Mark Hoofnagle has a PhD in physiology from the University of Virginia and is currently a 3rd year medical student. His interest in denialism concerns the use of denialist tactics to confuse public understanding of scientific knowledge.
I went to see Michael Moore's Sicko last night and it is truly worthy of being seen by every American. I say that knowing how many feel about Michael Moore and his tendency towards spectacle. I hope that people can set aside whatever prejudice they have towards Moore and see this movie.
This is a movie that contains more truth than any he has made so far. I went in with a skeptical mind, knowing the issues that face the practice of medicine in the United States in this new millennium, how easy they can be discussed inaccurately or flippantly and how medicine was once practiced in this country. Medicine is something deeply personal to me as I am a the son of two doctors - my mother a private-practice family physician who has been practicing for more than 30 years, and my father a research MD at the NIH. This movie struck many chords, as someone who has insurance, who studies medicine, who cares about fixing our current medical care system, who has known doctors, and who has received medical care. There is something for everyone in this movie, doctors, nurses, patient, and policy-makers alike, and I sincerely wish that everyone gives it a chance and an open mind. I doubt anyone will see it and be disappointed or unaffected.
Now, the rest will be below the fold, I'll try to keep spoilers to a minimum, but I'll need to discuss some scenes in order to describe the importance of this movie.
First let me give you my background so that you know my biases and understanding of the current medical problem.
My mother, who has long practiced as a general practitioner, hates insurance companies for what they have done to medicine. She has been in practice for decades, and when in the 90s HMOs and insurance companies began to dominate not just the financial side but the actual practice of medicine, she despaired. It has been heartbreaking to see someone who loved medicine and cares greatly about her patients' welfare lose interest in practicing medicine as she's had to hire extra employees to deal with the endless paperwork - not designed to clarify medical records but to create barriers to reimbursement. The not-so-secret policy of flat-out denying legitimate claims a set percentage of the time has set her teeth on edge, as she has to personally fight with insurance companies for reimbursement for procedures - like flu shots - which clearly the insurance companies feel doctors won't fight over since it isn't worth their time.
To see them second-guess her care of people, without knowing a damn thing about her patients' health, is perhaps the worst insult of all. To tell a doctor what to do with her patients, as if they know something she doesn't - quite the opposite. It is a system that is designed to demoralize doctors into being passive and unwilling to fight with insurance companies on behalf of their patients. Being as stubborn as all hell, she hasn't stopped fighting with them, but the joy of practicing medicine has clearly gone.
My father, on the other hand, works for a socialized medical system - the public health service and the NIH. Patients in clinical trials get free care. No one second-guesses care. No one is looking over his shoulder to tell him what to do (at least in the clinic). Patients get care as part of his protocols, the NIH provides it, and that incessant demoralizing fight over pennies simply isn't there. He will work as a physician until he dies at his desk, we're pretty sure.
The most important thing to remember about this movie is that it is about people who have insurance. It is about those who have done the right thing, who have tried to protect themselves and their families and be responsible citizens, and the values of a country that allows them to be abused by hopelessly defective system.
Some of the most emotionally effective scenes came from the claims adjusters, medical officers and workers in the insurance industry who are clearly distraught by the damage the insurance industry does to good people who have paid good money and are still denied the care they deserve. In tears they describe how they have ruined lives to meet quotas, and denied care to people who suffered and even died as a results of their decisions. These are not bad people who work for the insurance companies, they are lodged in a system that seeks profit, that is all. And this is the root of the problem.
Moore shows many examples of how the insurance system, in the course of seeking higher profit, is designed to deny care rather than provide it. The evidence is sound, we all know this is a problem, it can not be denied. Those who are most to blame are the medical officers of these companies, who deny care to sound claims under their signature as doctors. Not only do they deserve to lose their licenses, but probably also deserve jail time for the reprehensible and negligent practice of medicine on people they do not know, who they have not seen, and whose charts they clearly never have reviewed. One possible solution - a stopgap at least - would to make medical officers subject to Boards of Physician Quality Assurance in the states in which the insurance companies operate. That way, they will be forced to be licensed in the individual states, and their will be state, medical and civilian oversight of their decisions. My mother actually tried to get just such a law passed in Maryland a decade ago - she really is pretty fiesty. Industry, finally playing the "I'll Sail Away" card, managed to quash the legislation.
Moore is at his best when the movie is a true documentary. He points the camera at good people, who have done nothing to deserve the treatment they get, and the undeniable injustice of their treatment at the hands of insurance companies. The stunt of taking them to Cuba turned into the most emotionally poignant of the movie. These were firefighters and EMTs who were sick as a result of their efforts at the WTC after 9/11. The Cuban doctors treated them, without question, and these people in all sincerity were floored by the simple receipt of medical care. In a foreign country. In the third world. That is communist.
The movie had several flaws. The first, is the suggestion that it was solely the Republicans fault we don't have universal health care as a result of Hillary Clinton's efforts in the 90s. They deserve the lion's share of the blame. However, Hillary also made two fatal mistakes of her own in the attempted implementation of the health care. First, she tried to construct the system behind closed doors, out of the eyes of the public. Second, she didn't include any doctors, none, in the formation of her plan. Moore does show that now she is in their pocket, she's given up fighting with them, instead she has joined them. She will not get my vote.
The second flaw was in the somewhat credulous coverage of the medical systems in other countries. These systems are superior to ours, don't get me wrong. We pay more money per capita for medical care than any other country yet we receive the 2nd worst care in the industrialized world. There are states in this country that have infant mortality rates rivaling the third world. People, with and without insurance, suffer and die without medical interventions that would save their lives. I doubt anyone in Canada or Britain or France would trade their system for the American one in a million years. However, it will be a source of attacks on Moore and the film that will distract from the central message. Profit-motive must be removed from the distribution of medical care.
