What should a national health care system look like?

I was pleased to see president Obama deliver this address yesterday:

I was even more pleased because he has gathered the traditional opponents of healthcare reform around him and has convinced them to commit to reform in the US system. This is a positive sign. However, I’m concerned because, as with all political debates that challenge a dominant ideology – in this case free-market fundamentalism – we will soon see the denialists come out of the woodwork to disparage any attempt at achieving reforms that may result in universal health care coverage. This has, in fact, already begun, and typical of the tactics they selectively mention the British NHS. If you care to read a balanced article on the history and function of the NHS, you’ll probably agree it is wrongly demonized. What you will also see is that the denialists will ignore a few key facts which include:

1. The United States is the last industrialized nation that lacks a universal healthcare system. Once again, thanks to obstructive policies led by the free market fundamentalists, the US is trailing the rest of the world.
2. The US spends more per capita on healthcare than any other nation in the world.
3. Despite spending more, we get less. We have tens of millions who are uncovered – which does not mean they do not receive healthcare at all. They instead are treated in ERs, urgent care centers, or receive substandard care, and the state ends up picking up the bill anyway. So even without a planned universal health care system, you end up picking up the (higher) bill because the state has a vested interest in protecting hospitals from the economic collapse that would occur if they had to pick up the tab on every impoverished patient who doctors are ethically and legally obligated to treat.
4. Many national healthcare systems work. We will not hear about this from the ideologues who will soon harangue us with cherry-picked horror stories of long wait times and underfunded hospitals. You will likely not hear about Sweden or Italy or France, and I promise you will never hear them talk about Australia. For them to do so would be to admit to defeat of their fundamental premise that universal health care can not work.
5. Failures of national health systems are not related to universality but instead are due to chronic underfunding by government. If the British spent as much per capita as we did, they wouldn’t have the shortfalls in manpower and beds that they do.

We will of course hear a lot of chest thumping from the thick-browed morons about how the US is already perfect and can not learn anything from the rest of the world. We will hear how every other system in the world is imperfect, and that is why any reform is impossible. We will hear how this will lead to communism and socialism despite the fact that every other industrialized nation in the world has universal healthcare and amazingly they didn’t all go commy. In short, we are about to hear a bunch of denialist garbage designed to delay, to obstruct, to block, and drag down any meaningful action in healthcare.

But before that happens, let’s have a more balanced discussion on what a universal healthcare system could look like in the US.

Any discussion of changes in the US medical system must begin with a statement of principles guiding reforms in the system. Let’s start with some of the principles I would include, and I think most of us could agree on:

1. Universality: The major obstacle currently facing US medical care is 47 million uninsured, a proposal for reform must begin with a plan for universal coverage. Access to primary care is cost-effective and must be the basis for a medical system designed to serve the needs of the populace as well as to serve as the gateway to specialized services.
2. Health Care Reform: Health care can not be sustained with expensive interventions, tests, drugs, inefficient administration, and treatment protocols which have limited evidence of efficacy. There would need to be a reform of medical practice, ICU and end-of-life care, compensation for medical errors and patent law to prevent excessive costs of drugs. Finally, an emphasis on “best practices” must guide medical intervention as health care must be based on the best available science in order to be efficacious and efficient.
3. Portability: Health care must be available to individuals regardless of employment status, is consistent with the mobile culture of the US population, and allow for easy sharing of medical information between providers.
4. Justice: Health care that is universal must also endeavor for just distribution of resources, and address disparities in health care.

Universal health care in the US faces obstacles of expectations of patients for high quality care, and excessive expense from high tech modalities and testing. However, an inexpensive baseline of care should be available to all consisting of primary care, prevention, and treatment of chronic conditions that will save costs by preventing over-utilization of ERs and emergent treatment of preventable medical conditions. Ideally, a government-administered insurance program would be created with a progressive premium structure based on individual income. Low income subscribers would be subsidized by the government based upon income similar to the Massachusetts system. Patients could either pay, based on a progressive scale, for governmental insurance plans tailored to individual needs, or opt out/expand their coverage using a private insurer. Governmental insurance, which historically has lower administrative costs, could then compete with private insurance to decrease costs at the same time high-quality care is provided. Universal insurance would also have the advantage of increasing the pool of subscribers. Requiring uninsured who can afford health care to buy into the system would help to decrease premiums overall. Further, it would test the accepted wisdom that privatization is superior to governmental programs. If the governmental programs are indeed superior, then they will naturally evolve to replace private insurance for most patients’ needs. Finally, a government-administered program would have the advantage of increased accountability through transparency and input through the political system to address inequalities and deficiencies in care.

Affordability of such a universal system is problematic in the United States considering the current cost of medical care in the US which is not currently commensurate with quality based on international surveys of medical systems. The major obstacles to affordability include costs of pharmaceuticals, cost of malpractice insurance, use and overuse of expensive imaging modalities, excessive costs of care at the end of life, and inefficiencies in medical administration increasing overhead costs.

