% of patients in four hours. The UK media went into a fury about it, and some hospitals have begun postponing and rescheduling some non-emergency procedures in order to get those waiting times down.

In the US, having sat in many an ER waiting room for hours at a stretch, the idea of a hospital seeing nearly 9 out of 10 patients in four hours would be regarded as a miracle. Bear in mind that within that four-hour period the NHS doctors are triaging patients: If you get hit by a bus, you’re going to see someone instantly. If you broke a finger because you fell over while drunk at the pub, you’re probably going to wait at the back of the line. It’s not like people are literally bleeding to death while they wait for attention (although the British media loves it when it finds individual cases where that has happened).

So my overall impression is that currently, the Brits’ complaints that the NHS isn’t hitting that 95% mark is akin to saying, “This Rolls Royce isn’t moving fast enough!”

Show up when you’re told to — or else

The first major difference from the patient’s point of view is what happens when you call your doctor for a routine appointment. My specific health issue was that I thought I was going slightly deaf, and wanted it checked out.

I’m a dual US/UK citizen, so I qualify for NHS treatment. Here’s what happened to me.

In America, you call your doctor and request an appointment when it’s convenient for you. They might ask you what’s wrong with you, presumably to make sure it’s not something that requires immediate treatment. But basically, it’s first come, first served, regardless of how important it is. Usually, you can pick an appointment time that’s convenient for you if it is not an emergency.

In the UK, I was given an appointment whether I liked it or not. I called and leave a message. Within an hour or two a nurse practitioner called me back and asked me a few questions about my problem over the phone. (You’ve got to take the call in a private place if you don’t want your office mates to hear.) Then they said: Come in at 9am on Thursday. There was no choice over appointment times — the assumption is that if you’re ill, you’re going to come to the doctor when they say.

At first I found this jarring. In America, I get to choose when I see the doctor! In Britain, I better show up when I’m told. But the appointment came quickly, as the local health authority in London has targets it needs to meet. Ultimately, I saw the logic of it: This is a public health system. It needs to manage its costs and services. If you’re really sick, you’ll show up. If you only want to show up when it’s convenient for your schedule, then how sick are you, really?

America is worse at on-the-day care

In America, I’ve always had a long wait to see my doctor. I have read many a back issue of Newsweek in my primary care / general practitioner (GP) doctor’s office. I’ve sat there for an hour playing with my phone while the doc sees patients in the order they were booked.

In the UK, I showed up at 9am and was seen instantly, at the Waterloo Health Centre. For an American, this was bizarre: My butt barely touched the seat in the waiting room before my name was called. Turns out my doc and her staff are serious about patient scheduling.

This was one reason I became convinced that the NHS way of scheduling is superior: You might not get the time or date that you want, but once you’re in, you get seen super-quick.

The NHS actively discourages some patients — for good reason

The NHS actively discourages some types of patients: Interestingly, NHS offices and hospitals have posters up all over the place warning you not to show up at the emergency room if you have a cold or the flu. They’re actively discouraging patients with minor ailments from seeking emergency treatment, and trying to get them to see their regular doctors instead. It’s sensible — everyone knows that a vast amount of hospital time and money is wasted treating people who are not an emergency. And hospitals and doctor’s surgery waiting rooms are a hotbed of germs. But still, it’s a culture shock to see a medical institution put up signs that basically say, “go home, you idiot!” in every waiting room.

The US never discourages patients from doing anything. I’ve never seen any kind of public campaign to persuade patients to apply some common sense before dropping themselves off at an emergency room. The entire US pharmaceutical industry is also dedicated to running ads encouraging people to “go see your doctor” for even the most trivial of conditions.

The treatment from my primary care GP was the same in the UK as it was in the US. I’ve had great care from 95% of doctors I’ve ever seen in both the US and the UK. Doctors are doctors. They’re mostly really nice and good at what they do. The system that pays them doesn’t seem to make them better or worse.

There is basically no paperwork with the NHS

There is a load of paperwork for patients in the US. This is easily the worst aspect of US healthcare — the billing paperwork. If you’ve ever had any health issue that required more than a simple doctor visit, you will know that it precipitates a seemingly never-ending series of forms, bills, and letters. You can be paying bills months, years later. And it’s almost impossible to correct a billing error. It’s stressful. I developed an intense hatred for health insurance companies in the US because of this.