Expect a fair amount of the industry deck of cards to emerge as a result of this movie. Expect to hear "No problem", and "consumer freedom". Expect "Competition is magic" and "Jobs!". Hell, expect the entire deck, especially the bogey-man cards of "Bureacrats" and "Unamerican/foreign" and "communist/socialist". They will all be trotted out in turn. But there can be little doubt, our system sucks, and those of the other industrialized countries are far superior. The BS about rationing care and absence of technology are idiotic canards with no data to back them up. Don't believe it.
As I am going into medicine and one day will treat patients, I'd like to say I'd rather be paid a half or even a quarter of what would be expected if I could practice medicine unimpeded by the incessant fight for reimbursement, and the constant second-guessing of medical care by insurance companies that only want to deny, deny, deny. Medical education in such a system would have to be free, this another point made by the movie, debt is used to chain people to unjust systems. As much as free-marketers talk about "choice" there is no choice in our current system. If you lose your job, you lose your insurance. If you fight with insurance companies and get dumped you lose your safety net. If you are poor you have no choice. If you have debt you have no choice. Who cares if I got paid less, at best I could again be proud of my profession, at the very least I'd know if I got sick, I wouldn't be bankrupted myself.
When the doctors tell the 9/11 workers they would be happy to treat them I felt like that is the kind of medicine I want to practice. Treatment of patients, the correct care for the illness, the best care possible, without question, without consideration. The ability to do the right thing, all the time. Hopefully, I won't have to move to Canada or Cuba to practice this type of medicine. But after this movie, I frankly have no stomach for American medicine.
Comments
I grew up in the UK, and when I first moved here it simply boggled my mind that health care was run as a for-profit business. It was crystal clear that this was absolutely *not* the way it should be, for all the reasons you have stated so eloquently. Since then, the situation has only become worse - which to me is no surprise at all.
Now, I do understand that the UK system is not perfect (Maggie had a lot to do with that), but at least you won't go bankrupt or lose your home just because you are sick.
My brother lives in Canada, and he and his wife constantly bitch about the Canadian health care system. At least, they did until they learned from me what I pay for "insurance" each month (and that's just my share - my employer pays the bulk).
I concluded long ago that the American public is so utterly brainwashed that they truly believe this is "the greatest nation on earth" and that their health care system is "the best in the world". It's going to take something truly momentous to change things here, but perhaps this film might be a first move in that direction. If only all those voters would see what big business has done to them, perhaps there really would be a change, although it's going to be a hard and painful path because there are so many intertwined and entrenched interests in maintaining the status quo.
Posted by: Ray M | June 30, 2007 8:22 AM
I've lived in a system with public health care and I've lived with American-style HMO care. I can safely say that American-style HMO care sucks.
That said, many people who live with the public system have never known anything else, and complain about it. They hear about people traveling to the U.S. for elective procedures and paying out of pocket and having the procedure the next day and they think that is the norm. (I mean seriously, if you have enough money to pay for your care with cash, you'll get the best care in the world in the U.S.) *Many* people that live in countries with public health care would switch it for the American system. That said, they have no idea what they're saying. Their ignorance leads them to assume that the grass is greener on the other side.
Again, having lived many years in American and a country with public health care, I can safely say that American-style health care is vastly inferior (unless you have the resources to pay cash). And when people ask the question, "But do you want the government to be in charge of your healthcare?" I always answer "Hell, yes!".
Posted by: factician | June 30, 2007 8:36 AM
And when people ask the question, "But do you want the government to be in charge of your healthcare?" I always answer "Hell, yes!".
Is that what you really want? That would be just as bad as what we've got right now.
What you want is a government that is in charge of covering the costs... you want doctors in charge of your heath care. Petty bureaucrats can do terrible things to individuals, be they in insurance companies or be they in governments.
This question should be faced head on, and rejected as not the right question to ask. Admitting that it is the right question to ask, even with the answer of "yes," yields a lot of ground to those who see socialized medicine as putting medical decisions in the hand of government.
-Rob
Posted by: Rob Knop | June 30, 2007 9:31 AM
Rob, You make an excellent point. I am American but have been living in Montreal, Canada, for 3 years. My wife is an ER nurse and has worked in a major trauma center in the US and here in Montreal. I think we have a pretty good grasp of both systems. The current American system is clearly a failure on many levels detailed above. One of the major failures of the Canadian system is bureaucracy in the government that fails to get the right drugs on formulary and fails to keep up with technology. There is no question that the Canadian system is fair to all, but everyone ends up with mediocre care (on a daily basis) when they clearly have the potential to offer the best possible care to everyone. To the credit of the government (federal and provencial) there is much motivation to achieve this goal and there is a movement to increase the visibility of doctors, nurses and researchers in the decision making process on the level of bureaucracy. I should add that I had a major spinal injury while in Montreal. I recieved fast, professional and quality care that lasted over more than a year including surgery and therapy to get me up and moving again. I have paid virtually nothing and now, more than 1.5 years out, I am more or less normal again. I shudder to think what would have happened to our finances (and my career -- I'm a postdoc and make next to nothing) if I would have had the same injury in the US.
My opinion is that the US has a major opportunity to create a system that can be fair to all and offer first class care across the board. The question is, I suppose, if people will be willing to pay more taxes. I, for one, have never understood the problem in that regard because the higher taxes even out in not having to pay insurance premiums plus the extra charges that always come with a doctor's office or hospital visit.
