For those of you who have not seen "Sicko" yet, a large part of the movie discusses other countries’ health care. There is a part of the movie in which Michael Moore suggests that we could learn from other countries’ mistakes and triumphs with universal health care.
Really? We Americans could learn from others? What a concept! Great idea Mike!
....
Michael Moore and others such as John Conyers and Dennis Kucinich wish to destroy the health insurance industry by decapitation. While I applaud their efforts, their bills (HR 676 and HR 1200) will die on the vine because too many of their colleagues took money from this industry and are unwilling to let their benefactors go. I would achieve the same end by a different route. "Death by a 1000 cuts."
For those of you who have not seen "Sicko" yet, a large part of the movie discusses other countries’ health care. There is a part of the movie in which Michael Moore suggests that we could learn from other countries’ mistakes and triumphs with universal health care.
Really? We Americans could learn from others? What a concept! Great idea Mike!
So to honor "Sicko" I am going to start my "World Health Care Tour" with the 3 countries in the movie:
Country | Canada | England | France | US |
WHO Rank | 30 | 18 | 1 | 37 |
%GDP | 9.6 | 6.8 | 9.6 | 14.6 |
Public Spending | 6.4 | 5.8 | 7.1 | 6.5 |
Per Capita | $2312 | $1461 | $2077 | $4178 |
MD’s/1000 | 2.1 | 1.7 | 3.3 | 2.7 |
Drugs | No | Affordable | Yes | No |
Glasses | No | No | No | No |
Dental | No | Yes | No | No |
Co-pays | Drug only | Drug only | Yes | Yes |
Insurance | Never | Supplement | Supplement | Yes |
Type | Single-Payer | Single-Payer | Multi Payer | Pvt insurance |
Gatekeeper | Yes | Yes | No | Some |
MD Paid | Fees | Capitation | Fees | Both |
% satisfied | 46% | 57% | 65% | 40% |
Infant Mortality | 5.2 | 5.9 | 4.6 | 7.2 |
DALE | 72 | 71.7 | 73.1 | 70 |
CANADA:
This is single-payer medicine at its purest. The "payer" is the government. Everyone is 100% covered and everyone gets the same coverage...period. There is something almost utopian about that. How un-American. Doctor visits, hospitalization, and some drugs are covered. Other drugs, glasses, dental care and prostheses are not covered. There is no insurance...by law. There are gatekeepers—doctors that need to make a referral for you so you can see a specialist.
They pay their physicians fee for service. In other words the doctors submit a bill for each and every "service" they provide you, and the Canadian fee schedule pays a set price for every service. Services include everything from surgery to giving you advice.
The money comes from federal taxes and is filtered down to the Provinces. The Provinces in turn contract with the various hospitals, doctors and pharmacies to provide the care. A very top down approach.
Canadians utilize their health care—they have more doctor visits and more hospital days than us in the US. Yet they spend 9.6% of their GDP to our 14.6%. In dollar amounts Canada is at the high end on spending--$2312. They can’t touch what Americans spend at $4178 when the WHO (World Health Organization) study was done. Currently Americans are predicted to pay $7500 per person this year, which is unprecedented.
There are waiting lines for non-critical surgeries, but wait times for clinic appointments are less than in the US. Additionally, critical care (appendicitis for example) gets done faster in Canada than the US.
Canadians are not very satisfied with their healthcare. The long waiting lines for some surgeries, as much as 6 months at times, causes Canada’s citizens great dissatisfaction. There is also the criticism that the government cares more about the problems of young, productive patients and retired, geriatric patients wait for long periods.
UNITED KINGDOM:
Another single-payer system with a top down approach. The healthcare system is almost entirely owned and operated by the federal government. It is financed 82% by taxes, 13% by employer/employee contributions, and 4% user fees. Everyone is covered and gets the same health care. About 11% of the population opts to carry supplemental insurance which gives them options of skipping ahead in line or private rooms.
The health care is administered through 10 regional health authorities, which then control 152 primary care trusts, that then monitor and administer the health care. There are also mental health trusts, ambulance trusts and hospital trusts.
Doctors can have public or private or both aspects to their practice. Patients choose their own physician. The primary health care givers are paid by capitation, which means the doctors get paid for how many patients choose them as their personal physician.
England pays $1461 per person per year which is much less than America or Canada. Yet they achieve care slightly better than Canada and head and shoulders above the US. They include dental care and drugs in this amount. And they are better at pleasing their citizens.
Pitfalls are again the long waiting period for non-urgent surgeries like hip replacement, 38% of surgeries wait more than 4 months.
Lessons from Canada and England:
More money thrown at the health care system does not increase the fairness of the system or satisfaction with the system. It may also not improve health care markers like infant mortality or Disability Adjusted Life Expectancy (how long people live without serious disability).
Also, it is socially unacceptable to treat geriatric patients, who have given their entire lives to work for the success of their country and are now retired, less care than people currently working.
