Price-Less: Make America Red Again.

Posted on | March 21, 2017 | Comments Off on Price-Less: Make America Red Again.

Mike Magee

In the weeks ahead, we will see how far backwards our health will slide under Republican leadership. In the President’s budget proposal this week, we see that he doesn’t care much for the EPA. Juxtapose that with this week’s BMJ study revealing a link between global warming and rising rates of diabetes. “Fake News?”

OK, then let’s try another. In September, 2008, feisty Republican candidate for president, Sarah Palin, took some heat for installing a tanning booth in the Governor’s Mansion in Alaska. Tanning beds were big business back then. There were 25,000 plus tanning salons in business at the time, with 160,000 employees and 30 million customers spending $2 billion a year.

Skin cancer rates were soaring. At the time, the AMA called for three simple and reasonable steps to bring about change. Number one, tanning booths should be off-limits to those 18 or younger. Number two, the FDA should conduct hearings to weigh-in on risk and the need for increased regulation. And number three, booths should come with a Surgeon General’s warning.

Responsible legislators like Carolyn B. Maloney, Democratic congresswoman from New York, advanced bills to help limit the carnage. At the time, she said, “New cigarette packs say smoking causes cancer. We don’t want to wait another 50 years to have labels that adequately warn people that tanning beds cause cancer.”

President Obama won the election, and signed the Affordable Care Act into law in 2010. As part of the law, our country levied a 10% tax on all tanning sessions, which will deliver $600 million in health supporting revenues over the next decade. This, along with growing educational initiatives and stigmatization of what some called “cancer beds”, caused over half of the nation’s tanning salons to close down. About 9,500 remain.

American Academy of Dermatology President Henry Lim says that 8% of the 419,000 cases of skin cancer each year are the result of tanning bed UV exposure. He says “The indoor tanning tax serves as a deterrent to discourage this dangerous activity, especially among young women.” But Secretary Tom Price, the candidate supported by both the AMA and AAMC, doesn’t believe much in taxation or regulation.

The Republican plan, set for a vote this week in the House, will cut $883 billion in taxes that were associated with funding the ACA. 40% of the recipient funds would go to the richest 1% in our country, worsening the income disparity which Republican Peggy Noonan says is the largest threat to our democracy. Corporations will thrive with breaks of $145 billion to health insurers, $25 billion to drug companies, and $25 billion to medical device companies. Nearly an equal amount in total, $880 billion, will be removed from the poor and vulnerable citizens covered by Medicaid.

The bill, if passed, will also drop the 10% tax on tanning bed sessions.

Medicaid Caps and Paul Ryan’s “Good Old Days”.

Posted on | March 16, 2017 | Comments Off on Medicaid Caps and Paul Ryan’s “Good Old Days”.

Paul Ryan’s “A Better Way” is actually the same old way circa 1960 when Medicaid Caps were all the rage, with Welfare providing “medical vendor payments”. What did that look like?

1. State spending was low: $12 billion nationwide in 2014 dollars covering <2% of citizens.
2. Eligibility, coverage and utilization were tightly constrained.
3. No care for children in 11 of 50 states.
4. No hospital coverage, doctor coverage, medication coverage in 20 of 50 states.
5. Decisions on coverage could be quite arbitrary: Kentucky – hospital coverage only for “life-threatening ” conditions, Montana – coverage for hospital only if vision threatened.

Caps were lifted in 1965. Medicaid programs are now required to cover certain programs.

Expert Opinion:

“Federal mandates and open-ended federal cost sharing are meant to provide incentives for state spending, but states often balk at the large costs. Both state and federal budgets would benefit if each Medicaid recipient cost less. Unfortunately, a per capita cap on federal Medicaid spending is unlikely to achieve this aim. Rather than “modernize” Medicaid, the historical experience in the United States suggests per capita caps would simply shrink the program.”

Canada vs. U.S. Health Care: State Governance and Next Steps if Ryan Fails.

Posted on | March 15, 2017 | 2 Comments

Mike Magee

One of the most enduring myths that we Americans support when it comes to Canadian health care is that it is a nationally run, monolithic offering with little variability. That is patently false.