Posted by: Theodore Price | June 30, 2007 10:09 AM
I was in Havana in 1992 and the elevator attendant at my hotel received a checkup at work from a doctor.
Question: Couldn't you, or any doctor, work without managed healthcare clients? Couldn't you run your office and only take patients who pay out of pocket and do pro bono work or deeply discount your fees for those who couldn't afford certain things? I'm just curious? And I have this impression that this does happen in the really small towns of America. Does the small-town doctor still exist?
Posted by: Robin Southern | June 30, 2007 10:17 AM
Rob-- The problem is, the system we have right now does not work. To use 'Do you want the government in charge of medicine? They might mess it up!' as an excuse to keep using a system that does not work is lazy and morally unacceptable.
Personally, I am in favor of universal health care. But I dont care what plan someone has for the health care crisis in the US as long as we're trying something.
This inaction-- this "I hate insurance, but god dont change the system till I retire" attitude from physicians-- is infuriating, to say the least. Every damn one of us is an illness, an accident, away from medical bankruptcy.
Im disappointed he did the Republicans/Democrats thing. Well, I mean I do blame our lack of universal health care on Republicans, but the ones in Trumans do-nothing Congress. Not the 80's-90's Republicans.
Posted by: ERV | June 30, 2007 10:19 AM
Robin: Even if you only offered services to patients who could afford to pay cash, you would still need the malpractice insurance. But because you limited yourself to only those who can pay out of pocket, unless you could charge exorbitant rates, you wouldn't be able to cover your insurance costs, never mind paying rent on a shoebox.
Posted by: Josiah Carlson | June 30, 2007 10:44 AM
Josiah: That is what I suspected, but thanks for your input. Any other thoughts on the small-town doctor thing?
Posted by: Robin Southern | June 30, 2007 10:47 AM
Robin,
That is essentially what my mother does now. It's called fee-for-service. Some insurance companies still allow
you to see your doctor and get reimbursed after the fact. That's what her patients do. It shifts some of the burden onto her patients but she won't put up with insurance companies micromanaging her practice anymore.
Sadly her patient pool has dwindled as a result, and as HMOs have dropped her from their lists patients who have seen her for decades have to come in with the list of doctors and ask her who they should see now. It's really heartbreaking.
Posted by: MarkH | June 30, 2007 11:39 AM
i immigrated to the U.S. from a European country some nine years ago. your comment here (Americans of any stripe having a problem with excessive spectacle??!!) just serves to underscore an ongoing observation of mine: that hypocrisy, not "football", is the true national sport of the USA.
Posted by: Nomen Nescio | June 30, 2007 12:32 PM
...oh, and i should have kept on topic. i, too, saw Sicko last night. pay the movie ticket, all y'all, you need to see this film.
Posted by: Nomen Nescio | June 30, 2007 12:34 PM
Mark, is your mother a "GP" or a Family Physician? The members of the American Academy of Family Physicians are actively searching for the way out from under all these bureaucratic burdens.
Actually, the commenter who noted that it's better way to discuss universal coverage rather than universal care is correct. Unfortunately, each move to put medical coverage under government control has resulted in emphasis on "control" rather than "care." And it goes far beyond the limits of formularies or age-limits on new technologies that we've seen in the past (such as age cut-offs for dialysis).
For instance, nothing in the physician's office is private, thanks to the "Health Insurance Portability and Privacy Act." Everything and every record in your doctor's office is subject to viewing and most is subject to copying by anyone who comes into the office claiming to be working under the authority of the US Secretary of Health. The Clinton administration had a history of sending armed investigators into hospitals and doctor's offices and the heads of the FBI and the Department of Health and Human Services held rallies in football stadiums to encourage Medicare patients to turn in their doctors for "fraud and abuse."
Doctors who do fee for service are accused more than others of looking to profit off of other's misfortune, or running "boutique" practices for the rich and elite. Any effort to "discount" anyone's care puts us at risk of being accused of insurance fraud - or worse - being threatened with RICO violations.
The problem actually goes all the way back to the '70's and the invention of the HMO. The HMO was an attempt to control Medicare and Medicaid costs to the government. Next, came the attempt to control costs by controlling the number of doctors, then the "Stark" laws to control the control by doctors.
As late as the early '80's, we paid cash at the doctor's office and had major medical insurance for the hospital. By the time I finished med school, everyone had co-pays and deductibles and tons of paperwork.
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June 30, 2007 1:03 PM
Much of the deterioration of the Canadian system over the last decade is due to privatization and American-style tax cuts for the wealthy that have left social programs underfunded. I hope the movie convinces the Conservative Canadian government to stop trying to copy the U.S. system (but I doubt that it will). It may at least convince the Canadian public that the PR coming from the American insurance companies that's now appearing on our TV and radio commercials is BS. Those companies are making a big push north of the 49th parallel, and are contributing to the campaigns of Canadian politicians. They are making inroads.
Our healthcare system still works relatively well though, and British Columbians have the second highest life-expectancy in the world. How about moving to Vancouver??
Posted by: Booker | June 30, 2007 1:10 PM
and how would that be different from having an HMO, again...?
any health care system will be subject to abuses, naturally. as well, any health care system will have to ration care to patients, since we'll never have the infinite resources to provide everyone with just everything. but from my own position (clinging to the bottom-most edge of the lower class by my bare white knuckles)
Posted by: Nomen Nescio | June 30, 2007 1:12 PM
augh. cancel that last post; mouse pointer slipped.
i'm lower middle class, and my complaint is that under the current U.S. health care system i am not only subject to abuses but cannot feel sure of receiving any actual health care whatsoever. a rationing system that provided me with some care could scarcely be worse than one that does not reliably give me anything at all... yet still takes my money.