There was close to zero paperwork in the NHS. I filled in a form telling my doc who I was and where I lived, and that was pretty much it. The only other paperwork I got was a letter in the mail reminding me of my next appointment. They sent me a text reminder, too, which no American doc has ever done. It was incredibly refreshing.

The standard of care is the same

So, was I going deaf? Maybe. Maybe not. I’d lost my sense of balance in summer 2014, which an American doctor had diagnosed as Benign Paroxysmal Positional Vertigo. It’s a condition of the inner ear. It made my body feel slightly drunk and clumsy even though I am completely sober.

The US doc told me there is no treatment and it goes away on its own, mostly. A lot of people get it, apparently. I was managing fine and it doesn’t bother me, anyway.

The UK doc told me the same thing, but also suggested I might have Meniere’s Disease, and wanted to send me to a specialist to get it checked out. Meniere’s isn’t really a disease, it’s just a collection of symptoms: dizziness, hearing loss and a ringing in the ears. Again, there is no treatment. But it’s rare.

This freaked me out a little bit. I was used to the US system which is heavily “defensive.” Doctors tend to over-treat patients because they get sued if they miss something. They also get paid more money for doing more work. Yet it was the NHS doctor that suggested extra treatment.

It was going to be free — so I said yes!

A long wait for NHS treatment …

I then made an appointment with a specialist at the Guy’s and St Thomas’ Hospital in London.

In the US, I’ve always been able to see a specialist within a few days. Score one for America.

In the UK, they said “we’ll see you in January.” It was late November, six weeks or more away. This was a shock. I was going deaf now — not in six weeks! What the hell?!

NHS waiting times are a real thing, it turns out. I comforted myself with the assumption that the staff had made a decision that my condition was likely not life- or health-threatening, and had moved me to the back of the line. It was frustrating. Ultimately, I also needed to change my appointment because I had to leave the country on business, and this was quite difficult to do. I had to call a few times, basically to catch the hospital booking staff at the right time of day, in order to do it. I wished Guy’s and St. Thomas’ had an online system for this, but they don’t — just a bunch of people answering phones, most of whom don’t have access to the right appointment schedule.

It was that appointment system again: You’re booked in according to their priority, not yours. The big lesson with the NHS is, it’s a lot easier to just show up when you’re told.

Old people in Britain are really rude

In the US, I expect to wait up to an hour in the specialist’s waiting room on the day of my appointment. I often wonder if Time and Newsweek were such big magazines in the US because they’re needed for bored patients in American doctors’ waiting rooms. Nothing ever happens promptly on the day in US healthcare, as far as I can tell.

In the NHS, again, I waited only a couple of minutes. Credit to the staff at St. Thomas, they are cranking through their patients.

On two occasions I noticed old people complaining angrily (and rudely) to the office staff that they had been made to wait 15 or 20 minutes to see their doctor. As an American, I almost laughed out loud. Fifteen minutes to see a free doctor! This Rolls Royce isn’t moving fast enough! I asked a British friend — someone who has ongoing health issues and sees a lot of doctors — if old people complaining like this was common. Turns out, it is. Old British people love to complain to NHS staff if they wait more than 1o minutes. Everyone just expects their appointments to be exactly on time.

Again, the NHS care was great. I saw two different doctors within an hour, one for testing and one for diagnosing. A third admin staffer was coordinating the lists so there was no doctor downtime. It was like being in a highly efficient factory. It looked like hard work. I could tell that one of my doctors was not interested in chatting. She treated me, and wanted me out the door. There was a bunch of patients behind me, after all. In America, docs seem to be happy to chat as long as you want — and you can tell that extra couple of minutes with each patient creates long delays as the day wears on.

The good news: I am not going deaf! I have great hearing, it turns out. They even showed me a chart of it. But the tinnitus — ringing in my ears that started years ago because I used to go to a lot of punk rock gigs in my youth — has gotten worse, making me feel more deaf.

The UK NHS specialist said she was 99% sure there was nothing wrong with me, or at least nothing that could be treated, but she recommended an MRI to see what the condition of my inner ears is like. This was reassuring. In no way was my treatment rationed or denied, the way Americans fear. It was just the same as in the US, with the same number of docs and the same level of high-tech equipment.