In fact, Canada’s official beginnings in health governance began in the province of Saskatchewan in 1946.  For several decades they had been struggling to improve access to medical care, and then took their learnings and passed the Saskatchewan Hospitalization Act that provided universal coverage for hospital care to its citizens. Four years later, the province of Alberta followed suit with a public health plan that eventually covered medical services for 90% of its population.

In 1957, the national government upped the ante by offering to cover 50% of the cost of health care to provinces and territories that embraced their Hospital Insurance and Diagnostic Services Act, which eventually formed the pillars of the current Canada Health Act. By 1961, all ten provinces were aboard, and surprisingly controlled their own budgeting, priority setting, licensing, and provider participation within their territories. The national government set the mission and vision and agreed to pay part of the bill as well as administer the insurance details of the program. But the provinces did the rest.

In doing so, Canada traded control and systematic predictability for local support, involvement, and sustainability. What happened over the next few decades in terms of cost sharing, governance and variability well informs the current raging debate over replacement of Obamacare, and especially the fate of Medicaid in the U.S.

First the finances. To begin with, Canada never agreed to pay the entire health care bill for its citizens. In fact, national and provincial governments pay about 70% of the bill, and coverage is excluded for pharmaceuticals (although nationally negotiatated pricing puts their cost at roughly ½ to 2/3 of ours), dentistry, and optometry. The remaining 30% falls on Canadian’s shoulders, covered either by private supplemental plans or out of pocket.

Of the portion the government does pay, the original deal was that this would be a 50/50 split. But as in the U.S. after the institution of Medicare and Medicaid, costs rapidly escalated. Within a few years, the national government retreated to block grants, making these a line item in their budget. In the years that followed they first trimmed this line by 5% and later by 30%. The net effect was to alter the 50/50 bargain to 30/70, and finally to 15/85 today.

The individual provinces and territories then primarily control the decisions and most of the cost burden of their programs. There is considerable variability. In cost for example, Alberta pays roughly 20% more per capita than Quebec. In governance, some use province wide boards, and others rely on local hospital boards. And in outcomes, performance varies widely. Such is the price of a distributive system.

What is uniform however, is that all Canadians have coverage of the 70%, and this is provided through a single insurance plan administered by Canada itself. By doing this, Canada reinforces a national vision and basic access to services for all its citizens. As important, it eliminates some of the cost-shifting and payor-mix selection problems that have plagued the U.S. private insurer based model from the beginning. Stated plainly, we need charity care because: 1) Someone doesn’t have insurance, or/and 2) Someone has lousy insurance, or/and 3) doctors and hospital leave the poor and vulnerable in the lurch.

When President Obama chose the course he chose for the ACA, and Governor Romney chose the course he chose for Massachusetts, both were following, in part, the Canadian playbook. The starting point for both was, as in Saskatchewan, coverage. Broad participation by all would be necessary. The costs of the old and sick, needed to be counter-balanced by the contributions of the young and well. Both chose to use carrots and sticks to empower their mandates.

Massachusetts had the opportunity to adjust and fine-tune theirs. Obama, in the face of 8 years of determined and relentless opposition to kill his signature program, was never afforded the same opportunity. Specifically, 19 states not only didn’t stay neutral, they went nuclear. Many sat on their hands rather than work on state exchanges. 19 refused what became a 100/0 deal to cover cost of expansion of Medicaid. Remarkably, 20 million Americans still participated. Both legs of the program, as in Canada, embraced local control, and were provided a relatively free hand. For example, appeals for experimental models, as with Arkansas’s use of private insurers for Medicaid, were given a green light and proved successful, in part because it shielded and protected their poor and vulnerable citizens from discrimination by local providers.

But that was then and this is now. Paul Ryan’s plan, including caps on Medicaid,  has run into stiff Republican head wins. This is not because the CBO (which they preemptively undermined) believes 24 million will ultimately be uncovered as they once again arrive in desperation on ED doorsteps across the nation (the good old days.) Rather its because analysts, with near uniformity, are predicting disaster – especially for the rural and elderly poor who figured prominently in their own and Trump’s election.

So what should we do?

As in Canada, we need to embrace local support, involvement, and sustainability. That means dealing the states in, but remaining united.

We do need a mandate. All citizens must contribute up to their means. This means fine-tuning the incentives so that people, especially young people, act.

We also need to help fund our health programs with graduated taxes on our most wealthy. Income disparity is now the greatest threat to our democracy. Supporting national health helps spread the wealth in more ways then one.