Posted by: Nomen Nescio | June 30, 2007 1:14 PM
This is correct, and I think this is why Hillary's healthcare proposal failed - the doctors would not back it. Doctors should have control of medical care, they are the ones seeing the patients and they are the ones who know best what their patients need. To some degree government control would be beneficial and shouldn't be used as an absolute bogey-man to frighten people away from universal health care. If, for instance, the government refused to pay for some drugs, like Nexium, rather than omeprazole, I wouldn't call that interference so much as common sense. Many drugs that are expensive and paid for by insurance companies - due to lobbying by drug companies - are redundant and unnecessarily expensive. Some control of pharmaceuticals would be welcome to stop pointless waste.
Also, even if government control were invasive it could not possibly be worse than the current control and invasiveness of the profit-motive which denies necessary care while putting people in debt and bankruptcy. Some control could be reasonably ceded for the benefit of preventing the unmitigated harm of the uninsured, underinsured and ruthless practices in denying care that the insurance companies practice.
Posted by: MarkH | June 30, 2007 1:20 PM
Let's be specific, here: there are multiple kinds of profit, and not all of them are interchangeable.
Our medical system must not be permitted to function on the principle of maximization of monetary profit - that's a ridiculously bad idea. The system should produce a very different kind of profit - patient outcomes - and anything that leads to that end, including competition, should be used.
Posted by: Caledonian | June 30, 2007 1:47 PM
A few points:
- Anecdotes and personal experiences are not a rational basis for evaluating or comparing health care systems. I'd expect science bloggers especially to understand that.
- The "profit motive" is a major influence on the health care systems of all major nations. Even where health care funding is primarily public and non-profit (as in Canada and France), health care delivery is generally private and for-profit. The only major nation I am aware of whose health care delivery is primarily non-profit and state-owned is Britain.
- Countries with health care systems primarily funded publicy seem to be moving in the direction of greater private funding. This includes Britain, Canada and France, the three nations whose health care systems are most often cited favorably by proponents of reform in the U.S.
Posted by: Jason | June 30, 2007 3:07 PM
Countries with health care systems primarily funded publicy seem to be moving in the direction of greater private funding.
Quite possibly, but is anyone (apart from those who stand to make a profit) claiming this is a good thing? Or does it simply mean these countries are in a race to the bottom to see who can "catch up" to the US?
Posted by: Ray M | June 30, 2007 3:12 PM
Quite possibly, but is anyone (apart from those who stand to make a profit) claiming this is a good thing?
Yes, I am. The role of private funding is growing because public funding has been unable to satisfy the demand for services. As health care services become increasingly expensive and sophisticated, and governments find it increasingly difficult to make them broadly available to the population through public funding (that is, taxes), I expect the role of private funding to grow further. I also expect most health care delivery to remain in the private sector.
Posted by: Jason | June 30, 2007 3:19 PM
I don't understand the resistance to universal health care, because it seems to me that there will always be a private market for those who have more money and want special service. I have a boutique doctor, and love it. Never have to wait for anything...get scripts over the phone...can email the doctor...he'll see my friends as a favor...
So, half the privacy problems in the medical field are actually caused by the lack of single payer...Another thing to think about, esp when genetic information starts to be used to deny you for claims.
Posted by: Chris H | June 30, 2007 3:33 PM
"Yes, I am"
Well that settles it then.
Posted by: Mondo | June 30, 2007 3:42 PM
The problem with government control is that government is the ultimate example of bureaucracy. The growth of the bureaucracy (in size, security and power) seems to be the main agenda of government bureaucracy, outlasting any political changes. (All over the world, not just the US - I still laugh at the Civil Service ploys in the old reruns of the British show, "Yes, Minister") Unfortunately, government bureaucracy has guns and prisons to back it up.
Remember the fuss a few years ago when we found out that Medicare's experts gave wrong advice 4/5 of the time and that following the advice risked fines and even prison, half of the time?
( http://www.gao.gov/new.items/d011006t.pdf see page 8 ) That was about the same time that some Medicare patients were threatened for privately contracting with physicians. It turned out that only the docs were at risk, of course.
Last year, Medicare payments were purposefully delayed for weeks to meet Federal budget restraints. This last month, those who complied (or tried to) with the new National Provider Identifier mandate found their personal information open under the Freedom of Information Act and quite a few had significant delays in payment as the system choked on that new number.
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June 30, 2007 3:44 PM
While there may be atheists in foxholes, there can be no laissez faire attitude to healthcare after you have been to India. Here you can see an uncaring and unaccountable government; a very vast private sector where quality varies from best-in-class (Escorts, Apollo) to very-dodgy (hole-in-wall); and a public health machinery that has all but collapsed. The only bright spot is the success of the few 100 non-profit private health systems, such as the Sankara Netralaya in Chennai, Ramakrishna Mission Hospital in Calcutta, Arvind Eye Hospital in Madurai, and the Baba Amte run Anand Van for rehabilitation of people affected by leprosy.
Institutions can't be built, they can only be destroyed. Giving a free reign to a value-destroying intermediary like the health-insurance sector, serves no purpose. A friend of mine in US who has a successful private practice group has stopped working with private insurers, leaving patients to deal directly with them. She tells me that Medicare is far superior to any health insurer she has worked with.
My friends in Canada chortle when they hear the tall tales about the horrors of government healthcare in Canada from the likes of ignorants in the Cato Institute, Walter Williams, Thomas Sowell etc., One friend has been on a xplanted kidney for over 15 years; another recently underwent emergency brain surgery that was done in double quick time.