The cost to the patient is much cheaper in the UK, obviously

So how much did all this NHS care cost me? £0. Nothing. Zero. I paid not a penny for some top-notch healthcare. There is no such thing as a “free,” of course, but the per-capita cost of healthcare in the UK (paid by the government via tax collections) is generally lower than the US, according to the World Health Organization. Americans spend $8,362  per capita on healthcare annually, the Brits spend $3,480. Here is a breakdown:

NHS prices

    Doctor visit: £0
    Specialist: £0
    Diagnostic test: £0
    MRI: £0
    Total: £0 

Typical US prices*

    Doctor visit: $100
    Specialist: $150
    Hearing test: $72
    MRI: $1,000
    Total: $1,372 (Total payable by the patient in cash, or typically 90% from insurance and 10% as a patient copay. Prices taken from Healthcare Bluebook.) 

Sorry America, but NHS treatment really is better over all

The bottom line: I prefer the NHS to the American private system. It’s a little more inconvenient in terms of appointment times, but due to the fact that it is free, has no paperwork, and the treatment on the day is super-fast, the NHS wins. That Rolls Royce is moving at a pretty decent clip.

And, of course, there is the small matter of the fact that the NHS covers everyone equally, whereas Americans get care based on their ability to pay, leaving tens of millions with only minimal access to care. (Obamacare is changing that, but it’s leagues behind the NHS if you’re comparing them by the standard of universal full-service coverage.)

Americans think they have the best healthcare in the world. Take it from me, a fellow American: They don’t.

http://www.businessinsider.com/an-american-uses-britain-nhs-2015-1

By Joseph E. Stiglitz
The New York Times, Jan. 30, 2015

A secretive group met behind closed doors in New York this week. What they decided may lead to higher drug prices for you and hundreds of millions around the world.

Representatives from the United States and 11 other Pacific Rim countries convened to decide the future of their trade relations in the so-called Trans-Pacific Partnership (T.P.P.). Powerful companies appear to have been given influence over the proceedings, even as full access is withheld from many government officials from the partnership countries.

Among the topics negotiators have considered are some of the most contentious T.P.P. provisions — those relating to intellectual property rights. And we’re not talking just about music downloads and pirated DVDs. These rules could help big pharmaceutical companies maintain or increase their monopoly profits on brand-name drugs.

The secrecy of the T.P.P. negotiations makes them maddeningly opaque and hard to discuss. But we can get a pretty good idea of what’s happening, based on documents obtained by WikiLeaks from past meetings (they began in 2010), what we know of American influence in other trade agreements, and what others and myself have gleaned from talking to negotiators.

Trade agreements are negotiated by the office of the United States Trade Representative, supposedly on behalf of the American people. Historically, though, the trade representative’s office has aligned itself with corporate interests. If big pharmaceutical companies hold sway — as the leaked documents indicate they do — the T.P.P. could block cheaper generic drugs from the market. Big Pharma’s profits would rise, at the expense of the health of patients and the budgets of consumers and governments.

There are two ways the office of the trade representative can use the T.P.P. to maintain or raise drug prices and profits.

The first is to restrict competition from generics. It’s axiomatic that more competition means lower prices. When companies have to fight for customers, they end up cutting their prices. When a patent expires, any company can enter the market with a generic version of a drug. The differences in prices between brand-name and generic drugs are mind- and budget-blowing. Just the availability of generics drives prices down: In generics-friendly India, for example, Gilead Sciences, which makes an effective hepatitis-C drug, recently announced that it would sell the drug for a little more than 1 percent of the $84,000 it charges here.

That’s why, since the United States opened up its domestic market to generics in 1984, they have grown from 19 percent of prescriptions to 86 percent, by some accounts saving the United States government, consumers and employers more than $100 billion a year. Drug companies stand to gain handsomely if the T.P.P. limits the sale of generics.

The second strategy is to undermine government regulation of drug prices. More competition is not the only way to keep down the prices of essential goods and services. Governments can also directly restrain prices through law, or effectively restrain them by denying reimbursement to patients for “overpriced” drugs — thus encouraging companies to bring down their prices to approved levels. These regulatory approaches are especially important in markets where competition is limited, as it is in the drug market. If the United States Trade Representative gets its way, the T.P.P. will limit the ability of partner countries to restrict prices. And the pharmaceutical companies surely hope the “standard” they help set in this agreement will become global — for example, by becoming the starting point for United States negotiations with the European Union over the same issues.

Americans might shrug at the prospect of soaring drug prices around the world. After all, the United States already allows drug companies to charge what they want. But that doesn’t mean we might not want to change things someday. Here again, the T.P.P. has us cornered: Trade agreements, and in particular individual provisions within them, are typically far more difficult to alter or repeal than domestic laws.

