Health Care Reform - Freeness, Quality and Equity

It has been a long while since I have updated my blog. It’s not there haven’t been things of interest occurring in my life and the world; it’s just been that I have been a bit lazy and distracted. This post may have already been blogged to death, but here is my 2 cents worth on health care reform.

I recently watched a very interesting documentary called “Sick Around the World” on PBS. It compared the Healthcare system of the US to the developed countries of Japan, Germany, Taiwan, Switzerland and the UK. You may view the summary of findings here. The healthcare debate is raging here in the US Presidential elections as Americans clamor for a reformed system that is more affordable and responsive. Despite the broken system, most Americans abhor the idea of “socialized medicine” as practiced in Europe. The candidates have put forward their suggestion and unsurprisingly, the Republican John McCain is still advocating the continuation of a failed market based system. The democrats are somewhat better in their proposals, and despite the fear of “socialized medicine” propose plans drawing on features practiced in Europe. Hillary Clinton supports government mandated “Universal Health Care” where Americans will be required to purchase health insurance, facilitated by lower prices, with penalties that might include garnishing of wages for those who don’t. Barack Obama, supports lowering premium costs to allow more person to purchase portable insurance and access care in a system with reduced costs and improved services. He asserts that only those who don’t want to purchase health insurance would not have it. He essentially sees the issue as a problem of costs, not of will, and therefore would not institute a government mandate. In reality there is very little difference in the details between the democrats’ plans. They essentially share the same goals and strategies but seem to differ mainly on the issue of the mandate.

From the documentary I learned that US ranked highest amongst the countries in patient satisfaction but still had the most expensive system. It also appeared to have the most inequitable system of the industrialized countries. Among other things the costs are high and represent a significant and rising share of wages, patients with pre-existing conditions are routinely denied care and health insurance is not portable thus leaving or losing a job means you are without insurance. It is not uncommon for people to go bankrupt over healthcare costs. All the other countries basically found the notion of people going bankrupt to pay for health care ridiculous and alien. Starting from the point of view that health care is a fundamental human right that a government is obligated to provide to its citizens, these countries have designed various systems that guarantee affordable and access to quality care. The overarching features appear to be government set prices aimed at affordability not profitability. The ways people pay into the system vary from universal taxation managed by the government in the UK, to buying into non-profit “sickness funds” in Germany – home of socialized healthcare, and mandated health insurance purchase in Japan. In these countries those who can’t afford to pay are subsidized by the government. At the end of the day all the citizens have access to medicines, doctors and medical procedures. Additionally, the administrative costs are lower, record keeping is comprehensive and few have gate keepers in the form of doctors who must refer you to specialist before you can access those services. Gate keepers tend to raise the delivery cost and I find them to be a waste of time. In Japan you can go to any specialist as often as you like. This is good but there is no comprehensive medical history. In Britain, they reduce costs by encouraging preventative medicine. However, they are paid from the National Health System, not the individual patient as in the US. Switzerland has “frilly stuff” like massage therapy and spa treatments. But if it sounds frivolous just consider that the citizens of Switzerland and these other countries also have a longer life expectancy than the US and no doubt Jamaica.

These systems aren’t without their problems though. The doctors, highly trained specialist, do not feel adequately compensated and do not enjoy the rich lifestyles of their counterparts in the US. In Germany doctors were protesting the wages and a few in Japan complained that their businesses were unable to turn a profit because of prices being set by the government. The price of medicine, equipment and insurance were not reflective of the market situation. They are set by the government to eliminate competitive pricing and keep the system “affordable”. I wondered why doctors would continue to practice under such a system and although the documentary did not directly address this, there were references to a few individuals seeking more lucrative opportunities elsewhere. My own naïve opinion is that some people just continue out of love and duty. I couldn’t think of anything else.

Meanwhile, Jamaica has moved ahead with its plan of offering free healthcare to all its citizens. I commend Jamaica for its bold stance on providing healthcare as matter of human right and its acknowledgement of the role this plays in human development. I expect that if properly managed, this will undoubtedly contribute to our national development. However, I wonder about the efficacy of the new system. Worthy of note is that all these other developed countries commissioned studies to look at the best of the best systems around the world. They took the good, left out the bad and adopted it to their countries needs and abilities to produce a system that worked for them. I have not heard of any such thing in the Jamaican system and while I hope that this is just due to poor media reporting I seriously doubt that that is the case. The news of budget scrambling and tax increases that had to be enacted to pay for the system seems to bear this out. This does not sound like the most efficient and sustainable way to carry out of reform such a large magnitude and importance.

The Jamaican system was, and is still, seriously broken. The abolition of the user fees benefits the poorest in the Jamaican society and, according to The Caribbean Policy Research Institute (CaPRI), because it contributed little to the overall Health budget the government can make up the shortfall elsewhere. That might be true but CaPRI, the other experts, practitioners in the field and me all agree that we need to consider is that what we need is a system that is not only “free” but efficient and of a high quality. Free access to hospitals with insufficient nurses, doctors, beds and medical supplies is not really a substantial improvement in healthcare delivery. The two, healthcare quality and access, must work together if the overall system is to improve and people are to truly benefit. Until then Jamaica will continue to have a dual system of the haves of the have-nots. Those who can afford to will continue to use the private option, and those who can’t, will endure the inefficient government system. Truly, it is better than nothing, but this duality has no place in a society where everyone is equal and should be treated as such. The least fortunate in our society should have care as good as the most fortunate. That’s how human rights work – everyone is equal.

I advocate that Jamaica does the prudent thing and examine the systems of other countries to determine what works and what doesn’t. We don’t need to reinvent a non-functioning wheel, laboring stupidly over a broken system with hodgepodge solutions instead of implementing sensible tested solutions. I haven’t heard anything of bringing more payers into the system to spread the cost burden. There is no word of using technology to reduce administrative costs through information linkage, storage and sharing systems. The shortage of doctor’s in an open market system like Jamaica’s leads to higher prices, poor care and overworked doctors. The government has plans to recruit and train more doctors, nurses and other healthcare professionals. This should increase access and reduce costs. This is a long term plan though, and the government must seriously consider training these professionals while absorbing some of the costs and compensating through bonding them to public service, somewhat like they did for nurses. Additionally, I don’t necessarily advocate price setting but a review of costs for medical services should be conducted to ensure that they are fairly priced. Generally, facilities need to be improved, machinery installed and specialized services expanded. I am no healthcare policy professional but free healthcare is just a start and Jamaica needs to seriously consider how to improve the entire system.

At the end of the documentary it was noted that the US has a disjointed system, offering “separate systems for separate classes of people”. Jamaica faces a similar dilemma. It also notes that while the plans of the US Presidential candidates represent some improvement they are not comprehensive enough, and they need to contemplate more seriously the successful examples of other countries. I agree with the documentary and believe that both countries need a system that serves everyone equally, fairly and cheaply.