Posted by: rimpal | June 30, 2007 4:41 PM
Chris H,
Part of the problem is that "universal health care" is a term of art that can refer to many different kinds of policy. Cuba and France are both commonly said to have "universal health care," but the set of services provided by France's "universal" health care system is far more comprehensive and sophisticated than the set provided by Cuba's "universal" health care system.
Another issue is waiting lists and rationing of services. In its ruling striking down the ban on private health insurance in Quebec, the Supreme Court of Canada wrote that "access to a waiting list is not access to health care." Delayed service can be effectively equivalent to no service at all.
Yet another issue is co-pays and other out-of-pocket costs to the consumer at the point of delivery. These are obviously a disincentive to the consumer seeking services. The higher the cost, the greater the disincentive. For some group of people covered by a system that nominally provides "universal health care," these out-of-pocket costs may represent an absolute barrier to the receipt of services, just as they do for many uninsured Americans.
The point is that "universal health care" isn't a clearly defined set of health care services that a country either provides or does not provide, but a vague and ambiguous phrase that can refer to a wide range of different services whose actual availability to people may be severely restricted in a variety of ways even if they are nominally available to everyone on demand.
Posted by: Jason | June 30, 2007 4:45 PM
What can I say? I am diabetic. I have had my share of crazy experiences with our health system.
I have posted my own personal take on this (it's aRe: to Moore's call for personal testimonials about issues with the healthcare system):
http://manuelhp42.blogspot.com/2007/06/anticipating-michael-moores-sicko.html
And I invite you to read what others diabetes have to say about the movie, in TuDiabetes.com, a community for people affected by diabetes that I run:
http://www.tudiabetes.com/forum/topic/show?id=583967%3ATopic%3A3488
(you are invited to join if you are touched by diabetes in any way).
It's very interesting how the message, coming from Moore can be disturbing even to some people who acknowledge many of the points he makes to be true...
Posted by: Manny Hernandez | June 30, 2007 6:12 PM
I feel compelled to make a statement that may be perceived as naive but worthy of long thought:
A fundamental value is lacking -- that of the highest well-being of all persons and their environment, both short- and long-term.
If this value were a primary principle guiding the decisions of individuals and institutions, things might be better. That said, I realize that good intentions make for nothing without real commitment and action.
Posted by: Richard Gay | June 30, 2007 11:39 PM
Jason, you appear to conclude that because universal health care can be abused sometimes (throwing out some major strawmen along the way), therefore everything is fine here? You talk about anecdotes and personal experience but completely avoid any of the data and studies that MarkH provided too. I don't feel like looking right now, but anybody want to go find the cards this guy is using?
Posted by: CaptainBooshi | July 1, 2007 8:35 AM
Chris H: "I don't understand the resistance to universal health care"
I can think of a couple reasons:
1) It's [insert ominous sound effect] Socialism(TM). Obviously, to the extent that universal health care is socialist at all, it's socialistic in the way many European governments are, which works pretty decently, rather than the way the USSR was. Still, that fear of "socialism," which usually takes the form of scares about Big Government(TM) and the denialist "Competition is Magic" card, dies hard.
2) It's against the interests of certain groups with enough money to buy legislators. Insurance companies would be made superfluous by a single-payer system, IIRC. The government would have even more bargaining leverage to drive drug costs down, which wouldn't sit well with pharma businesses. There is a lot of business invested in the current broken system.
Posted by: J. J. Ramsey | July 1, 2007 10:23 AM
The problem with government control is that government is the ultimate example of bureaucracy.
And the insurance companies are chopped liver?
Posted by: Graculus | July 1, 2007 2:04 PM
any healthcare system will ration services, by necessity. providing completely comprehensive services to everyone would take effectively infinite resources, which we do not have; rationing, then, is unavoidable.
the major complaint could be stated as, the current U.S. system uses unacceptable rationing criteria. it provides totally comprehensive services to those few wealthy enough to pay cash out of pocket; provides effectively no services to those who can't pay at all; and to the middle class, provides an "insurance" system, which on some occasions appears to be set up to rob them of their moderate means while providing token, or at best moderate, services.
rationing is unavoidable, but making the rationing system one giant argumentum ad crumenam does not seem obviously the best solution.
Posted by: Nomen Nescio | July 1, 2007 3:38 PM
Nomen,
Yes, there is always rationing. The point is that "universal health care" doesn't mean that everyone will get the health care services they need when they need them. They may not get the service at all, even if it is nominally "covered" by the system. The long waits for services that plague the British and Canadian health care systems illustrate this. And the waits are not just for minor consultations and treatments, but also for major, potentially life-saving services.
For example, according to this report in Britain's Observer newspaper, delays for colon cancer treatment under Britain's "universal health care" system are so long that 20% of cases considered curable at the time of diagnosis are incurable by the time of treatment. And the average wait for heart-bypass surgery is a year. The story also reports the case of a diplomat who had to wait seven months for a referral from his Primary Care Physician for a diagnosis of prostate cancer, and then faced an additional eight-week wait for a body scan to see if the disease had spread to his bones before he was allowed to see a consultant.
And according to this editorial, from the Canadian Medical Association Journal, during one 12-month period in Ontario, Canada, 71 patients died waiting for coronary bypass surgery while 121 patients were removed from the list because they had become too sick to undergo surgery with a reasonable chance of survival.
Health care system horror stories are not limited to the United States, you know.
Posted by: Jason | July 1, 2007 4:58 PM
By the way, I said the profit-motive must be removed from the distribution of medical care - that is - coverage, payment, insurance etc.
The bogey-men of rationing and bureaucrats are tiresome. We have a far worse system of rationing now. We have bureaucrats, who rather than being unable to provide service to all actively try to deny care to save money.