We can’t be sure which of these features have made it through this week’s negotiations. What’s clear is that the overall thrust of the intellectual property section of the T.P.P. is for less competition and higher drug prices. The effects will go beyond the 12 T.P.P. countries. Barriers to generics in the Pacific will put pressure on producers of such drugs in other countries, like India, as well.

Of course, pharmaceutical companies claim they need to charge high prices to fund their research and development. This just isn’t so. For one thing, drug companies spend more on marketing and advertising than on new ideas. Overly restrictive intellectual property rights actually slow new discoveries, by making it more difficult for scientists to build on the research of others and by choking off the exchange of ideas that is critical to innovation. As it is, most of the important innovations come out of our universities and research centers, like the National Institutes of Health, funded by government and foundations.

The efforts to raise drug prices in the T.P.P. take us in the wrong direction. The whole world may come to pay a price in the form of worse health and unnecessary deaths.

Joseph E. Stiglitz, a Nobel laureate in economics, a professor at Columbia and a former chairman of the Council of Economic Advisers, is the author of “The Price of Inequality.” 

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U.S. Trade Deal Will Devastate Poor Peoples’ Access to Medicines

By Medicins Sans Frontieres (MSF) /Doctors Without Borders
Medicins Sans Frontieres, Jan. 26, 2015

Many countries and treatment providers like MSF rely on affordable quality generic medicines to treat life-threatening diseases. But the U.S.-led Trans-Pacific Partnership Agreement (TPP) would make it much harder for generic companies to produce cheaper drugs that are vital to people’s health. The TPP would give pharmaceutical companies longer monopolies over brand name drugs and the ability to charge high prices for critical drugs for longer periods of time.

The United States government continues to demand intellectual property provisions in the Trans-Pacific Partnership Agreement (TPP) that will limit access to medicines for at least half a billion people, said the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF) on Monday as negotiators continued another round of secret meetings in New York.

“MSF and many others have repeatedly voiced concerns that the TPP is a looming disaster for people who rely on access to affordable generic medicines, both internationally and in the United States,” said Rohit Malpani, director of policy and analysis at the MSF Access Campaign. “Despite this outcry, the US continues to work behind closed doors, without any input from the public, experts, or elected officials, to aggressively push for intellectual property provisions that put the profits of pharmaceutical companies ahead of people’s health.”

If signed in its current form, the TPP—a far-reaching trade agreement involving the US and 11 other Pacific-Rim countries—would force all countries to  grant additional drug patents, extending monopolies on medicines beyond 20 years, a practice called patent “evergreening.”

The agreement would also impose an unprecedented extended period of exclusivity for clinical data required to prove the safety and efficacy of drugs and vaccines that are “biologic” products, extending monopolies in TPP countries, which will delay lower-cost versions of these medicines from entering the market.

“The intellectual property provisions of the TPP completely undermine the Administration’s stated public health goals, including its own goal to achieve an AIDS-free generation,” said Malpani. “While President Obama speaks of expanding health care and tackling issues of income inequality at home, he is actively promoting a trade agreement that will exacerbate economic disparities and endanger people’s health care worldwide.”

MSF has relied on leaks of the TPP text for information because the negotiations have been held in secret. While MSF and other civil society groups have been excluded from official negotiations on the TPP, industry groups representing various multinational corporations have had the opportunity to read the text and suggest revisions.

In the coming weeks, the US Congress could vote to renew “fast-track” authority on the TPP, which would allow the agreement to be put to an “up or down” vote without revision.

Renewal of fast-track authority without public health safeguards that mandate major revisions of the intellectual property chapter will all but ensure that these damaging provisions remain in the text.

“The TPP is the most damaging trade agreement we have ever seen in terms of access to medicines for poor people,” said Malpani. “With USTR [Office of the United States Trade Representative] publicly stating that these negotiations are winding down, it is now more urgent than ever that concerns about access to medicines be addressed.”

[Read MSF’s Open Letter to President Obama.]

http://www.doctorswithoutborders.org/article/tpp-trade-deal-will-be-devastating-access-affordable-medicines

By John Geyman, M.D.
The Huffington Post, Jan. 30, 2015

On this occasion honoring the anniversary of the birthday of Martin Luther King 86-years-ago, coinciding with the release of the movie Selma, it is fitting to recall his leadership on moral principles toward equity of health care in this country. Among his many classic quotes about health care, he had this to say in 1966 in a speech to the Medical Committee for Human Rights:

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

Were he here today, Martin Luther King, Jr. would be appalled to see what Americans are facing, even five years after the passage of the Affordable Care Act.

