Thoughts on US healthcare reform–on return from Europe

May I tiptoe onto a ledge for a moment?

Some (just-back-from-Europe) thoughts on health care policy, perhaps?

One of the many differences between the European Society of Cardiology Congress and a typical American cardiology meeting was the scarcity of healthcare policy sessions at ESC. That’s hard to explain; perhaps European countries are settled on their own systems and do not wish to–or can’t–influence their neighbors.

It goes without saying that little about healthcare is ‘settled’ here in the US.

On return from Europe, the first article I saw in my local paper reports that 101,000 residents (16%) of my affluent county live without health coverage.

This is a real problem. So is the fact that it has become easy to gloss over this stuff. You get numb to it all. It’s normal, sort of.

Until you get an email like this:

Hi John,

I have a friend in his 60’s with no health insurance experiencing symptoms like great pressure on his chest and can’t get to a doctor because he can’t afford it. Is there a service in Louisville (a public health clinic or something like that) that you know of where he can get looked at by a doctor?

My e-response:

I don’t know. I think. Maybe. He could go to the ER. I could see him for free, but of course, there would be tests–that are not free.

I’ll get back to you.

This stinks, doesn’t it? Not for this particular guy. He got to me; I’ll see to it that this one patient gets cared for.

What about the other 100,999 residents of my county who don’t have a friend who can email a cardiologist?

This got me thinking about how Europeans approach healthcare. I spoke with an Austrian: “We have excellent healthcare…Everybody gets care.”

From a German cardiologist:

“All Germans get health coverage, whether they work or not. The extremely rich can buy ‘extra’ coverage that allows them to get private rooms in the hospital, or to make contracts with eminent professors and the like. We don’t buy private coverage because it’s expensive and the basic plan is enough for us.”

Lest you think everything German runs as perfectly as their trains, there’s this article published recently in the prominent Journal of the American College of Cardiology, showing that Germans also act according to human nature. It turns out that (even in Germany), if you compensate well for procedures, then it is procedures you will get.

I also learned some basics about British healthcare: Citizens are not billed for health services. You can be admitted to the hospital, treated and when discharged the paperwork includes instructions on medical matters, not a bill. The government pays all the medical bills. Wow.

But another British convention goer reminded me that British care isn’t exactly free. Primary care doctors control care. They determine whether a problem warrants further evaluation or referral to a specialist. And these gatekeepers are more than tacitly incented to contain costs. I guess it’s not surprising then that many of the sessions at ESC that centered on cost-effectiveness came from the UK.

I’ll try to distill my feelings about US healthcare reform down to four simple certainties:

–In a country of such great wealth and wisdom, we mustn’t accept a system that doesn’t cover all the people. I mean all the people—not just citizens. To do so is not just sound policy; it’s more than that—it’s the right thing to do.

–Everyone must start seeing (really seeing) the obvious–that healthcare spending isn’t infinite. We, as a people and a medical community, must accept limits. Choosing Wisely applies to both the patient and the doctor. This won’t be easy. It means making a 180-degree turn in current thinking. If we want things to be better, all parties must accept more responsibility.

–Whichever new delivery system is implemented, be it the Affordable Care Act or an alternative, the patient-doctor relationship must be protected above all else. Medical decision-making should not come from an expert panel or third-party payer, but from the patient and doctor.

–On risk. The idea that humans, not machines, practice medicine must be remembered. Humans make mistakes. They sometime fail to diagnose; they sometimes fail to perform perfect surgeries; they sometimes make real-time decisions that they wouldn’t have made in hindsight. The new US healthcare system must do better at accepting the humanness of its professionals.

JMM

15 comments

  1. LOTS of wisdom in this post John!
    In my efforts to help a family member with an ongoing medical problem – I am currently experiencing from a different perspective what it is like not to have health insurance (and to be “uninsurable”). If not for some “doors” that I have been able to “open” because I know the system – there would NOT have been any good alternative ….

    Like ACA or not – like the person whose plan it is or not – the bottom line is as Dr. John says – our country has got to find a way to get health care coverage for all Americans … ACA is at least a start.

  2. Greetings from Canada, your neighbour to the north (a.k.a. as “commie pinko land of socialized medicine”).

    As former Washington Post writer T.R. Reid wrote:
    “The United States is the only developed country that lets insurance companies profit from basic health coverage. Instead of dismissing foreign health care models as ‘socialist’, we could adapt their solutions to fix our problems.”

    Your friend’s email reminded me of a tragic story that for some reason still haunts me, representing what Reid was talking about: the heart attack death of writer Melissa Mia Hall, who worked full-time, owned a home, paid taxes – but who became one of the 47,000+ Americans who die each year as a direct result of having no health care coverage:
    http://myheartsisters.org/2011/02/03/melissa-mia-hall-heart-attack/

    1. You shouldn’t have to be haunted by that. It should never have happened in the first place, but we know all too well that there are many more stories like that.

