Welcome Back to Denialism Blog

Despite rumors to the contrary, I am not dead. Instead I’ve been working hard as a new surgical intern and sadly not finding the time to write for the denialism blog. However, now more than ever, it seems that we need to talk about the problem of denialism.

Two major new issues for denialism have cropped up, and both are major new forms of political denialism. The first, I’ll broadly describe as Obama-denialism. Obama is a muslim, Obama was not born in the US, there is a giant conspiracy involving the Hawaii Secretary of State, the Democratic Party and muslims worldwide to take over the US government with a madrassa-trained presidential double agent etc. These are of course nonsense. FighttheSmears a website created by Obama supporters has most of the more ridiculous rumors debunked, including the absurd birth certificate/birther conspiracy theory. appropriately mocking LA Times blog entry. Whatever. As readers of denialism blog, it should have been clear from the get-go that this is just the usual conspiracist-drivel propagated by people who are upset at having a black president, and, just like the truthers, holocaust deniers, AIDS denialists, or any other group driven by racism, paranoia or just plain stupidity they won’t be satisfied by any evidence that contradicts their illogical conclusions. The format of the arguments is prima-facie absurd. The conspiracies are non-parsimonious, and lead immediately to more questions that just don’t make any sense. Despite this, bigots and crackpots like Fox News and Lou Dobbs “cover the controversy” to keep it stirred up. We must address it for what it is, closet racism and sour grapes over losing an election.

The second major issue, even more distressing to me now that I’m fully immersed in our health-care system, is that of universal health care denialism. Most upsetting to me was pronouncements like that of Sarah Palin that health care reform will lead to “death panels”. This is where the political opponents of progressive governance have crossed the line from the usual political ignorance and lies to truly despicable tactics designed to sink health care reform at any cost. The reality of the language originally in the bill was that it was designed to encourage physicians to have end-of-life discussions with their patients by paying them for such consultations. This is an area in which our health system currently fails miserably to the detriment of our patients. We truly need to have all patients interacting with our health system to have frank discussions about their wishes at the end of their lives, to have living wills, and make their desires for their level of intervention clear before they end up in the ICU, on a ventilator, and having invasive treatments performed ad nauseum that they may or may not approve of if they were able to communicate their wishes. But no, the political opponents of health care reform have instigated a scorched-earth policy, and even something as noncontroversial as asking people what they want their physicians to do when they’re sick has been thrown under the bus by the denialists. Other lies? Universal health care reform will turn us into communist Russia! A belief inconsistent with the fact that every other country in the industrialized world has survived the conversion to universal systems without requiring Stalinist dictatorships to enforce the dastardly public option. These arguments transcend mere denialism and can only be described as ideological insanity.

There is a legitimate debate to be had over health care, but we clearly are not having it. One legitimate question is how do we pay for it? I’m confident that reform will pay for itself and it is more expensive not to have universal access. As we discussed in our health care series, every other country in the world has accomplished this feat, provide equivalent or measurably better care in terms of access, health of populations, and life expectancy. Despite their universal coverage they all spend less than half as much per capita than the US on health coverage. Having people access the system in our ERs, lacking preventative care, and failing to provide the universal inexpensive interventions costs more than just providing care to people. After all, we already pay for the uninsured, hospitals and doctors are ethically obligated to provide care for everyone who walks in the door, insured or not. The costs of covering the uninsured are already built into our excess costs. Worse, having a administrative system designed to deny care is costly and unnecessary. The “privatization” or “subcontracting’ of medicare administration under Bush increased the cost of healthcare administration by 30% in three years despite the number of patients covered increasing by only about 4%. Paying for things in a planned, thoughtful and systematic way is cheaper than allowing problems to stew and boil over. I’ve already had way too many patients showing up in the ER with disastrous and expensive health problems requiring a huge expenditure of resources that if they had been addressed early would have cost next to nothing. And yes, they always tell me they didn’t get it addressed before it was critical because they lacked insurance. This is stupid and not the kind of care I want to be providing. Another legitimate question is will universality damage our technological and research prowess? Again I believe the answer is no. The US has excellent technology and research because we pay for it through government agencies like the NIH. The technology won’t go away because that has more to do with the culture of our healthcare system than the fact that we have oodles of money to pay for it (because we don’t really). It’s also not a fact that our technology necessarily makes our care better. CT scans, and MRIs are not as important to provision of health care as having ready access to services and adequate access to primary care physicians and preventative care. Another good question, is a public option necessary? Again I believe not. While I believe countries that provide a public option like Australia are ones on which we may model our system, other countries such as the Netherlands or Germany have developed excellent healthcare systems through insurers by tightly regulating them and not letting them screw their citizens. Here’s a great question, would anyone under these systems choose the US one? As evinced by the commentary from our health system, the critics of universal healthcare are speaking from ignorance when they claim citizens of other countries are suffering in their systems. The data we presented, and reinforced by commentary from all over the world, was that these systems have problems, but no one in their right mind would trade them for the US system.

