Canada vs. U.S. Health Care: National Governance Reform – HHS, FDA, NIH, CDC.

Posted on | March 11, 2017 | 2 Comments

Mike Magee

As we have seen, America’s health care system – disintegrated, opaque and heavily conflicted – didn’t just happen. It is the result of thousands of conscious decisions over nearly a century. Choices made have tipped the scale toward intervention, technology, and medicalization at every turn. Peggy Noonan suggested this week that Paul Ryan’s bill will likely hyper-accelerate income disparity which she highlights as the most pressing threat to American democracy. Granted, that’s depressing.

But strangely enough and contrary to prevailing views, I remain optimistic for three reasons. The first is that we already expend more resources than necessary to lead the world in health performance. The silver lining of our remarkably inefficient delivery system is that we need not raise additional funds but simply reallocate them. After all, we expend just under $3 trillion a year on health care.

The second encouraging finding is that the pathway to solutions involves less complexity, not more. This is primarily an exercise in governance and editing. Our comparison with Canada reveals obvious course corrections that, until now, we have avoided. We currently lack a concise, long-term plan for a healthy America.

Finally, the MIC’s power and influence derives from secret collusion, limited checks and balances, and an integrated career ladder, all of which are amenable to policy corrections. Segregating research/discoveries from education and patient care will take us 90% of the way. Transparency and appropriate independent checks and balances should do the rest.

So let’s take a critical look at our current organizational assets – first national with state to follow.

Guilds and Unions:

Our nation is rich in guilds and unions that represent segments of our health care sector. They are interested foremost in advocating for their members financial needs and privileges. And there is nothing wrong with that. Foremost among the group are the AMA, ANA, AHA, PhRMA, AHIP and their distributive federation members. Add to these players multi-focused organizations like the AAMC which sees itself as the champion of post-Flexner quality medical education, but has yielded considerable high ground to its own Council on Teaching Hospitals and Health Systems which primarily seeks federal research and education dollars with few strings attached. Then there are the historic non-profits like the American Cancer Society and the American Heart Association, and the more recent collection of industry funded advocacy organizations.

These bodies need to play a critical participatory role in the provision of care. But it is important to recognize that they are neither independent nor an adequate substitute for an official national body to guide our health care future.

Governmental Entities:

America has a range of governmental bodies that have developed and evolved over the past half century. In general, they lack clarity, focus and long-term visions, and have long ago lost their independence. Rather than being planned deliberately, these bodies have “happened”, usually in response to crisis or politics.

FDA:

The FDA’s three major evolutions – the 1906 Food and Drug Act, the 1938 Federal Food, Drug and Cosmetic Act, and the 1962 Kefauver-Harris Drug Amendments – were all in response to tragedies, namely tetanus-laced vaccines, childhood deaths from antifreeze tainted sulfonamide elixir, and thalidomide.

In the mid 20th century, free-marketers used “Red” baiting” and the Soviet Sputnik lead in space to bolster charges of a U.S. “drug lag”, and to justify green-lighting new drugs to the market. The late 1970’s recession offered another opening for industry intrusion. Today that push is on again, and yielding the same questionable results – for example, the use of “golden vouchers” to push generics with stratospheric prices. Through it all, the creation of new “diseases” and intrusive professional marketing of cures for these maladies has reinforced physicians and patients addiction to drugs and quick fixes.

NIH:

The same players who have infiltrated the FDA do double time on Advisory Committees and Foundations at the NIH. The NIH, strangely enough, owes its odd existence as a conglomerate of “Institutes” to two middle-aged women philanthropists, Mary Lasker and Florence Mahoney who with the help of their fabulously wealthy PR/Media magnate husbands first staged a takeover of the American Cancer Society in the late ‘40’s, replacing its doctor Board members with New York City businessmen, and then pushed through an unprecedented federal infusion of cash into “research institutes” whose purposes matched their own parochial interests.

To pull off this feat, they engaged academicians, who in later decades would be called “thought leaders”. As the NIH grew, it remained true to form – medicalized and specialized – a career escalator.

Today you will find descendants of Mary and Florence on NIH Boards, funding colloquia, and attending government/industry/academia galas hosted by Research America! and Friends of Cancer Research. Genomics, Precision Medicine, and yet another “War on Cancer” are today’s darlings – again, fine. But from a national health governance standpoint, it would be a huge mistake to confuse scientific progress with human progress.