The first step in addressing affordability would be reform of the patent system. Currently, drug manufacturers are able to patent drugs which don’t represent significant innovation over previous chemicals. Incentives must be created to restore a pattern of drug innovation in pharmaceutical R&D, and appropriate use of pharmaceuticals by the population. First, all direct to consumer advertising must be banned, as it is in all other countries, to prevent the irrational over-utilization of pharmaceuticals, disease-mongering by pharmaceutical companies, and promotion of more expensive brand-named drugs over more inexpensive, and sometimes superior alternatives. Second, the patent system must be reformed to create graded-levels of protection for new pharmaceuticals based on the level of innovation the drug brings to the market. New classes of drugs would enjoy the longest protection from generic competition (20 years). Sibling drugs would enjoy shorter protection (5-10 years), and preparations which are combinations of existing drugs (e.g. hypertensive combinations), purifications of existing drugs (e.g. Nexium), or using existing extended release technology will not enjoy patent protection and may be made by generic manufacturers.

Malpractice insurance is a source of great expense for physicians, increasing overhead and failing to resolve disputes between patients and doctors in a fashion that is satisfactory to patients, physicians and society. While lawsuits for negligence or misconduct should be allowed to protect patients from harm, lawsuits for expected complications and other negative outcomes of medical care that is standard of care should be discouraged. This could be done by creating victim compensation funds that are funded by a surcharge on medical care commensurate with the known risks and expected costs of complication of medical interventions. Thus when more complicated and risky procedures are performed, the expense of insuring for negative outcomes would be built into the cost, and access to the compensation fund would then require a patient to waive their right to pursue compensation in court. This would help shift the burden of cost of medical complications off of doctors and the legal system, decrease costs by avoiding expensive litigation and legal fees, and prevent adversarial interactions between patients and the medical system.

ICU and end of life care is a leading source of waste in medical expenditures, but reform is complicated by the inability to predict when medical care is truly futile, and issues of equality and justice in the provision of medical care. However, significant reductions in overuse of medical care at the end of life could be obtained by increased patient education, the requirement of patients in a universal system to provide a living wills, and better adherence to evidence-based guidelines in ICU care. Unfortunately, extended ICU stays and aggressive interventions at the end of life have become a routine part of the process of dying. Public education about the reality of end-of-life care could create awareness of the invasiveness, pain, cost and frequent futility of extensive ICU stays. While many patients feel it is their obligation to “do everything” for their loved ones, a better understanding of the pain, indignity, and reasonable expectations for improvement involved in intensive care may help people avoid medical interventions that are futile. Further, a universal health care system, combined with the electronic medical record, will allow for universal application of living wills, and more time for patients to discuss with their physicians and decide what kind of interventions they want at the end of life.

Higher emphasis on evidence-based guidelines on the efficacy of interventions in different populations will provide physicians with higher quality information on when medical care is appropriate or futile in the treatment of patients near the end of life. Universal healthcare, and electronic medical records, will facilitate the collection of such data, and help ensure its application in ICUs. However, physicians also have a professional responsibility to decrease useless and redundant testing and prevent overuse of expensive imaging modalities when the results will not impact treatment decisions. This must not be accomplished using the current insurance company method of creating punitive paper work or peer consultation that places physicians in the position of begging for permission to use their medical judgment. Instead, guidelines on when imaging modalities and labs are appropriate and useful must be generated and physician use or overuse of resources should be monitored with possible remediation if poor use of resources is suspected.

Importantly, a standardized, universal electronic medical record (EMR) must be created that will allow physicians to easily share information, protect patient confidentiality and maintain integrity and high information quality. The government does not need to mandate a single front-end service to access such records, but, a panel of medical and software engineering experts should be convened to decide on a universal standard for storage of medical information in a single database. A record must be designed that would allow multiple programs to interpret the records so a competitive market of software designers could create a variety of efficient and user-friendly systems, differential access based upon need to access the information (administrators and insurers would have limited access to private data, physicians full access), and a high-level of data encryption and protection of private information, a high level of data integrity (a tiered system of access for correction/modification of the record to prevent errors). This is similar to the successful model previously used by the government for the searching of SEC records by law firms using private software such as that designed by Thompson, Lexis, and EDGAR to access a government database with uniform record design. Finally, this record must be transparent and programs designed for the records must agree to be open access as “there is no security in obscurity”. EMRs, well-applied, would decrease the cost of medical administration, decrease overhead, prevent errors, allow for better data-mining for scientific study, and make transfer of information between providers more efficient.

Portability of medical care must be ensured as the culture of the US is highly migratory. Not only do US citizens typically change jobs frequently, but they rarely stay in the same state or region of the country for their entire lives. Medical care must be ensured despite employment status, or region of the country in which the patient lives. The EMR is critical for portability, as is universality.

Finally, the principle of justice must be applied to medical care as the United States still struggles with inequalities among healthcare for its citizens related to race, sexuality, and poverty. Provision of care must be decided based upon science and evidence, but also must be monitored for just allocation of resources, and disparities in access and quality of care. The nature of political systems is to reward those who are politically powerful. In this country that would tend to generate a system designed to benefit wealthy, older, white men. Thus before a system is even implemented it must be studied for the differential impact of resource allocation for women, minorities, homosexuals, and immigrants. One must approach the application of medical care with the realistic expectation that inequalities will inevitably be built into the system. Such inequalities must be constantly sought out and corrected, ideally with an independent panel of experts consisting of physicians, legal experts, bioethicists, and community leaders that will monitor and address such inequalities when they arise, not if they arise.