Here’s one patient vignette that puts a human face on the outcomes facing patients unfortunate enough to live in states that opted out of Medicaid expansion, as more than twenty states have done.

Charlene Dill was a 32-year-old mother of three who earned $11,000 a year cleaning houses and babysitting in Florida. That was too much to qualify for Medicaid, and too little to afford health insurance. The ACA would have provided subsidies for health insurance if her income was more than $23,550. When she developed a heart condition, and later, abscess on her legs, she did go to emergency rooms, but couldn’t afford those bills or any other care.

This is not an isolated anecdote, but more the rule for many millions of Americans. Access to care has improved for some, especially in states that expanded Medicaid, but there are still more than 30 million uninsured and tens of millions underinsured. Lacking any mechanisms to rein in markets and contain costs or prices, the ACA has unleashed increasing consolidation and control by hospital systems and insurers.

Wall Street is happy, and health care stocks are soaring. Yet one-third of insured Americans cannot afford to pay their medical bills, often leading to bankruptcy. Meanwhile, our safety net continues to deteriorate. We can expect that to worsen in the months and years ahead if Republican governors impose more restrictions on Medicaid, and if the Republican-controlled Congress cuts spending for critical programs.

As Martin Luther King knew full well, health care is a moral issue. Virtually all advanced countries around the world recognized long ago that health care is a human right, not a privilege based on ability to pay. Dr. Edmund Pellegrino, leading medical ethicist for many years at Georgetown University’s Center for Clinical Bioethics, summed up the issue this way at the Annual Meeting of Academic Health Centers in 2000:

Access to health care is a moral obligation of a good society.

Yet, as a society, we still seem to have a moral blind spot when it comes to health care. As the income gap widens between rich and poor in America, and as the middle class falls into increasingly dire straits in affording health care, our sense of social solidarity continues to erode. The political process toward reform has been corrupted by money, especially in the wake of Citizens United and the McCutcheon rulings of the U.S. Supreme Court.

We can expect that Martin Luther King would see our present health care “system,” despite limited progress from the Affordable Care Act, as a political failure and a moral crisis unnecessarily harming a large and growing part of our population. He would be a leader toward the concept of health care as a human right, not just a commodity for sale on a largely for-profit market. He would speak truth to power and be a beacon of hope if he were on the scene today. He was never one to give up in a fight, and has left us with this perspective:

We must accept finite disappointment, but never lose infinite hope.

We need to carry on his spirit to best honor his legacy. This would address his strong belief that injustice in health care is a major expression of inequality and inhumanity. An answer to health care reform is in plain sight if we just take off our blinders — single payer national health insurance along the lines of H.R. 676 Improved Medicare for All, the Conyers bill in the House of Representatives. That will assure all Americans full access to necessary care, with full choice of physician and hospital care anywhere in the country. It includes public financing, coupled with a private delivery system, at a cost far less than we are paying today.

John Geyman, M.D. is professor emeritus of family medicine at the University of Washington School of Medicine in Seattle and past president of Physicians for a National Health Program 2005-2007. Adapted in part from his just released book “How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans,” Copernicus Healthcare, 2015.

http://www.huffingtonpost.com/john-geyman/martin-luther-king-jr-hea_b_6526410.html

By James Besante, MS4
Common Dreams, Jan. 25, 2015

This past week the world celebrated the life of Dr. Martin Luther King Jr.

Marches of remembrance also served as painful reminders of unhealed wounds along the lines of race in America, particularly the failure to realize equal access to health care for all.

In 1966, while addressing the second convention of the Medical Committee for Human Rights, King declared, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

The true magnitude of race-based health inequality is staggering: In his seminal paper “What If We Were Equal,” former Surgeon General David Satcher calculated approximately 83,000 excess deaths per year among African Americans, also known as the “black-white mortality gap.”

Despite progress in civil rights, housing, education, and employment from 1960 to 2000, this gap has remained. Shockingly, it has widened for infants and African American men over the age of 35.

The King holiday was a sobering day of reflection, but it was also the crescendo to the very audible justice movement loosely organized under the banner Black Lives Matter.