      I’m an out of work LPN at the moment, without health insurance. I’m lucky enough to at least be able to be covered with a sliding fee scale service through my local clinic. Without that I would have nothing.

      The only thing I have to say about this is SHAME ON YOU United States for treating your citizens this way! Imagine what other countries must think of the way our government treats its own.

      1. The few that I talked to from other countries all pointed to one common theme: the ‘best’ system would be somewhere in the middle, taking the good aspects of each and jettisoning the bad. It’s fair to say that the worst aspect of US healthcare is that we don’t cover all people.

    2. Thanks for sharing CT. Real stories, like this tragic one, emphasize the need to keep working toward a better, more just, more compassionate system. It won’t be perfect, but it could be better.

  3. Important thoughts, John! I like your transatlantic perspective because only the important things remain visible. The reality of health care politics is a bit more complex though. European health care is not as good as it appears. Balancing the expenses is one important issue. The DRG system rewards almost all medical efforts. Thus, economical reasons easily lead to over-treatment. Also, prevention is given a less important value in terms of remuneration.
    In earlier times it was common that doctors were treating patients for free that had no money to pay them and asked for more money from patients, which were able to pay. I agree with you, also nowadays this Robin Hood like attitude should be considered sometimes.

  4. John, what a refreshing thing to read after the wild ride this week at the Republic Convention. Although I am, and shall remain staunchly conservative, as a Nurse Practitioner, I’m seeing way too much of ‘them’ and ‘us’ in our healthcare system. And after spending time with a friend who is disabled at 62 but can’t get coverage under our system, but also can’t work, I am distressed to have seen many, many who did get coverage although they have NEVER worked.

    Our system is so broken I could cry!!! I want to scream, “Not in America!” but I can’t cause I know it’s so true!

    Could I nominate you to be on the President’s committee………or how about Secretary of Health? Yeah, that’s it!

    Love you,
    Lynn in Sugar Land, TX

  5. “I could see him for free, but of course, there would be tests–that are not free.”

    I have been told that a physician treating a patient for free constitutes billing fraud per Medicare guidelines. However, I have also heard that you can offer a “prompt pay discount” to get around this. What has been your experience?

  6. Dr. J — Heart wrenching, and I mean it. But of course nothing is free, including medical care and services. How much does Austria or Germany or Canada contribute to their own national defense? Almost nothing, at least for Austria. I lived in Austria for 4 months, and there are very few legitimate parallels between that society and the USA. Germany and Canada are closer examples of course, but still very different. And checking out of the hospital without a bill seems nice, but the bill comes from the taxman. In the US, it would go to that dwindling slice of Americans that still pays taxes. What happens when that slice is too small to raise the funds, or when they decide (as inevitably happens when the government demands too much) that they won’t work as hard, or invest as much or comply as freely with the tax code? And while it may be imperative that the doctor-patient relationship be protected at all costs, under government health care it simply won’t be. Medical care personnel will not be doctors but “providers”; effectively employees of the federal bureaucrats who will control decisions. It is simply a fact. Why else does the abomination that is IPAB provide for 15 unaccountable bureaucrats, whose appointment is not subject to the democratic process, and whose decisions can only be overridden by unrealistically difficult votes in Congress? As for providing coverage for all residents, including non-citizens, if you mean to include illegal aliens, plan for even more illegal aliens, because if you subsidize it you get more of it. At what point do we say no to providing medical care at the expense of the American taxpayer to people who have no right to the benefit of our laws, much less of our medical system?

    As always, thanks for your observations and insights…..

    1. I consider it a fine compliment indeed to have such a comment on this blog. Excellent points, all–and a poignant illustration of the challenges ahead for this strong country.

  7. We should have universal health coverage for all American citizens.

    Whatever system evolves here, it must be sustainable.

    Articles which appear to be nonpartisan and hence believable name German physicians and the most demoralized, unhappy, and underpaid group of professionals on the Continent. Did you see any evidence of this?

    Any plan that renders a profession into yet another victimized grievance group is not going to attract “the brightest and the best” and will not be sustainable.

  8. I enjoy following you on Twitter and reading your blog for thought provoking posts just like this. I am not a physician so I enjoy seeing an apolitical perspective on this huge issue.

    I agree that the system needs reform but I am not in support of a system like the UK’s NHS system. One of my biggest arguments against the NHS system is given by The Economist which can hardly be explained as Conservative.

    Private paying patients are pushed to the front of the line and receive preferential treatment:
    http://www.economist.com/blogs/blighty/2011/12/nhs-reform

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