Rationing, bureaucrats, these things are inevitable when it comes to any distribution of money. The question is what is the value of throwing away 30% of the money to stockholders and profit when we know that medical systems can operate with lower overhead? And how can anyone justify our current system when we spend more per capita yet the quality of our care is 37th in the world? We are spending more than any other country for less than any other country. What kind of capitalist thinks that's a good deal?
Posted by: MarkH | July 1, 2007 6:16 PM
By the way, I said the profit-motive must be removed from the distribution of medical care - that is - coverage, payment, insurance etc.
Well, good luck with that. I think your imperative is politically and economically naive in the extreme. As far as I'm aware, not a single industrialized democracy has a health care system in which the "distribution" of medical care is not significantly determined by the profit motive. Even Britain has a substantial supplementary private health insurance system that provides superior or faster health care for those who can afford it. And the role of the private, for-profit sector seems to be growing, as governments find it increasingly difficult to satisfy the demand for health care services through public funding.
The bogey-men of rationing and bureaucrats are tiresome. We have a far worse system of rationing now.
I'd like to see your evidence that "we have a far worse system of rationing now."
Rationing, bureaucrats, these things are inevitable when it comes to any distribution of money. The question is what is the value of throwing away 30% of the money to stockholders and profit when we know that medical systems can operate with lower overhead?
We're not throwing it away. Again, your argument is just so economically naive. On your account, we should fund products and services in general through the government, not just health care services. Think of savings we'd get from eliminating profit and stockholder dividends and marketing costs! Only it doesn't work that way. The market is much better at matching up supply and demand than the government. That's why our economy is based on private enterprise and not state-owned enterprise.
And how can anyone justify our current system when we spend more per capita yet the quality of our care is 37th in the world? We are spending more than any other country for less than any other country.
There's no serious evidence that the quality of our care is 37th in the world, or that we don't get more than other countries.
Posted by: Jason | July 1, 2007 6:57 PM
No serious evidence? So the WHO report that shows that we provide poor medical care in terms of access, coverage, life expectancy etc., is just a big lie?
Someone is starting to sound a bit cranky...
Posted by: MarkH | July 1, 2007 10:10 PM
Off topic, but Tag
Posted by: Anonymous | July 1, 2007 10:30 PM
Mark,
Assuming you're referring to the WHO World Health Report 2000, it's a joke. Its methodology and conclusions have been strongly attacked in the academic public health community as fundamentally flawed. For instance, its ranking of countries by health care system effectiveness relies on a single aggregate health indicator--disability-adjusted life expectancy--that is known to be only very weakly related to the services provided by a nation's health care system (life expectancy is determined primarily by social, environmental, and genetic factors, not health care services).
See, for example, this paper by Vicente Navarro, of the Johns Hopkins School of Public Health.
Posted by: Jason | July 1, 2007 10:41 PM
OK, this is a bit snarky but since 2 of the suspects in the terror attacks in the UK are physicians, how long do you think it will take for there to be a socialized medicine/terror link?
Posted by: rmp | July 1, 2007 11:19 PM
Hmmm. From your reference:
From what he writes it sounds as if the criticism is that the WHO report is unfairly biased towards making industrialized countries look better - and attributing all their mortality benefits over the third world to better medical care. Nowhere in that paper does it suggest that the US rankings relative to the other industrialized nations is unfair. So, try reading the link next time.
I'm not talking about making us a communist country and this is a despicable little straw man. There are some things that are too important to be left to private enterprise. Critical infrastructure. The military (sadly we're seeing our government hire mercenaries - and the absence of oversight is disgusting). Critical services like power, water and communications need to be at the very least tightly regulated. Fire, police and emergency response - all socialized. We're saying that healthcare belongs in this list, not that we need to become communists, that's classic industry denialism there - the communist socialist card.
No? 44-46 million uninsured? The higher morbidity and mortality of US citizens - controlled for race and class even - compared to Canada and Britain on just about every measure from life expectancy to things like high blood pressure, heart disease, MIs, etc?
You're using arguments right out of the deck, and the data not just on access but on outcomes shows the inferiority of US health.
Posted by: MarkH | July 2, 2007 1:15 AM
I have to be cynical about the taking patients to Cuba and the Cuban physicians being all over themselves to treat them.
I'm not saying that Cuban doctors, or Cubans in general aren't generous. I think it's a disgrace that the 9/11 rescue workers aren't being treated as (basically) war heroes and given every assistance by their Government. But I do recall that Cuba and the USA have "issues", and the Cuban Govt. would be happy to do anything that would make the US of A look very, very bad - or themselves very good by comparison.
That being said, I am only just a little bit cynical. And I am very glad I am Australian. BTW, I would happily admit that, strictly from the technological and scientific viewpoint, US medicine probably is the best in the world. The problem lies in getting access to it. I'd rather have not quite such a whiz-bang system, and free access when I needed it.
Posted by: Justin Moretti | July 2, 2007 3:08 AM
I'm no expert, and can't produce evidence but, Jason, it's my understanding that:
Even Britain has a substantial supplementary private health insurance system that provides superior or faster health care for those who can afford it.
is only half correct.
Faster: yes; superior: only in the sense that you might get more or better ancillary hotel type services. The actual medical care is not, to my knowledge, better. Even 'faster' is less of an issue than it was: I think it's telling that your example of waiting lists is from 2001.
The private sector is very dependent on the public one, too, as the latter does all the training, much of it on the job.
Posted by: David | July 2, 2007 5:32 AM
MarkH: "There are some things that are too important to be left to private enterprise."