HHS:

And then there is the Health and Human Services Department or HHS. Way back in 1798, our early leaders were worried about sick and disabled seamen. They passed an act and funded their care. That was the early beginnings of what became the U.S. Public Health Service. A half century later, President Lincoln launched the Bureau of Chemistry within the powerful Agriculture Department. As the new century approached, the focus was on immigrants and communicable diseases. We had the National Quarantine Act of 1878 and a one room research lab set up on Staten Island a decade later.

The Flexner medical education reforms would come and go before the single “National Institute of Health” name was placed on the Public Health Service’s Hygienic Laboratory in 1930. In the middle of the Great Depression in 1935, we passed the Social Security Act, and a decade later created the CDC. By 1953, it seemed time to consolidate. So Eisenhower created the Cabinet-level Health, Education, and Welfare (HEW) Department.

When a separate Department of Education was created in 1980, HEW became the Department of Health and Human Services. By then we had Head Start, Medicare, Medicaid, funding formulas for medical education, Community Health Programs, the National Health Services Corps, a National Cancer Act, and a Health Care Financing Administration (HCFA) to manage Medicare and Medicaid separate from Social Security. After that came AIDS, DRG’s, HMO’s, Organ Transplantation, Health Care Policy and Research (now AHRQ), Ryan White, Nutritional Labeling, the Human Genome Project, HIPAA, SCHIP, the Centers for Medicare and Medicaid (instead of HCFA), Medicare Part D…and on and on.

So you see what I mean. Canada planned its health system. Our’s just happened. Our major bodies now under HHS include the FDA, NIH, and CDC. They are non-transparent, MIC infiltrated, expansive, expensive enterprises. They scream for editing and focus.

Shuffling The Deck:

FDA needs to drop the gimmicks, focus on risk/benefit, and eliminate from its advisory and evaluative bodies any individuals with financial conflicts. Period. Do your job. Make sure our drugs are safe and effective. You are not an agent of industry. Attention Scott Gottlieb: Nowhere in your job description does it say “Make the American pharmaceutical, biotech and medical device industries great again!”

CDC needs to admit that there is more to creating a preventive health care system than adding an initial to your name. The Centers for Disease Control and Prevention is good at infectious disease, food borne pathogens, environmental health, occupational safety and health. Their Epidemic Intelligence Service is the best in the world. But agents in the transformation of U.S. health delivery from intervention to prevention, they are not. Programs like “winnable battles” which focuses on a few issues like obesity feel like add-on’s at best, and have yielded spotty results. Better to split off Prevention, bump it up, and give it some real resources and status.

NIH needs to own its “for-profit” status. You have become a national gold mine for innovative, transformational medical science and entrepreneurial marketable ideas. And that’s just fine. We gave you Bayh-Dole and along with collaborators in industry and academic medicine, you’ve mined it brilliantly. Keep up the good work!

But from now on your grants can only go to “for-profit” arms of the non-profits and will be taxable. That’s only fair since the recipients get to keep the profits and patents derived. Let’s be transparent here, and call your multi-sector collaboration what it is now – an engine of American industry. As speculative scientists, don’t complain that our checks and balances to protect the public from oversteps in pursuit of fame and fortune will treat you as business rather than health professionals.

With those new rules, we’ll trust that at least some of the valuable scientific progress you uncover will lead to broad human progress. Also, stop asking for more and more money. Your partners in the “for-profit” arms of academic medical centers and industry can help your budgeting and prioritizing better than the descendants of Mary Lasker.

HHS? You need to proceed on two fronts if the U.S. is to reach its’ health delivery potential. First, re-focus and re-form the CDC, NIH, and FDA as I’ve suggested above. Second, create a consensus national vision and guiding principles for our nation’s health, and appropriately organize and resource prevention. In this regard, Health Canada (their version of HHS), has a piece titled “Health Canada – a partner in health for all Canadians”. It’s worth a read.

And what are the states’ responsibilities? That’s next.

Comments

2 Responses to “Canada vs. U.S. Health Care: National Governance Reform – HHS, FDA, NIH, CDC.”

Karl Polzer
March 13th, 2017 @ 9:28 am

Another excellent piece. posted to http://www.inequalityink.org
Mike Magee
March 13th, 2017 @ 10:30 am

Thanks, Karl. Next stop – states and Medicaid.