Let’s get back to having a public debate that is not overwhelmed by the ideological fanatics and deniers and instead focus on the very real and critical problems that this president was elected to address. The denialists and their scorched earth tactics have done a great deal of harm to our debate on reform. Now more than ever, we need to talk about the difference between denialism and debate.

The Obama Plan – Part I

We’re starting to hear about how Obama intends to implement healthcare in this country.

President Barack Obama says he’s open to requiring all Americans to buy health insurance, as long as the plan provides a “hardship waiver” to exempt poor people from having to pay.

Obama opposed such an individual mandate during his campaign, but Congress increasingly is moving to embrace the idea.

In providing the first real details on how he wants to reshape the nation’s health care system, the president urged Congress on Wednesday toward a sweeping overhaul that would allow Americans to buy into a government insurance plan.

Obama outlined his goals in a letter to Sens. Edward Kennedy, D-Mass., and Max Baucus, D-Mont., chairmen of the two committees writing health care bills. It followed a meeting he held Tuesday with members of their committees, and amounted to a road map to keep Congress aligned with his goals.

The letter published at whitehouse.gov, lays out some basic ideas, but it seems as though Obama is willing to have congress work out the specifics.

Let’s go through his recommendations and talk about the implications.
Continue reading “The Obama Plan – Part I”

What is health care like in the UK, Canada and New Zealand?

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Three systems widely cited as examples of universal health care are the so-called single-payer systems in the UK, Canada and New Zealand.

These systems I would describe as “socialized”, and rely for the most part on taxation for funding. The system in Canada for instance, uses taxes to pay for health care administered by the individual provinces, and provided by a mixture of private and public hospitals and health care providers. Private health care is restricted in Canada, but is available in some provinces under publicly-funded private organizations called P3s. Private health insurance is limited in Canada but is available.

The UK’s National Health Service (NHS) similarly uses taxes but 8% of their population still utilizes private insurance to augment their national health care services. Services from the NHS are entirely free of charge for residents, and prescriptions have a nominal fee regardless of the cost of the medication. The government is the primary employer of health care professionals, and general practitioners (GPs), act as independent contractors employed by the NHS who serve as gatekeepers into the health system. A GP manages your health care and decides if you can see a specialist.

The New Zealand system is more decentralized with funding of community health boards to serve the needs of the population, primary care since 2001 has been subsidized by the government through Primary Health Organizations designed to allow broad access to primary care for a nominal fee and hospitals and other health services are funded through taxation. They also have a single payer drug service to subsidize prescription drugs and users pay a nominal fee for prescriptions.

How satisfied are patients with these systems, and what is their quality of care?
Continue reading “What is health care like in the UK, Canada and New Zealand?”

What is the cause of excess costs in US healthcare?

The question has come up again and again in our discussions on health care in the US and around the world, why does it cost so much more in the US when we get so much less?

The drug companies and their lobbyists are already out in force trying to make sure their pocketbooks aren’t hit by the inevitable reforms that are coming. In particular they insist drugs aren’t the problem in the US, it’s administrative costs! I would tend to disagree.

Based upon my experience working in the sytem, the main causes of excess costs I would hypothesize are the following (in order of importance):

  1. An excess of cost in administration far out of line with most countries around the world.
  2. Pharmaceutical costs – especially due to the effects of direct to consumer advertising (DTCA) encouraging use of more expensive, newer drugs (which is only allowed in the US), Medicare part D which forbids collective bargaining for lower drug prices, and a broken patent system that allows drug makers to patent and charge more for non-novel medications.
  3. The absence of a universal system that prevents risk-sharing, and causes the uninsured to avoid treatment until problems are more critical, and more expensive.
  4. Excessive reimbursement of physicians for procedural skills, rather than cost-saving physician roles such as primary care and family practice that emphasize early diagnosis and proper management of disease.
  5. Excesses of cost caused by “defensive medicine”. While torts themselves don’t cause a great deal of monetary damage, the culture they create is one of paranoia in physicians who make decisions with lawsuits in mind, rather than the interests of patients and society
  6. The excessive costs in ICU care, especially at the end of life, which may also be reduced by better EMRs with recording of living wills, and public information campaigns designed to inform people about the pain, invasiveness and futility of “doing everything” in the elderly.
  7. The absence of an electronic medical record that is universal which causes redundancy in testing as patients see new doctors who then order redundant tests because sharing of information is so inefficient.

But these may just be my biased views based on my own limited experience. Let’s see what the data show. The McKinsey Global Institute has generated a report on this, and has broken down the data according to the individual costs in our system, while comparing it to that of other countries.

Continue reading “What is the cause of excess costs in US healthcare?”

What is health care like in France?

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Here it comes. How dare I suggest the US could learn anything from France? By most assessments France provides the best health care in the world, with excellent life expectancy, low rates of health-care amenable disease, and again, despite providing excellent universal care, they spend less per capita than the US. Using about 10.7% of GDP and about 2000USD less per capita than the US they are providing the best health care in the world. To top it off, France’s system isn’t even socialized. That’s right. It’s yet another system that is a mixture of public and private funding that, if anything, provides the greatest level of physician and patient autonomy in making health care decisions. It is not, I repeat, not a single payer system. Doctors are largely self-employed, there is no big government authority telling doctors and patients what to do, just a progressive tax structure and requirements to pay into the system that fully subsidizes a functional healthcare system.