We need to build on the Medicaid success, and continue to support state waivers in the interest of openness and experimentation.

We should not move to block grants. That just passes the buck.  Instead let’s work with state leaders to incentivize the creation of compassionate financial brakes on the system. We are all in this together, and we’ve proven that some states, if left in the darkness, will tolerate great suffering of their people rather than share resources or responsibility.

We need to be confident that many of the 19 state hold-outs will now choose to participate. If they do not, we need a back-up plan that does not depend on the largess of private insurers.

We need to call the private insurers bluff. They want to get out of the business. Fine. Get our best national and state public health financial people on the first plane to Canada, and figure out what they did to make Canada the top payer. If our private insurers wilt, we will have gained resources not lost them.

 

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.

Canada vs. U.S. Health Care: Common Wealth

Posted on | March 8, 2017 | Comments Off on Canada vs. U.S. Health Care: Common Wealth

Mike Magee

Republicans this week demonstrated with clarity that further tinkering with our broken health care system will almost certainly add cost and undermine quality and coverage. To begin to define a way back home, we need to initially focus on two fundamental challenges.

Problem 1: Defining a National Health Care Vision

There is an actual “American Dream”. The phrase is attributed to New England social historian and writer James Truslow Adams. In 1931, he wrote The Epic of America in which he described “a dream of a social order in which each man and each woman shall be able to attain to the fullest stature of which they are innately capable, and be recognized by others for what they are, regardless of the fortuitous circumstances of birth or position.”

When Canada embarked on developing its national health care system in 1947, they identified the most knowledgeable and respected leaders they could find on the national, provincial, and territorial stages, and empowered them to create a mission and vision for Canadian health care.

Their output, reaffirmed in 2005, mirrored Adams vision. It said, in part, “As a nation, we aspire to a Canada in which every person is as healthy as they can be—physically, mentally, emotionally and spiritually.”

They defined a healthy nation as “one in which all Canadians experience the conditions that support the attainment of good health. The strategy identifies two goals: improved overall health and reduced health disparities.”

The U.S. skipped this critical strategic planning step and has been paying the price every since. Our government needs to appoint a representative body and charge them to create a consensus national vision  and guiding principles for our nation’s health.

Problem 2: Disentangling the Medical Industrial Complex.

Seeing the premier academic medical institutions to the south veering off into speculative entrepreneurism, patent seeking, and fortune hunting, Canadian health leaders took the time to define the social accountability responsibilities of their medical schools. The set of principles linked the schools to the national health care system and stated in part that:

“Medical schools respond to the changing needs of the community by developing formal mechanisms to maintain awareness of these needs and advocate for them to be met”, and  “Medical schools work together and in partnership with their affiliated health care organizations, the community, other professional groups, policy makers and governments to develop a shared vision of an evolving and sustainable health care system for the future.” In contrast, America’s premier academic health care systems chased the golden patent ring and research discovery laden profitability, leaving patient care and medical education in the wake.  

Our “system” began as a series of self-interested professional guilds, industries, hospitals, insurers and government agencies which together formed a messy, unruly aggressive complex. For a time their conflicts with each other created some element of informal checks and balances on the system. But in the past half century, the major players in the sector infiltrated the government, and cross-fertilized each other to the point that they realized it was better and more profitable in the long run to collude behind closed doors than to fight with each other out in the open.  Cooperating as an invisible united front, they now maintain control of policy, legislation and future profitability.

Piecemeal attempts by reformers have been easily repulsed. In 2008, Don Berwick acknowledged an absolute need for universal coverage and for organizational leadership. He called his leader an “integrator” who’s roles included guiding individual and family partnerships, primary care network building, population health, finances, and macro system integration. But compared to the Canadians, his faith in prevention versus carefully re-engineered high-tech intervention was qualified. His words: “Good preventive care may take years to yield returns in cost or population health.”

At around the same time Mayo Clinic’s CEO Denis Cortese, now director of Health Care Delivery and Policy at Arizona State University, endorsed “a U.S. Health Board modeled after the Federal Reserve Board… An independent board made up of providers, payers, and patients could focus on the complex decision making that must be insulated from the politics of Capitol Hill.” Yet, as we see today, politics remain front and center.

