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.

Garrisons of the mind - USA and Jamaica

It’s campaign silly season again and the candidates are busy trying to do as much damage to each other as possible. I am personally fatigued by the bickering over the minutiae and the media’s perpetuation of these inconsequential matters while acting as if they are valid news stories – Hillary’s beer and whiskey shots, Obama’s bowling etc. These stories are supposed to give an insight to the soul of the candidates and help voters gain a personal understanding of these people. None of these gets us any closer to seeing how they lead. The last election all of America voted on who they wanted to “have a beer with” and got George Bush as President. Now they probably wouldn’t even want to share a table in the bar with the guy. His beer drinking facility spoke nothing about his leadership abilities. This politics of personality is petty, and can be destructive, as it distracts the focus from genuine issues. However, some of these non-issue stories reveal character traits and can give us a glimpse into how they would lead. Cindy McCain’s plagiarizing of Food Network recipes and Hillary’s lying about Bosnia is dishonest. Hillary as a Candidate did herself damage by showing she has no problem bending the truth to serve her own purposes. She appropriately paid the price by the dip in the polls of her trustworthiness ratings.

Now Obama has gone and messed up his sweet ride by lumping together bitterness, God, guns, anti-immigration sentiment etc. The media is making a big hoopla over the story but has once again missed the point. The statement was made in response to a question of how race factors into his difficulty getting working class whites to vote for him. He was in essence defending these people by saying it was not race related but due to the fact that people don’t always vote their economic interests. They instead vote on issues where they feel they will get some results like religious and gun issues as opposed to one’s where they would be neglected – economic issues. This is nothing new. I learned of this phenomenon watching shows like Chris Matthews Hardball and Joe Scarborough’s Morning Joe. They have often referred to poor people voting against their economic issues to support republicans because of these other issues – God and guns. It’s a well known phenomenon. Obama stated it inarticulately and he has apologized but defends his sentiment. The media pretends to have no clue of what he meant and his rivals call him elitist. They do not mention that he was denying accusations of racism in his inability to get white voters and that he was trying to get people to realize that poor people are angry over a lack of government responsiveness on economic issues over the last 25 years.

The upshot of all of this is that both Clinton and McCain have said that they do not believe he is an elitist but is statement is. His defense is that he and his wife has working class roots, dragged themselves up from the circumstances of their birth and fought hard to acquire the things they now have. Now all the candidates vie to prove the same record of working class roots and I believe they all have validity. Some, like Obama, stayed in this class longer than others, while other like McCain and the Clinton’s moved up a while ago. All of them did this through hard work and sacrifice. However, elitism is not only an affliction of the wealthy, because as a philosophy on government and social organization, anyone holding those views, even with middle class or working class status, can be elitist. So this “I am rich, but once was poor defense” is inconsequential.

According to www.dictionary.com elitism is:

1. Practice of or belief in rule by an elite.
2. Consciousness of or pride in belonging to a select or favored group.
and
1. The belief that certain persons or members of certain classes or groups deserve favored treatment by virtue of their perceived superiority, as in intellect, social status, or financial resources.
2.
a. The sense of entitlement enjoyed by such a group or class.
b. Control, rule, or domination by such a group or class.

Is Obama an elitist? No. Was his statement elitist? No. I do not see, based on these definitions, how such conclusions can be drawn from Obama’s statement or subsequent explanation. How can a statement defending working class poor that encourages them to consider their economic interests in choosing a leader be seen as elitist? I really don’t know. If Clinton and McCain don’t believe he is elitist why accuse him of this then. The simple answer - political expediency. They cater to the simplest base instincts of people, telling them what to feel, what to think and how to interpret these “complex” issues. They do not trust the electorate to consider these issues and draw their own conclusions. They make sure they know they should be outraged. Even if they do not believe the charges, they will make them because they know they can gain political mileage.

This theory of winning by all means is even more disturbing to me coming from Hillary Clinton because as it stands she has no real path to winning the nomination except through the super delegates. She is willing to tear down Obama and damage her party to acquire power. She trails in elected delegates and says these party officials have no obligation to follow the will of the voters. The super delegates, on whom she is banking to hand her the nomination despite the popular vote, know better than the ordinary voter what is best for the country, and that is her. She is behind in number of states won, and calls the small ones she hasn’t won “boutique” states. What does that mean? The people in these states are mere decorative trinkets in the democratic process. She has a lead, albeit dwindling, among the super delegates, the true party elites, whom she has an inside track to because of her years in Washington. Her supporter James Carville was so upset at Bill Richardson’s support for Obama he called the Governor “Judas”. How dare he go against the Clinton’s who had given him so much? Doesn’t he owe his allegiance to this dynasty? He had no right as an elected official and servant of the people to think in the interest of those he represents only to give loyalty to the former and aspiring dynastic rulers. These things are by definition elitist. They reflect a belief that she is part of the ruling class and that the will of the people can be ignored as necessary to get her to the seat of her power, the White House.

Someone should call her on this, but the media has abdicated its role as an unbiased provider of information to the masses and is now an entertainment source providing “witty” sound bites taken out context and the shallowest most sensationalized analysis. The 24 hour news channels are perhaps the worst things to happen to democracy, they crave ratings so much that they dare not do their job for fear of upsetting their advertisers and losing their economic lifeline viewers. They underestimate their viewer’s intelligence and pander, like the politicians, to the lowest instincts. It is this failure which allowed the government to go unchallenged into Iraq. No one dared asked the hard questions. At the onset of the Iraq war they focused on “Shock and Awe” and put up eye-catching graphics while reporting from the dessert, excited about the sensationalism of being on the battles frontlines. No one asked where were the WMDs or how the country could prove they didn’t have it (How can you prove a negative?). In 2000 they all wanted to know who would Americans most like to have a beer with. Now they act all outraged over the Iraq war and amazed at Bush’s failures but still refuse to make real probing news. Now the media is more concerned about Obama’s “bitter” comments, how they are being interpreted, and how they affect his ratings instead of putting the comment in the appropriate context and discussing the validity, or invalidity, of his assertion. In this election can we move beyond the bar shots, bowling alleys and cow farm bottle feedings please?

I hate when politicians and media speak condescendingly and patronizingly to people. When we are not properly informed we are unable to make decisions in our best interest. Knowledge is power and perhaps some of these characters enjoy keeping us in the dark, distracted, and upset over trivialities so we don’t have enough time to focus on the real issues affecting us. I use to think America had no garrisons, but apparently I was wrong. If you are trapped into a purely politically biased stream of thought so that you cannot rationally consider other alternatives then you are in a mental garrison. It is as much a state of mind here as it is for the people in Rema and Tivoli. No one kills each other over the politics but they operate on the same narrow minded levels. Apparently politicians and media are the same the world over.

I really hope one day to be able to start a Political and Economic think tank in Jamaica that caters to Jamaican people, particularly those in garrison communities and other ghetto areas. It would be non-political but educational, giving people information in an unbiased way to be able to assess economic, political and social issues independently. I know many people have the foundations of this through life experiences but people with formal education they are better equipped through wider and deeper exposure. I hope to give more people the tools to be able to do this. How they vote after that is their business. I just wish they would think.

P.S. – This was written before the last debate in Pennsylvania. That debate raised new distractions and resurrected some old ones. However, the constants of questionable media behavior and inordinate focus on issues of no value to voters remain. I’m so over it and apparently so is most of America.