Political expediency versus the population’s need

One of the reasons that services such as healthcare are hard to reform in a political context is that politicians feel they need to produce quick results for the electorate.  This political fact always gets in the way of producing long-term workable solutions. Change in large systems does not occur overnight. Nor does it occur within a four year presidential term. Unfortunately, appropriate solutions are frequently overlooked so that measurable, but inappropriate, progress can be shown to voters.

Healthcare delivery is not the same as producing cars on a production line. You can’t shut down the delivery pathway, retool and prepare for a new model in the same way that Ford or GM would do in one of their plants. Also, the very nature of health care being delivered at a local level to defined and small group of the population makes it incredibly difficult to standardize all aspects of that patient pathway. This inherent flaw produces in places such as the United Kingdom a postcode, or in the United States a zip code, lottery  in terms of the quality and quantity of healthcare delivery.

In the United Kingdom there are measurable differences between differing geographic areas and the quality of the health care they provide. There is also measurable differences in the way that those areas ration healthcare based primarily on budget constraints and not necessarily efficacy or clinical need.

In single-payer systems there is also the issue of the two-tiered provision system. You can see this in both the Canadian and UK systems. In the case of Canada many thousands of people who paid for their healthcare through the national health care tax, seek routine care that they have to pay for themselves across the border in the United States. They pay for that care twice. It could be argued that if they had waited the one or two years that is required to access certain procedures then they would’ve avoided this unnecessary expense. In the UK you see private provision sitting adjacent to national health service facilities. As I’ve outlined in previous posts the people who provide services in the private facilities are the same people that provide the services and the NHS. Again, people who have the disposable income to jump the line by paying for private procedure can have any, hip or cataract procedure done in a matter of weeks and not months.

This begs the question; are we prepared to replace one two-tiered system with another? Interestingly, the replacement will flip on its head the perceived inequality that currently exists in the United States. What we will have is a system where the very rich will exist outside of a government-sponsored, run and provision health system, and the majority will be forced to accept a lower standard of care than they were used to in the past.

The debate until now, has centered around the overall cost of health care. I hear little about what the contribution of our health system is the country’s GDP. I also, and I suspect the politicians don’t understand it either, don’t have a clear view as to what the national clampdown on health spending will do to the real economy.

Political expediency is a dangerous phenomenon. Near-term decisions are made about long-term needs. I’m not suggesting that changes in policy and the reforming of systems by politicians is done cynically and only for political gain; but the reality is their world is one where quick wins and the appearance of making a difference is far more important than creating a long-term and sustainable program of reform.

In the United States we tend to avoid severely polarized politics. In the United Kingdom change of government has typically meant that the new incoming government completely dismantles the reforms of the previous one. Therefore, change, or the lack of change, centers around superficial and cosmetic attempts to affect reform. It would appear however, that the United States Congress has never been more polarized on the issues. If one thinks back to 1994 and Hillary Clinton juggernaut that was bearing down on the health system at the beginning of Bill Clinton’s presidency, drawing comparisons to the Obama plan are hard to avoid. You have an administration who is dedicated to reforming the system, not only a reform, but a complete change in the way that health has been delivered and paid for in the United States. Without dialogue and providing salient argument around why such a wholesale change to the most personal of all services provided to voters is needed, Government will only ever fail to carry the day.

Partisan politics is not a good foundation for change in such a sensitive area. Neither is a highly skeptical and worried, if not scared, population. The new president has embarked upon a journey and appears to have left behind him the majority of the American population. Until there is a coherent argument and a well thought out plan as to how and why a system, however flawed, must be changed to the extent that he is suggesting currently, I can only see failure in his future.

Americans have every right to be skeptical of the proposed changes. You can look around the world compare our system with others and yet, if you are seriously ill whether insured or not, the United States still remains the best place to receive care. In Other government controlled health systems, waiting for care or the inability to access that care kills people. If you look around the world you don’t see foreigners, unless they are poor, flocking to European publicly delivered health systems. What you do see are are people attending the private clinics of London, Berlin, Zürich, and those of the United States.

I’m not sure if there is a specific solution to the “crisis” in American health delivery. I’m also unsure as to the extent of the crisis. The noise around the overall cost of the delivery of healthcare in the United States is always loudest during economic downturns. The American system covers its citizens through insurance products that are primarily paid for by business, and understandably businesses when times are bad are looking at ways of cutting costs. Business however should be very careful around the current suggestions for the reform of the system as this will only add significantly to their tax burden. As I’ve said before, to suggest that the government will be a better steward of health delivery then insurance companies is folly and a lie.  What we will end up doing is creating many further layers of bureaucracy which will only add to cost, it will erode access, it will impact adversely quality, and most importantly it will put into government hands one of the largest industry in the United States.

Filed under: Government Policy , big government, cost, government, healthcare policy, healthcare quality, healthcare reform, innovation, intervention, nationalized healthcare, obama, rationed care, rationed healthcare, underinsured, uninsured

Healthcare Reform – Proceed with Caution

I spent the best part of five years at the UK’s Department of Health. Most of that time was spent on its board. While I was there, along with my colleagues, implemented the governments healthcare reform. The central theme of the government’s reforms was to create a plurality of provision within a monolithic health delivery system. This had been deemed necessary because over a period of years the NHS had been underfunded and had become a relatively underperforming system.