A few years earlier, two former NEJM editors offered their prescriptions for change inside the Medical-Industrial Complex. In 2004, Marcia Angell zeroed in appropriately on the pharmaceutical industry defining “how they deceive us and what to do about it”. But she appeared to deliberately leave academic medicine’s culpability unaddressed. A year later, Jerome Kassirer filled in the dots, focusing on “how medicine’s complicity with big business can endanger your health”.

He correctly concluded that “Like-minded people with ‘unique’ knowledge may have similarities of thought and come up with a uniform conclusion that is biased (or even completely wrong)”. Lending a term from the military, he highlighted “incestuous amplification” and recommended that, when filling governmental medical science advisory boards, the nation “save such ‘prizes’ for those with no financial ties, that is, to reward people who stay free of personal financial entanglements with industry.”

This is not the place, nor is there adequate space here to address how best to disentangle co-conspirators from industry, academic medicine and government. I will only say that where there is a will there’s a way – many ways.

President Obama realized, in looking for a starting point, that Governor Romney was on the right track in Massachusetts in 2006. Republican or not, the governor realized there had to be a plan; leaders had to held accountable; all citizens had to have mandated coverage because history had proven more than once they would not do so voluntarily. Channeling the spirit of our northern neighbors, Romney ally, Democratic Speaker of the House (MA), Sal DiMasi, spoke truth to power, “It was supposed to be a community of people where laws were made for the common wealth. That’s why we became a ‘commonwealth’. Nobody in Massachusetts will ever be turned away for health care”.

How should we re-organize to deliver health in America? That’s next.

Canada vs. U.S. Health Care – “You Can’t Handle The Truth!”

Posted on | March 7, 2017 | 2 Comments

Mike Magee

In the 2008 classic movie, A Few Good Men, Jack Nicholson explodes under the relentless pressure of prosecutor Tom Cruise, and yells “You can’t handle the truth!” A careful critical examiner of the US health care dilemma in 2017, in the shadow of our neighbor to the north, might easily draw the same conclusion.

As we’ve seen in the prior three segments of this series, the US health system diverged sharply from the Canadian approach in 1947, 1957, 1965 and 1984. As our costs escalated out of control, uninsured numbers rose and performance lagged, leaders expended energy defending our system as “the best health care in the world”, and defamed the Canadians and others with unsubstantiated claims that they were piggy-backing on our system to cover their own weaknesses.

In contrast to our own penchant for opaqueness, complexity and tolerance of conflict of interest, the Canadians – while far from perfect – have attempted to continuously and responsibly evolve their system and have transparently exposed their strengths and weaknesses to the light of day. As a result, Canadians support their system in far greater proportions that do the Americans.

The fact that Trump and the Republican Congress have no real plan beyond repealing Obamacare, or that the Democrats and President Obama did not manage perfection while facing constant opposition over eight years, could lead many to believe that this whole mess is just too complicated to understand let alone fix.

But the pathway out, on the surface, is pretty clear. Everyone needs to be covered to share risk. The administration and choices need to be simple and clear so that the general public can understand and participate. Elements that add cost but not value must be eliminated. And accountability must be anchored by a strategic long term plan, committed national and regional leadership, and a vision and value proposition.

What is increasingly apparent, and the truth we refuse to acknowledge, is that the problem is not the system specifically, but rather our culture and values which have been hijacked. Beginning just after WWII, but accelerating in the 1970’s and 1980’s, cross-sector leaders in energy, finance, health care and the military coordinated a deliberate attempt to seize control of power in industry, non-profits and government in pursuit of career advancement, profits, and power. These “complexes”  focused on dismantling checks and balances, and managed, in a twisted dialogue among themselves, to simultaneously chase government subsidies while excoriating government intervention.

As multi-nationals expanded so did large profit-chasing, entrepreneurial “non-profits” who diligently avoided taxes while aiding and abetting the rapid expansion of poverty and income disparity. Between 1960 and 2015, “non-profits” percentage of the GDP grew three fold with 1.6 million “non-profits” now employing 10% of all American workers. As boundaries blurred, associations of associations evolved to allow coordination of government relations strategies. Attendants at their conventions were multi-sector true believers in the free-market and profits. Their cover? The claim that entrepreneurial zeal and imagineering would, through discovery, solve all of America’s problems. And those problems were growing at an alarming rate, fueled by organizations like the U.S. Chamber of Congress which spent over $1 billion lobbying in the past decade.