FRANCE:
The WHO picked France as having the best health care in the world. Apparently the French don’t think so because only 65% of them approve of their health care system. The French are soooo picky.
Health care is paid out of a fund like social security via employer contributions. The care is supervised by a council of employers, union supervisors (remember in France unions are very powerful players) and the government called "sick funds". There are no gatekeepers, no competition, and no micromanagement by government or insurance companies. And yet their spending on health care is comparable to other countries in Europe.
The system does not cover everyone--the very rich can opt out. You must prove you make so much money before opting out, however.
Physicians choose when and where to practice—and yes they make house calls. Doctors only make about half what they make in the States. Patients choose which physicians they will see. There is a strong prevention aspect to the health care and average Frenchman sees the physician 6 times a year. The French have excellent and modern facilities.
Ninety percent of the French carry supplemental insurance to cover those little extras or what certain medical professionals charge who remain outside the system. They also cover the co-pays and user fees. The patient is responsible for 20% of the hospital bill. That amount of money is standard in the US with insurance. In Europe that amount of money paid out-of-pocket is considered unaffordable, so the French insure themselves against it. On the average the government pays 75.5% of health care with insurance companies picking up 12.4% and out-of-pocket expenses equaling 11.1%. Insurance companies are regulated so that they are not allow to micromanage providers or compete for rates by cherry-picking which services that they will provide or which patients they will accept.
Physicians negotiate en mass with the government each year for the prices they will be paid and hospitals do the same. However both physicians and hospitals remain independent of the government. Most medications are paid for and so are house calls, homeopathic therapy, spa therapy, nursing home care, mental health, dental and vision. There are no lines for services like Canada and England.
But wait there’s more! Unlike the US system that bankrupts the few insured people who have catastrophic illness (like fire fighters who are ill due to their work post the 9/11 clean up in New York), the French system caps payments from patients after they reach $100. If your earnings are below a certain minimum, or if you spend more than 30 days in the hospital or if you are diagnosed with one of a list of chronic diseases you don’t pay anything.
There are problems with the French system. In years gone by physicians have actually gone on strike over wages. However, almost every group of workers in France has gone on strike at some point. Critics state that there is poor coordination between the different specialties and there is definitely a difference in the care a rich person can get and what a poor person can get. But the French are some of the only people in the world who do not feel that their care is being rationed to them.
Lessons from France:
Most Americans do not realize that most European countries have some sort of insurance. Only two of the countries I studied did not allow insurance, Canada and Norway. The difference is that they do not allow insurance companies to take over and totally control health care. I find it ironic that I, after 12 years of upper education and 4 years of grueling residency, have to argue with someone from an insurance company who has not graduated from high school to get the appropriate care for my patients on a daily basis. I also find it interesting that in most countries the rich can opt out of the system or pay higher insurance premiums or just pay cash. It does create some inequity but mostly inequity of convenience—getting a shorter wait, or a private room. Universal health care systems guarantee a baseline of care to everyone so that no one dies or suffers needlessly. (In the US 18,000 or more die each year due to lack of insurance.)
Even more interesting, though, was the fact that France does not have gatekeeper physicians, or much government control of what doctors do with their patients. And yet their health care spending is about the same as other countries. They do not ration care by only allowing a certain amount of some procedures to get done per year. There are no lines for health care and still the amount the French spend on health care, even with all the perks, is similar to other countries and way below what we spend. In fact countries that ration health care are finding that the act of rationing is itself expensive. When you wait 6 months for a knee replacement surgery, you consume more pain medication than if you had the surgery relatively sooner. If you wait for heart surgery you need to see the doctor weekly until the surgery and so use up more of the doctors time and more medication. Eventually, everyone in the line gets the procedure so the country does not really end up saving anything.
A Bold Social Experiment:
I feel great today—don’t you? The birds are singing, the sun in shining and Carl Rove quit! That has nothing to do with health care—I just felt celebratory.
Michael Moore and others such as John Conyers and Dennis Kucinich wish to destroy the health insurance industry by decapitation. While I applaud their efforts, their bills (HR 676 and HR 1200) will die on the vine because too many of their colleagues took money from this industry and are unwilling to let their benefactors go. I would achieve the same end by a different route. "Death by a 1000 cuts."
I have several other countries I would like to discuss and the lessons I learned from each. I will follow that with a discussion of what American health care should look like in the future.
Finally, I am currently working on an initiative to cure the health care crisis. I am rewriting HR 1200 to be a more local bill. This initiative will be reprinted here on this blog when I am done. It can be downloaded and used in your own City or County to guarantee health care for all the citizens of the City/County. I will make it as bone-head as possible. You will simple need to plug in the name of your County and submit it for a vote. I will then provide advice to get the bill passed and advice on what to do if it does not pass. I will then use the blog as a bulletin board for those who attempt this idea. We can cross communicate our triumphs, losses, and lessons learned.
As far as I know, this is the first time this scheme has been tried on the internet and it should make an interesting social experiment in pure democracy.