Wednesday, April 8, 2009

Should we be doing it like the French?

Ezra Klein, an editor at The American Prospect, writes in the Los Angeles Times that "When it comes to health care, the U.S., Britain and Canada are hurting" noting that in Canada and Britain "the two countries most often cited in discussions of what nationalized healthcare might mean, some patients report having to wait months for some elective treatments." But he also observes that "we've got waiting lines too - along with 50 million uninsured and a system that costs more than twice as much per person as that of any other country. We've just managed to hide our lines through clever statistical gimmickry."

He also notes that Germany, France, Japan and Sweden are examples of countries that have achieved universal coverage without long waits, and "all of them have more of a mix of public and private options" than the U.K. or Canada. The American College of Physicians reached a similar conclusion in a 2008 position paper that my colleague Jack Ginsburg and I co-wrote for ACP's Health and Public Policy Committee. It was approved by our Board of Regents in October, 2007 and the edited version appeared in Annals.

We looked at a dozen different health care systems around the world, and found that they all outperformed the U.S. on most measures of access, quality, and cost of care. We also found that the best performing systems could be found in countries like France and Germany that combined publicly-funded and guaranteed coverage with private coverage options. (Canada actually scored second to worst, with the U.S. taking last place, on most of the elements of a high performing health care system as defined by the Commonwealth Fund, one of our principal sources).

Now, to be clear, we didn't find any one country had it all together. There were some advantages associated with single payer systems. And countries with mixed systems of public and private options tend to be less egalitarian. We found, though, that either a pluralistic model with guaranteed coverage, or a single payer model, would out-perform the U.S. on most metrics and therefore had elements that should be considered by the U.S. as it tackles health care reform. We also recognized that any solution for this country would be uniquely American.

President Obama and top congressional leaders also seem to be looking more to France than Britain or Canada. They are putting together legislation that would combine subsidized private insurance, a public plan option, and guaranteed coverage. They aren't advocating a single payer model, despite the exaggerated fears in some conservative circles that this is exactly what they are hoping to achieve, and to the great disappointment of those on the left who argue, with great passion, that single payer is the "only" answer to the U.S. health care crisis.

Today's questions: Do you believe that it is possible to achieve universal coverage in the U.S. without long waits for appointments? And what do you think of doing it the French way - a mix of public and private options - instead of Canada's single payer model?


Steve Lucas said...

Having spent time, and spoken to people from other countries about health care, there is one over riding concept missing in the American system: People from other countries view health care as a cost.

This translate into a great change in behavior vs the American system by both the patient and the doctor. The doctor ask the patient: How can I help you today? While interested in a patient's overall health the doctor only treats the issues raised by the patient.

The patient view their high taxes as a direct cost of medical care, thus they accept a certain level of medical problems as just part of the human condition. They also accept death as a certainty, something we do not do in America, thus limiting end of life cost.

The French and German systems have many positives and produce a health population at a much lower cost than the American system. The real issue is can we change American behavior patterns to allow this system to work.

Steve Lucas

Bohdan A. Oryshkevich, MD, MPH said...

The reality is that we have a dysfunctional system with many impediments to improvement. We need some set of rules or a social contract. At this time we have a free for all.

We have to change many things before we can reach even the Canadian level.

All these plans have one thing in common. They have a primary care workforce that maintains a relationship with the population. That underlies the system. They have an emphasis on basics such as history and physicals before technology is utilized. In the case of Japan, they have access to technology at very low prices.

We have a specialized workforce which works inefficiently. It is likely to stay in place for a generation. We have broken down the doctor patient relationship with patients forced to change doctors.

There really can be no meaningful health care reform without a renewed emphasis on primary care.

The stark reality is that we can have a pluralistic or single payer system. Each system has its advantages and disadvantages. But each can only work with a primary care based workforce. That is what all these plans teach us.

Nothing that anyone has proposed in health care reform even touches what we have to do to get a primary care based workforce. It is not going to happen through spontaneous combustion.

Bohdan A. Oryshkevich, MD, MPH

Christopher M. Hughes, MD said...

To answer the question:

I think we can do this and do it well.

First, if we took 1/6th of Canada's or Britain's population out of the queues altogether the uninsured) and make another sixth very reluctant to use the system (the underinsured), I expect they would have no significant waiting times, either. We, in the US, just pull people out of the eligibility pool to even GET in line, based upon income. Makes one proud, doesn't it?

This fear of 'rationing' so often trumpeted by conservatives is already taking place, as noted above, but also additional rationing occurs through private insurance denials. I think that will not happen with a public plan, because it will be responsible to the public (hence the name!)

Finally, I do believe the "hybrid" public private plan is the way to go. We do not have the political will for more than this. But it also has all of the advantages outlined in your position paper. We need to get this message out that this is where we want to go.