With President Reagan in power, enabling legislation opened the floodgates. New laws, like the 1980 Bayh-Dole Act, actively incentivized government-industry-academic non-profit collusion. In its wake, community needs faded as corporations became persons and free speech morphed into free spending. This was an opaque and deliberate hostile takeover, executed by experts with patience and near unlimited resources. Bill Moyer’s notion of “public action for public good” became a quaint euphemism for old-fashioned, out-of-touch PBS dreamers.

What felt like progress was finally revealed for what it was in the 2008 financial crisis. But this near societal collapse at the hands of free-market zealots surprisingly only tightened the embrace between the state and the private sector. The 2010 Citizen United and 2014 McCutcheon decisions solidified an American world of opaque complexes, integrated cross-sector, conflicted and cooperative power elite who continued to shift the distribution of wealth to their own kind as everyday Americans became more and more disillusioned.

So the truth we can’t handle is that, unlike Canada, we have let our highest ideals slip away from us, and we’re not quite sure how to right this ship. And yet, until we acknowledge that truth, we can’t address U.S. health care which now encompasses nearly 1/5 of our economy.

This is a nation where business and government are now largely indistinguishable from one another. This is a nation where checks and balances have melted in the face of a half century of deliberate assault creating a world absent countervailing self-correcting instincts. This is a world that for the chosen few celebrates individualism in the extreme and survival of the financially fittest, an environment where free-market ideologies routinely fail us, but then are re-subsidized and reinforced and recast by compromised insiders.

Under these conditions, we should not be surprised that the Trump administration and Congressional Republicans are now presenting health policy solutions that would increase complexity, further burden the poor and disadvantaged, and add cost at every turn.

As one commentator concluded, “Today health care in America is dominated by the medical-industrial complex…a mix of intimately interacting for-profit businesses, non-profit enterprises, and government agencies…every part of it is completely dependent on government spending and completely integrated with public-sector institutions and programs. Huge non-profit enterprises play a central role not just in the actual administration of health services but also in the generation of profits for the for-profit sector….the American health care system is both built on and reinforces an individualistic, free market ideology that simultaneous embraces government subsidization and scorns government intervention.”

That’s the truth we can’t handle. But we must. Next time – how we’ll fix it.

Canada vs. U.S. Health – Report Card

Posted on | February 28, 2017 | 13 Comments

Mike Magee

In 2007, the Cambridge based National Bureau of Economic Research (NBER), self-defined as “the nation’s leading nonprofit economic research organization”, produced a singularly myopic white paper comparing the U.S. and Canadian health care systems. Noting that Canada is a “single-payer and mostly publicly-funded system” while the U.S. is a “multi-payer, heavily private system”, NBER stated that “Much of the appeal of the Canadian system is that it seems to do more for less.”

At the time of the paper, Canada was devoting about 10% of its GDP to health care versus 16% in the U.S. While spending less, Canada managed a significantly lower infant mortality rate, and higher life expectancy. The authors attempted to explain these negative findings by first noting that low birthweight is associated with high infant mortality, and then offering this analysis, “Low birthweight-a phenomenon known to be related to substance abuse and smoking-is more common in the U.S. For babies in the same birthweight range, infant mortality rates in the two countries are similar. In fact, if Canada had the same proportion of low birthweight babies as the U.S., the authors project that it would have a slightly higher infant mortality rate.”

Moving next to the troublesome issue of life expectancy, they declared, “The gap in life expectancy among young adults is mostly explained by the higher rate of mortality in the U.S. from accidents and homicides. At older ages much of the gap is due to a higher rate of heart disease-related mortality in the U.S. With such a disease, it is necessary to take with caution. While this could be related to better treatment of heart disease in Canada, factors such as the U.S.’s higher obesity rate (33 percent of U.S. women are obese, vs. 19 percent in Canada) surely play a role.”

That the NBER economists could present such arguments with a straight face well illustrates the remarkable disconnect between cause and effect, prevention and intervention, and scientific progress versus human progress in the U.S. health care system and its Medical-Industrial Complex. Eight years later Canada would boast a life expectancy of 82.2 years and an infant mortality rate of 4.9/1000 live births versus U.S. numbers of 79.3 years and 6.5/1000 live births. It should be noted as well that the per capita health care expenditure in Canada at the time was $5,292 compared to $9,403 in the U.S.

