Healthcare Reform

I wanted to engage with the Healthcare debate as it is such a high-profile and contentious issue within the USA at the moment. Yesterday saw a bipartisan Healthcare Summit convened by Obama in a last-ditch attempt to pass the latest healthcare reforms by conventional means (i.e. 60 vote Senate majority). The outcome was widely predicted and is summarised in today’s lead story in the Washington Post:

http://www.washingtonpost.com/wp-dyn/content/article/2010/02/25/AR2010022502369.html?hpid%3Dtopnews

It is now suggested that Obama will force the reforms through using the simple majority needed by the Reconciliation process. Although Republicans are ‘crying foul’ at this approach, according to Julie Rovner at NPR (National Public Radio), the Reconciliation process has been widely used to introduce healthcare reform in the past:

http://www.npr.org/templates/story/story.php?storyId=124009985

The New York Times provides a very useful interactive website which shows the history of federal healthcare provision:

http://www.nytimes.com/interactive/2009/07/19/us/politics/20090717_HEALTH_TIMELINE.html?ref=politics

It is difficult for Europeans to understand American reluctance to adopt universal healthcare (although Obama’s watered down reforms cannot be described as such, they are certainly viewed as such by some of the American public) given our lack of experience with any other system. Their current system is the most expensive in the developed world – and the most demographically-stratified. For example, it is not uncommon for a family of four to pay $20,000 per year in medical insurance whilst, as reported in the New York Times this week, 45 million Americans lack any insurance at all. However, if you fall on the plus side of this equation (and many Americans do) then you benefit from healthcare that most Europeans could only dream about. Having experienced both systems I thought it may be helpful to provide a few personal anecdotes.

The quality and choice available to those with good insurance is outstanding compared to the UK. Those that can afford it fear that both will be compromised by universal healthcare – and I suspect that they are right. In order to continue to enjoy their current benefits they would need to pay for private insurance in addition to compulsory contributions imposed by government (as happens here). They resent any such proposal. In other words, the ‘haves’ do not want to subsidise the ‘have nots’. Our system provides good, basic care (and critical care) for all, however the ability for us to deliver much more than that universally is compromised by cost. So, as a generalisation, people with chronic conditions are worst served under our system – and preventative care is very poor compared to what is available for the ‘haves’ in the U.S. system.

Many in the U.S. system have (like me) good insurance courtesy of their employer. The majority of middle-class professionals fall into this category. My doctor ex-husband’s employer provided just such a policy. As a result:

- Specialist doctors are the norm. We had a Family Practitioner (like a GP), plus a gynaecologist, dentist, periodontist (both also doctors), opthamologist , cardiologist - and would also have had a paediatrician and obstetrician if we had children. The system is totally competitive so you choose all of them. My ‘GP’ was based at the Mayo Clinic – a world-leading centre for transplant surgery and cancer treatment. There is no way I could ever afford to pay for his equivalent in the UK.

- Preventative annual check-ups are included. Gyne, optician and dental appointments each took around three hours and involved every state-of-the-art test and treatment. It is thanks to this that I discovered the extent of my gum disease - something not reported, let alone treated, under the UK system (despite regular dental check-ups). If I was in the US right now, the expensive dental treatment I am currently suffering would be covered by my insurance, here it is not.

- There are no such things as ‘waiting lists’ and hospitals do not resemble nineteenth century prison buildings. They come complete with carpets, room service, en-suite bathrooms, a la carte menus, smiling receptionists in smart uniforms and piano players in the lobby.

- If you are admitted as an emergency, the treatment you receive is not dependent on the time of day/week/year/area. In the UK, most hospital consultants only work office hours – as do most pathology labs, radiographers, radiologists, etc., etc. Not hearsay – my ex has worked in the NHS too. It is not recommended that you suffer any kind of serious injury out of office hours in the UK unless you happen to be in the area of a large teaching hospital or trauma unit. In addition, you will not have to wait days/weeks for any test. Admitted as an emergency and you will have everything from an MRI test to blood tests within hours.

However, good medical insurance is so expensive that, if provided/subsidised by an employer, it may tie you to a specific job (a little like public sector pensions here at the moment). Middle-class healthcare in the USA is very, very good under the current system. Most of the downside is, as always, suffered by the less advantaged members of society – the ‘undeserving poor’ (as we know, US ideology suggests that poverty is self-inflicted):

- Ex-husband worked in a ‘public’ hospital on the Southside of Chicago during his training. This is Obama’s old stalking ground. Here basic medicines are provided by pharmaceutical companies – often as free samples. Doctors prescribe what they have, not what is best for the patient.

- Tests and treatment are minimal. Preventative treatment does not exist. Chronic disease becomes acute before treatment is available. Emergency rooms are choked by patients with minor problems who use the ER as a substitute for a GP service (as anyone presenting at an ER must be treated by law).

- The mandate to treat all emergency admissions at all hospitals has created peculiarities and protective actions by leading hospitals. It is common for the uninsured to travel long distances in order to present themselves as emergencies to such hospitals (often, to be fair, to obtain general, not emergency, medical treatment). The hospitals, receiving little (or often zero) recompense, therefore use every possible manoeuvre to avoid treating them – let alone admitting them. This is the law of the market operating at its 'most efficient'.

- Because medicine is competitive, doctors have free choice where to work. Unsurprisingly, most choose to serve middle-class patients in ‘nice’, cosmopolitan areas where they will earn most. This leaves the urban poor and rural areas desperately short of medical professionals – even if they could afford them. State, city and town governments offer doctors huge incentives to set up shop in these ‘under-served’ areas but shortages are still acute.

Like so much in US society, healthcare is therefore very economically stratified. The difficulty faced by the American people is whether the ‘haves’ will ever forego their exceptional advantage in order for the ‘have nots’ to have the basics. So far, it would appear not. Speaking as someone who has enjoyed that advantage, before we condemn the American system, I wonder how many of us would be prepared to do likewise.