Activists marched in cities across the nation to bring attention to numerous highly publicized incidents of police violence. More broadly, organizers sought to underline the subversive elements of racism still deeply etched in our nation’s subconscious, and no doubt represented in unequal health outcomes for African Americans.

As a nation, we do not provide universal access to even the most basic medical services. This is not likely to change anytime soon since the Congressional Budget Office estimates that 27 million people will remain uninsured after the full implementation of Obamacare.

The absence of universal health care coverage sets the U.S. apart from all other developed countries. It is the only member of the elite G7—a group of nations accounting for 66 percent of net global wealth—without universal health insurance for its citizens.

Dr. Satcher proposed national health insurance as the evidenced-based remedy to finally close the racial mortality gap and address persistent health injustice in America.

Polls show most Americans also support universal health care. In fact, the majority of physicians agree the private health insurance industry should be replaced with a streamlined, publicly accountable system, like “single-payer,” also known as “improved Medicare for all.”

What is single-payer? It simply means the government pays for health care costs without routing money through private insurers who manufacture paperwork, billing complexity and profits. This is how traditional Medicare insurance is able to operate with overhead costs of 2 percent, which is far more efficient than private health insurance plans, with overhead costs of 15 to 25 percent.

Harvard researchers recently calculated the administrative savings of single-payer’s simplified financing structure to be $375 billion annually, nearly 15 percent of total health spending. This would help to lower the sky-high cost of our current system, which is approaching 18 percent of the gross domestic product.

Single-payer would free patients from out-of-pocket expenses, like co-payments and deductibles—proven barriers to care that are administratively unwieldy and unnecessary for cost containment.

National health insurance would also give patients free choice of providers without the narrow networks that are commonly encountered by insured Americans.

The comprehensive, high-quality care that is equitably accessible in a single-payer national health program stands in stark contrast to our current market-based system in which health care is rationed based on an individual’s ability to pay.

The implications of ensuring a right to health care go well beyond medicine, because “health” is of fundamental importance for the exercise and enjoyment of all other civil, political and economic rights. Dr. King envisioned a world of justice for all. In spite of this, preventable or treatable illnesses continue to needlessly compromise the liberty and dignity of countless Americans.

A right to health care is therefore instrumental for effective citizenship and promotes active participation by the greatest number of citizens in a more robust democratic process.

Equality—whether in health care or any other sphere—is not a “dream deferred,” to quote Langston Hughes, but is attainable. We simply need the political will.

James Besante is a fourth-year medical student at the University of New Mexico School of Medicine and a board member of the Chicago-based Physicians for a National Health Program.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://www.commondreams.org/views/2015/01/25/mlks-vision-and-right-healthcare

Apathy and fear are among the biggest stumbling blocks, experts say

By Joyce Frieden
MedPage Today, Jan. 28, 2015

WASHINGTON — The lack of greater movement toward universal healthcare coverage — especially a single-payer system — in the U.S. can be boiled down to four letters: AFIG, according to Philip Caper, MD.

The “A” stands for Apathy, Caper said Wednesday during a briefing on barriers to healthcare reform sponsored by the National Academy of Social Insurance (NASI). Caper is with Maine AllCare, an organization devoted to getting universal healthcare in Maine.

The attitude of many people is “‘I’ve got mine; why should I worry about anyone else?'” said Caper, a founding member of NASI, whose mission is to increase public understanding of how social insurance contributes to economic security.

“Or think of young invincibles, who think it’s worth the risk to go uncovered,” continued Caper, who was speaking by phone from Maine. “Perhaps apathy is the result of our emphasis on personal liberty and personal responsibility.”

The “F” stands for fear, Caper continued — “fear of change; the fear of losing coverage they already have; or the fear of loss of income or profitability” on the part of those working in the healthcare industry.

“I” is for ignorance, he said, making it clear that he was not equating ignorance with stupidity, rather a lack of information and understanding. “Most Americans don’t understand the healthcare system and don’t understand there are better ways of financing this,” Caper said.

“I definitely include doctors in this group,” he added. “I can tell you from personal experience that it’s almost impossible to get health policy into the medical school curriculum, where the focus is rightly on clinical medicine.”

And finally, there is the “G” — for greed. “This may seem harsh [but] the widely accepted view of healthcare as just another business is uniquely American, at least in degree,” he said. “I have heard some people say the healthcare system is becoming a wealth extraction machine. This view is reinforced by news stories of opportunistic pricing of drugs for chronic diseases such as hepatitis.”