Start with the Wikipedia entry, if you can stand to read it try the WHO document on the structure of the French system, or various articles which all seem to agree the French system rocks. The few criticisms stem from it’s relative cost compared to the other European systems and perhaps overutilization by citizens. But no one asserts that it provides poor care, that it rations care, that it limits doctor or patient autonomy, or has poor resources.

As with most health care systems, the more you read about it the more you see how the system reflects the values of the country. But these should be universal values.
Continue reading “What is health care like in France?”

What is healthcare like in Germany?

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What better argument for universal health care can you make than that of Germany? By far one of the most successful systems, it has had some form of universal health care for almost 130 years, and is currently one of the most successful health care systems in the world. It is again, a mixture of public and private funding, with employers providing most of the funding for health care by paying into one of several hundred “sickness funds” that provide health care funding to their employees. Germany is widely regarded as having excellent access, short wait times, care with the best technology and pharmaceuticals available, and this again while spending 10.7% of GDP (US 16%) with per capita spending of ~3.3k USD (approximately half of that in the US).

The German health care wikipedia entry is a good starting point, and it’s always fun to try to translate German web pages and try to make sense of Google translations. But I’ve found several good articles describing the system including several articles in the MSM like this NYT piece which refers to Americans as having an “… immature, asocial mentality [that] is rare in the rest of the world,” one for travelers, and one for those looking for German jobs. The consensus seems to be that Germany rocks when it comes to health care.

Let’s talk about how it performs and how it works.

Continue reading “What is healthcare like in Germany?”

What is healthcare like in the Netherlands?

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The Dutch really have it together on health care, they have a system that has been proposed as a model for the US to emulate. In stark contrast to many other European systems, it’s actually based entirely on private insurers, rather than a single-payer or entirely national system. Yet the Dutch system is universal, has far superior rates of satisfaction with quality of care and access, and still costs a fraction of what we pay for health care per capita in the US. How is this possible?

You can read the Wikipedia entry on the Dutch system or read about it on their Ministry of Health’s English webpage or watch the short film on their reforms below.

So, how does the Dutch system work?

Continue reading “What is healthcare like in the Netherlands?”

What’s health care like in Australia?

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To start off some balanced discussions of what universal health care looks like around the world, I thought I would begin with Australia, a system that we could learn a great deal from.

In the US system, we do not have universal healthcare, we have mostly employer-subsidized healthcare, private insurance and medicare covering people’s health expense. We also lack a universal electronic medical record, our main recourse for responding to poor care is lawsuits, and we have a high disparity in services available to those with money and those who do not. We still manage to spend more on health care per capita than any country in the world, while being ranked 37th in the world by the WHO, 72nd in the world for healthiness of its citizens, and 19th among industrialized countries (last) by the Commonwealth fund. We have a very poor infant mortality rate, which is only partially explained by our willingness to treat more premature infants than other countries, and is mostly a result of poor health care infrastructure in several of the poorer, Southern states.

Australia’s system is not too fundamentally different from the mixture of employer and public based funding found here in the US. An outline of the health system is available from the Australian government and the Wikipedia entry is here. It’s spends about 8.8% of GDP on health care, compared to the US at 15.3% based on 2007 OECD data (or 9% and 16% respectively according to the Commonwealth fund data). Of that, about two-thirds is public, one third private expenditure. Let’s take a closer look…

Continue reading “What’s health care like in Australia?”

Are Patients in Universal Healthcare Countries Less Satisfied?

ResearchBlogging.orgA dishonest campaign has started against healthcare reform in this country and the first shot has come from Conservatives for Patients Rights (CPR), a group purporting to show that patients in universal health systems suffer from government interference in health care. To bolster their argument, they have a pile of anecdotes from people around the world who have suffered at the hands of evil government-run systems. The problem, of course, is that anecdotes are not data, it is impossible to determine the veracity or reasonableness of these claims, and there is no way, ethically or practically, to respond to claims against doctors in these systems.

And should we be surprised? Every other country in the industrialized world has universal healthcare. Some are government run, single payer systems, others are mixtures of private and public funding to guarantee universal coverage. I would be shocked if you couldn’t find a few people to provide testimonials about how they’re angry at their coverage. After all, Michael Moore made an entire movie about such testimonials against our system.

So what do we do? How do we find out the truth when the ideologues and financially interested parties have started a campaign to muddy the water with anecdotal attacks?

We look at the data of course. And surprise, surprise it doesn’t support CPR’s assertions that our system couldn’t stand some improvement.

During the next couple of weeks, I think we should talk about what healthcare looks like here in the US and around the world. Rather than a few horror stories, let’s take an in-depth look at what’s happening in universal systems, and whether or not we should consider a change.

Let’s start with an examination of some data from the literature on different experiences people have with these healthcare systems.
Continue reading “Are Patients in Universal Healthcare Countries Less Satisfied?”

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:
Continue reading “What should a national health care system look like?”