The Labour government had correctly, in my view, identified that broad and sweeping reforms to Britain’s public services were not only needed but had become a necessity if the United Kingdom was to remain a global player and not slip into the role of little remembered imperial power. The Labour Party, under the leadership of Tony Blair, had correctly identified that people were becoming consumers of public services and were demanding more for their money. No longer could a government be seen to ignore, minimalize, or try to explain away the push towards accessibility and choice in the public provision of services and expect to remain in power.

The Internet and international travel had forever changed the British landscape. Assessments of services provided by the government were no longer based on speaking to a neighbor or possibly bumping into a friend from another area of the United Kingdom. Comparisons were now being made with other countries in Europe, and indeed, other countries on different continents. Just in the same way that competition had clearly been injected into the traveling British public their knowledge and ability to choose had become the burning platform that could undermine services such as the national health service.

The Labour government of the time firmly believed that if they did not address this lack of choice, accessibility and need to improve quality of services that services like the NHS could easily become a poor service for poor people. To some extent this two-tiered delivery of care already existed. Alongside the NHS sat private providers who sold their services to the monied few based on the ability to access that care quickly and the perceived/real improved quality they claim to deliver. Interestingly, the same doctors, nurses and cleaning staff that worked in the NHS also worked in these private facilities. The disparity between the private sector and public sector had not gone unnoticed by the government. Data showed that in the case of cataract surgery the private sector during a measured period of time did on average four times more procedures than did the public sector. Before Labour took power they had been courted by the unions associated with the NHS and told, “if only you would leave us alone and give us more money” we would become far more efficient and provide better care. The reality had been that in the absence of competition the NHS had digested the money and shown little or nothing for the extra cash.

By 2001 the Labour government had come to the conclusion that in the absence of competition the NHS was likely to never change. They also had concluded rightly, that there had been significant underfunding and that the NHS needed a substantial injection of cash. Along with the largest increase in cash ever in into the NHS system, the government also mandated that there was a need to inject competition into the service so as to change the systemic weaknesses of lack of productivity, inward facing instead of client facing behavior, and little innovation.

To help with access and waiting lists issues unprecedented numbers of new doctors and nurses were added to the NHS headcount. The private providers were injected into the system through programs such as the Independent Sector Treatment Center Program, the choice agenda were patients for the first time were given a choice of both NHS and private providers still free at the point of service. Foundation trusts were created so that more autonomy was given to providers and policy was created that created a payor/provider split in the system..

The NHS reforms are still ongoing. Unfortunately, the current crop of ministers have allowed most to stall. There appears to be little political appetite, and most importantly knowledge, that the path they began down almost a decade ago was the correct one. It is much easier politically to appease than it is to change. There are very few politicians that have the backbone to continue what they started when confronted with the inevitable noise that will be generated by self-interest, especially when it comes from the members of the worlds third largest employer not to mention, largest group of voters in the UK. There is little doubt that reform of the NHS must take place if the United Kingdom is to offer itself up as an international player on the world stage, or even more fundamentally, keep within its borders the highly mobile professional class that adds so much to its GDP.

This brings me on conveniently to the debate in the United States around health reform and what that reform should look like. Interestingly, there’s been much commentary from the United States with respect to the quality of care received in the UK health system. Commentators are picking the worst examples from the UK system and playing them back to the American people as a reason not to follow the UK’s path. This however is not a new phenomena. UK politicians of both parties have for years, as has the NHS, used the United States health system as a reason not to reform our own. It is frequently pointed out, in a less than sophisticated manner, that there are 40,000,000+ people uninsured and the United States of America, and that the cost of healthcare in the US is the highest on the planet. Frequently, the question is asked “do you want a system like that?” Understandably, now that the debate on health reform is alive and heated on the other side of the Atlantic, the NHS being used as an example of what not to wish for in the United States.

At a time when choice has become the mantra for change in UK public services, the United States is exploring a path that would appear ultimately take it towards top-down provision of health services. A larger role by government in how health is delivered and rationed. There are many issues with the US system if you use life expectancy as a measure of effectiveness in the United States, it is shorter than many European countries. Demographically however, the United States is significantly different still two its European cousins. They’re also variations in how mortality is measured, and because the United States has done little to reduce teen births and the use of drugs, the US has the highest rate of underweight births in the Western world. There is also the myth that if you are uninsured or underinsured in the United States you will not be treated as just that, a myth. Federal law makes it quite clear that dumping patients will not be tolerated and potentially can put the perpetrator and the prison for up to 10 years. I think most people would agree this is a fairly strong deterrent.

Having spent a number of years with a government that was trying to distance itself from the provision of healthcare directly, it is almost surreal to watch the bastion of capitalism, the United States, travel back down the road of top-down government intervention. There is little doubt in my mind that this is a route fraught with danger and will ultimately leave us with a mess larger than the one we have now. Universal coverage should be a right. Whether Medicaid is the right product to effectively close this gap, I’m not qualified to say but I can say that rationing will not solve the problem either.

There is however one thing I’m sure of; government intervention never increases quality, productivity, innovation, or choice. Those countries with monolithic systems are trying their best to change them. Americans, even in the face of very high priced health care, have asked themselves is a decrease in quality, choice and innovation something that they will trade for lower priced health care. I would also argue that the government will not be able to decrease the price of healthcare. It will only serve to layer an onion that it says is far too big already.

Filed under: Government Intervention , cost, government, healthcare reform, innovation, intervention, nationalized healthcare, obama, quality, rationed care, rationed healthcare, underinsured, uninsured