Nitpick: I don't think it's a matter of more important or less important so much as the right tool for the job. The market is good tool for some forms of distribution, while the government is better at others. Based on comparison of healthcare in the U.S. with that of other countries, it so happens that the market isn't such a wonderful tool for healthcare.
Posted by: J. J. Ramsey | July 2, 2007 8:28 AM
I'm ok with a government run single payer system but I'm not convinced that it's the only solution. The current system is broken, not denying that. I'm just not sure that the system couldn't be made vastly better by regulation .ie (no pools/cherry picking, mandatory participation, ...)
Posted by: rmp | July 2, 2007 9:10 AM
I have a few questions about what you wrote in your original post.
"As I am going into medicine and one day will treat patients, I'd like to say I'd rather be paid a half or even a quarter of what would be expected if I could practice medicine unimpeded by the incessant fight for reimbursement, and the constant second-guessing of medical care by insurance companies that only want to deny, deny, deny."
Could you please explain why you think that government will not act this way? I thought that Medicare negotiations for reimbursement were worse than any insurance company. There always seem to be articles talking about how few medical providers will accept the heavy handed neogitations for reimubrsement from Mediare and Medicaid.
I am somewhat familiar with with pharmacist aspect of medical practice. The average cost to a pharmacy in term so labor, supplies, benefits and expenses is $10 to fill one prescription. Recently, there were bills in Congress trying to set a cap of $7.00 for Medicare reimbursement for the pharmacy's expense in filling a prescription. No insurance company would have that kind of clought to devastate a branch of medicine like the federal government would have.
Posted by: Anonymous | July 2, 2007 11:00 AM
This scene was almost certainly scripted. Americans do not get to walk around Cuba with video cameras freely. They almost certainly had minders, and it's likely that things were made quite easy for them because the Cuban government would like to embarrass us.
We should remember, that Castro went to Spain for his GI surgery. While Cuban doctors are apparently very good, and very well trained, they lack a great deal of the technology we do. This is unlikely to be from having national health care though - more likely the 50-year embargo that keeps them driving cars from the 1950s. They do a lot with what they have.
Posted by: MarkH | July 2, 2007 11:24 AM
Of course government has the ability to abuse people just like insurance companies. The difference is we elect the leaders of our government, have oversight and things are done publicly and openly. Insurance companies tell doctors all the time what they'll pay for and what they won't pay for, what the doctor should do to treat a specific problem, and by the way, they'll only be reimbursing 70% of the cost of the procedure (which medicare and medicaid do as well). Who do we lobby to change their practices? To explain how they come up with cost structures? To change their policy?
Posted by: MarkH | July 2, 2007 11:28 AM
Could you please explain why you think that government will not act this way? I thought that Medicare negotiations for reimbursement were worse than any insurance company. There always seem to be articles talking about how few medical providers will accept the heavy handed neogitations for reimubrsement from Mediare and Medicaid.
Well, that's because the doctors are having to tackle the bureaucracy one by one, just like they have to do with the HMO's, who have been driving doctor's incomes down as well. In Soviet Canukistan we aren't allergic to collective agreements, the doctors get to negotiate en bloc, just like a (*gasp*) union.
Having to negotiate even single payment strikes me as like an employee having to negotiate every single paycheck, an idea that loses several IQ points to dirt. However, it wouldn't suprise me if this was a deliberate tactic to make Medicare look bad.
Posted by: Graculus | July 2, 2007 2:33 PM
Mark H,
Nowhere in that paper does it suggest that the US rankings relative to the other industrialized nations is unfair.
It most certainly does. Navarro's very first point is that the report's measure of health care system "effectiveness" is fundamentally flawed:
As I said, the primary determinants of mortality and morbidity are behavioral factors (diet, exercise, smoking, alcohol, stress, etc.) and environmental influences (things like air pollution, climate or the safety of food and water supplies). Most of the services provided by a nation's health care system have very little effect on overall rates of health and premature death.
I'm not talking about making us a communist country and this is a despicable little straw man. There are some things that are too important to be left to private enterprise. Critical infrastructure. The military (sadly we're seeing our government hire mercenaries - and the absence of oversight is disgusting). Critical services like power, water and communications need to be at the very least tightly regulated. Fire, police and emergency response - all socialized. We're saying that healthcare belongs in this list, not that we need to become communists, that's classic industry denialism there - the communist socialist card.
Sorry, but you haven't provided any serious argument to justify your position that health care funding should be removed from the private sector, but not health care delivery, or the funding and delivery of almost all other products and services we consume, including basic necessities such as food, housing, clothing and employment. Those would seem to be even more "critical" to human welfare than health care, and yet you don't seem to be proposing a government takeover of them. The military, police and fire services are "socialized" (at least with respect to funding) because they are public goods, unlike food, housing, employment or health care.
No? 44-46 million uninsured? The higher morbidity and mortality of US citizens - controlled for race and class even - compared to Canada and Britain on just about every measure from life expectancy to things like high blood pressure, heart disease, MIs, etc?
That's right. The higher morbidity and mortality of Americans has little or nothing to do with shortfalls in our health care system. Health care services have very little influence on those statistics.
Posted by: Jason | July 2, 2007 3:22 PM
Faster: yes; superior: only in the sense that you might get more or better ancillary hotel type services. The actual medical care is not, to my knowledge, better. Even 'faster' is less of an issue than it was: I think it's telling that your example of waiting lists is from 2001.
"Faster" effectively is "superior." A health care system that provides services promptly is superior to one that provides them only after substantial delays. The human cost in pain and suffering of having to wait for even "non-essential" services like hip replacements or hernia repairs is considerable. And in some cases it can make the difference between life and death, as the examples I cited above demonstrate. Those costs must be included in any serious comparison of different health care systems. But proponents of health care reform in the U.S. often ignore or dismiss the huge costs imposed by rationing and waiting lists in Britain and Canada, and focus only on the costs imposed by the lack of "universal coverage" in America. Any honest evaluation of the merits of different health care systems must involve a comprehensive analysis of costs and benefits. Long waits for services are certainly a cost.