Satisfied With the Status Quo

Another barrier to changing the way health insurance is delivered comes from the fact that many people are satisfied with their employer-provided health insurance, said Laurence Seidman, PhD, professor of economics at the University of Delaware in Newark.

“But they don’t seem to realize two things,” he continued. “First, what would happen if they lose their job? And second, [they don’t realize] that the rising premiums for medical care that their employers are paying is a key reason why their wage and salary growth has been so low.”

Many people also believe that using the private sector to provide services is better than using the public sector, “but it’s not better for things like national defense or health insurance,” he continued. “Many people also believe prices should be set without interference by government. I agree that’s true for most goods and services, but medical care is different [because] consumers can’t shop around; the best mechanism is for the government to represent consumers and negotiate prices for medical care with doctors, hospitals, and drug companies.”

Merton Bernstein, emeritus professor of law at Washington University in St. Louis, pointed out that most of the crowd at the meeting consisted of older people. “Millennials are not here, and that’s the problem,” he said. “How do we reach them to make them understand their stake in universal healthcare that’s affordable and comprehensive?”

Mischaracterization of the issues is another barrier to reform, Bernstein said. “One [mischaracterization] is that Medicare is not adaptable to the entire population because one size doesn’t fit all. People have to be told what in fact Medicare does — it is a massive program that’s the basis of the well-being of tens of millions of people, and it’s enormously popular, and yet it’s treated by many as if it’s an impediment to appropriate care.”

Suspicion of Government

Marcia Angell, MD, of Harvard Medical School in Boston, noted that “We distribute healthcare like a market economy, according to ability to pay, and not like a social service, which would be distributed according to medical need. But the people who most need healthcare are precisely those least able to pay.”

In terms of barriers, “much of the public often opposes the health reform law and [people] claim it expresses their antipathy toward big government. I believe that’s largely a canard promulgated by [the healthcare industry] and much of the media,” said Angell, who is also a past editor of the New England Journal of Medicine. “The issue for the public, I suspect, is not the size of government but the feeling that it doesn’t often work for their benefit and instead serves special interests.”

“Americans have no problems with programs [they consider beneficial] but are very suspicious of the private healthcare industry, which has the largest lobby in Washington,” she added. “So the major barrier … is the ‘medical industrial complex,’ as my late husband, Arnold Relman, pointed out in the New England Journal of Medicine 35 years ago.”

Joseph White, PhD, director of the Center for Policy Studies at Case Western Reserve University in Cleveland, said that three things needed for a policy to work were “technical capacity, institutional capacity, and political capacity … Most of the barriers to [single-payer] are political barriers; most barriers to other kinds of reform are technical barriers.”

The only way to overcome the political barriers would be to get businesses on board and make them realize that single-payer healthcare would be advantageous to them because they wouldn’t have to provide health benefits any more, “but business finds it easier to cut benefits,” White said. “I think it’s fair to say that the people who would be most necessary to cooperate, to overcome the power of the medical industrial complex, are much more interested right now in cutting benefits.”

Joe Antos, PhD, scholar in healthcare and retirement policy at the American Enterprise Institute, a right-leaning think tank here, said it is not clear what kind of reform people want, “for lots of reasons. One of the reasons is, not everybody’s going to agree to everything, so you have to decide who you want to listen to. So I think it is a good question … what is it that people prefer? The partial answer is, they just want something that works.”

Donald Berwick, MD, former administrator of the Centers for Medicare and Medicaid Services (CMS) in the Obama administration, said that after he left the agency and decided to run for governor of Massachusetts, “I did not enter the race as single-payer advocate, but my mind got changed very early” as he looked at the state’s budget and saw the increasing amounts of money going to healthcare. During his tenure at CMS, Berwick was criticized by Republicans for stating his admiration of the British healthcare system, which they said indicated support of rationing healthcare.

When he was campaigning, Berwick said he encountered a lot of confusion about the issue. “The first was confusion between the consolidation of payment in single-payer, and socialized medicine, where the government takes over delivery of care. People thought single-payer meant that the government becomes the provider of healthcare.”

In addition, the rising cost of healthcare was kind of buried, Berwick said. “People sort of know their own contributions to healthcare are going up, but when they actually do the subjective math, they can see the problem.”

Joyce Frieden is news editor at MedPage Today.

http://www.medpagetoday.com/Washington-Watch/Reform/49764