At the same time as the privately and opaquely funded NBER economists were penning their insights, actual public health leaders in Canada, after two years of thought and debate in the public square on a vision that would govern Canadian health care into the future, released its’ “ten year plan”. It included these five principles:

1)”Prevention is a priority. Canadians value their health.

2) They prefer to live a long life in good health while preventing disease or injury, rather than experiencing severe illness and the pain, suffering and loss of income that they can cause; they also want to avoid premature death.

3) Promoting good health just makes sense. While we have the means to prevent or delay many health problems, Canada’s current health system is mainly focused on diagnosis, treatment and care.

4) To create healthier populations, and to sustain our publicly funded health system, a better balance between prevention and treatment must be achieved.

5)Prevention is a hallmark of a quality health system. Internationally, health promotion and prevention are recognized as essential pieces of high-quality health systems.”

In a remarkably insightful summary, Canada’s national, provincial and territorial public health leaders declared:

“Health promotion is everyone’s business. While it is clear that health services are a determinant of health, they are just one among many. Others include:

1)environmental, social and economic conditions;

2)access to education;

3)the quality of the places where people live, learn, work and play;

4)and community resilience and capacity.

Because many of these determinants of health lie outside the reach of the health sector, many of the actions to improve health also lie outside the health sector, both within and beyond government. This means that many government departments and a wide range of people and organizations in communities and across society play a role in creating the conditions for good health that support individuals in adopting healthy lifestyles. Promoting health and preventing diseases is everyone’s business—individual Canadians, all levels of government, communities, researchers, the non-profit sector and the private sector each have a role to play.”

This is not to say that the Canadian health care system is perfect. Far from it. The Commonwealth Fund in 2016 compared performance of 11 developed nations on measures of quality, cost, access and communication. The charts below are derived from that survey and compare  Canada, the U.S., and the average of all 11 nations.

On Quality: The U.S. compares favorably on having a regular doctor, receiving good care, and having patients drug lists reviewed. We are also a bit ahead of Canada in team care since they rely more heavily on private fee-for -service doctors. But when patients assess whether our system as a whole is optimal and whether it works well and needs only minor changes, it is clear our citizens lack confidence compared to the Canadians, and that the Canadians trail the national average.

On Cost: The Canadian system does not cover dentists, eyeglasses or pharmaceuticals. If citizens want coverage for these they must purchase a private plan. Even so, the chart above clearly illustrates that U.S. citizens by significant margins feel greater financial stress than their neighbors to the north and purposefully ration their own care by avoiding necessary but expensive treatment.

On Access: On nearly every measure, Canadians score worse on access to care than do the Americans. These are issues they have focused on for over a decade and not resolved. The waits are concentrated in the area of elective surgery and specialty referral. They have the same number of doctors per 100,000 as do Americans but have not added physician extenders and team approaches to the degree the U.S. has. Instead, they have fallen back on ED visits in the off hours, which are free, resulting in long waits after hours.

On Communications: The results are mixed. Canadians lag in their use of online medical records though the U.S. has a long way to go as well. The American system shows the signs of excessive complexity with more repeat and unnecessary tests, more breakdowns in communication between generalists and specialists, and information unavailable at the time of appointment.

By moving toward universal care, adjusting our payment incentives, inserting performance bonuses to coax quality measures and electronic medical records, President Obama was heading in the right direction. But the Republicans seem determined to roll back the clock, insert even greater complexity, and place a greater burden on vulnerable populations who’s greatest need is simplicity and clarity.

What will happen next? We’ll look at that next week.

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  Ralph Snyderman
Prospective Health Blog
BIOGRAPHY   Meredith Magee Donnelly
Homegrown Friends
BIOGRAPHY   Eric Dishman
NIH Precision Medicine
BIOGRAPHY   Barbara Ficarra
Health in 30
BIOGRAPHY   William L. (Larry) Minnix, Jr.
Larry's Letters
BIOGRAPHY     Eric Dishman
Precision Medicine, Euthanasia, Abortion, Communism, Trillions of Dollars, Losing Freedom, and Town Hall Mobs BIOGRAPHY   Michael Millenson
Yearning for Universal Coverage Is Not Universal
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