Posted by: Jason | July 2, 2007 3:44 PM
Well, that's because the doctors are having to tackle the bureaucracy one by one, just like they have to do with the HMO's, who have been driving doctor's incomes down as well. In Soviet Canukistan we aren't allergic to collective agreements, the doctors get to negotiate en bloc, just like a (*gasp*) union.
Huh? American doctors generally make two to three times as much money as their Canadian counterparts. So, apparently, your Canuck collective bargaining isn't terribly effective from the doctors' point of view.
This is one reason, by the way, why you're not likely to get most American physicians to support a Canadian-style health care system in the U.S. They stand to lose half or more of their incomes under such a system.
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Posted by: Richard Sorbo | July 2, 2007 4:13 PM
This is one reason, by the way, why you're not likely to get most American physicians to support a Canadian-style health care system in the U.S. They stand to lose half or more of their incomes under such a system.
Are you honestly claiming that half your doctors make $800,000 or more per year as NET income?
The AMA doesn't think so.
Posted by: Graculus | July 2, 2007 4:22 PM
Graculus,
See the table of average annual income of physicians by country on page 14 of this document:
http://www.pnrec.org/2001papers/DaigneaultLajoie.pdf
It indicates that on average American physicians make twice as much as Canadian physicians. Admittedly, the data is from 1996, but there's no reason to think the ratio has changed dramatically since then.
The disparity is probably lower for primary care physicians than for specialists, but the basic point is that American doctors would stand to lose a huge amount of income under a single-payer, government-funded health care system. So they're not likely to support such a policy.
Posted by: Jason | July 2, 2007 4:54 PM
Incorrect and inaccurate reading of this paper. The author is saying that the assumptions are incorrect, not the data. Further he is critical of these assumptions because of the comparison of non-industrialized countries to industrial countries does not make sense. Nowhere does he say that comparison between the industrialized nations is invalid using these metrics. Here is the rest of the paragraph:
This paper does not mean what you think it means
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Ow, my gut. That was good. Thanks man.
Umm, then what is it? It was a comparison of people of similar class, weight, and health habits. Free for all to read here in JAMA. Explain that away. Is it the weather?
What about infant mortality? Those infants been lighting up in the womb?
This is BS and classic American exceptionalism. And why are we only talking about Britain? How about Sweden? Or France? We're the only ones operating on a private insurance model without some form of universal national healthcare. The best system to emulate would probably be the french or the swedes - not even necessarily the Brits or Canucks - although I know few who would trade even their systems for ours.
Posted by: MarkH | July 2, 2007 5:54 PM
Mark H,
Incorrect and inaccurate reading of this paper. The author is saying that the assumptions are incorrect, not the data.
The rankings are based on the assumptions. The assumptions are incorrect, so the rankings are meaningless.
Further he is critical of these assumptions because of the comparison of non-industrialized countries to industrial countries does not make sense. Nowhere does he say that comparison between the industrialized nations is invalid using these metrics.
Yes, he does. As he says, the assumption that disability-adjusted life expectancy is a meaningful indicator of the "effectiveness" of a health care system is erroneous.
Umm, then what is it?
I've explained this repeatedly. The primary determinants of morbidity and mortality in a population are behavioral and lifestyle factors such as patterns of diet, exercise, tobacco consumption, alcohol consumption, stress levels, etc. and environmental factors such as air quality and food and water safety. The services provided by a nation's "health care system" have very little influence compared to these other factors. That is why you cannot meaningfully rank the effectiveness of different nations' health care systems on the basis of morbidity and mortality statistics. In fact, studies suggest that shortfalls in medical care contribute only about 10% of the causes of premature death. The other 90% comes from other sources. The relationship between "health" and "health care" is WEAK, and the relationship between "health" and "health care insurance" or "health care coverage" is even weaker.
It was a comparison of people of similar class, weight, and health habits. Free for all to read here in JAMA. Explain that away. Is it the weather?
I guess you missed this sentence: "...health insurance cannot be the central reason for the better health outcomes in England because the top SES tier of the US population have close to universal access but their health outcomes are often worse than those of their English counterparts."
And you still haven't provided any serious argument in support of your position that it is imperative (or even merely important) to eliminate the profit motive from the funding of health care, but not from the delivery of health care, or from the funding or delivery of other important goods and services such as food and housing and employment.
Posted by: Jason | July 2, 2007 6:38 PM
Mark H,
The best system to emulate would probably be the french or the swedes
In 2003, a commission established by the French govenment to evaluate its health care system concluded that the system is overburdened, wasteful and in urgent need of overhaul. Its annual budget deficit as of 2004 was projected to be 11 billion Euros. Projected to increase to 66 billion Euros by 2020. In U.S. terms (adjusting for population size and currency), the corresponding annual deficit figures would be about $70 billion and $415 billion.
The closest thing we have to the French health care system in the U.S. is Medicare. Medicare is already a fiscal train wreck in progress. The latest Medicare trustees report projects that Medicare will be bankrupt in little more than a decade. Extending a Medicare-like system to the entire U.S. population is probably impossible as a matter of politics, and would be grossly irresponsible as a matter of fiscal policy even if it were politically feasible.
Posted by: Jason | July 2, 2007 6:52 PM
Jason, when you said 'faster, superior', I read it that you were not double counting there. So if speed is the only source of superiority (except for the