Maybe. Uwe Reinhardt notes that our socialized health care system rates well above the national average. But first, let us have our definitions clear. People misuse the term “socialized medicine” quite frequently.
I must note that there is a widespread confusion in this country over the terms “social health insurance” and “socialized medicine.”
Among policy wonks, “social health insurance” is understood to be health insurance to which the individual makes contributions on the basis of ability to pay, rather than on the basis of health status. Such a system can be coupled, and often is, with purely private health care delivery systems, including for-profit enterprises. Canada, Taiwan, Japan, South Korea, Germany, the Netherlands and Switzerland come to mind.
Socialized medicine refers to systems that couple social health insurance with government-owned and operated health care facilities, such as Britain’s N.H.S. or the Hong Kong Hospital Authority, a still-appreciated legacy of British colonialism. Socialized medicine also typified the health systems operated by the former socialist countries in the Soviet orbit. Evidently, the V.A. health system perfectly fits the definition of socialized medicine.
It is in the last sentence that Reinhardt mentions our one truly nationalized heath care system, the VA. As he notes, people do not generally bash our socialized system, though they are quite free in bashing others, often with wrong information.
The most humorous illustration of American N.H.S.-bashing was supplied during the heated health reform discussions in 2009 by Investor’s Business Daily. In an editorial, the paper asserted, “People such as scientist Stephen Hawking wouldn’t have a chance in the U.K., where the National Health Service would say the quality of life of this brilliant man, because of his physical handicaps, is essentially worthless.”
Dr. Hawking, who has lived and worked in Britain all of his life, responded: “I wouldn’t be here today if it were not for the N.H.S. I have received a large amount of high-quality treatment without which I would not have survived.”
Eventually, Prof. Ara Darzi, a former minister of health, head of surgery at Imperial College in London and Britain’s ambassador for health and life sciences, and Tom Kibasi of McKinsey & Company, an honorary lecturer at Imperial College, gently lectured American readers on this amusing episode and on the actual modus operandi of the N.H.S. The episode also opened a lively and sometimes bemused blog traffic in Britain.
Although I personally have never advocated adopting an N.H.S.-style approach to health reform in the United States, I have been puzzled for decades by the almost instinctive habit among many Americans of incessantly running down every other country’s approach to health care and health insurance.
Is this habit born of the deep-seated insecurity that might naturally arise from the cognitive dissonance of boasting “ours is the best health system in the world,” all the while beholding daily the travails and hand-wringing over the sometimes glaring shortcomings of the American health care system?
I have found that one effective way I can stop N.H.S.-bashing dead in its track is to ask bashers this simple question: “Why don’t you like my son?” I posed that question to a congressman who had berated “socialized medicine” during a hearing on health insurance reform at which I testified.
In response to the stunned look this question invariably elicits, I go on: ”You see, our son is a retired captain of the U.S. Marine Corps. He is an American veteran. Remarkably, Americans of all political stripes have long reserved for our veterans the purest form of socialized medicine, the vast health system operated by the U.S. Department of Veterans Affairs (generally known as the V.A. health system). If socialized medicine is as bad as so many on this side of the Atlantic claim, why have both political parties ruling this land deemed socialized medicine the best health system for military veterans? Or do they just not care about them?”
I think that there are many reasons why politicians, and pundits for the most part, do not go after the VA system. Many politicians pander for votes by pretending to care about the military, or lionizing them. Besides, if the VA system was abolished, it would be difficult to find a system where they could receive care that is of equal quality. While the VA is far from perfect, the Rand Corporation notes that it is well above average.
Using indicators from RAND’s Quality Assessment Tools system, RAND researchers analyzed the medical records of 596 VA patients and 992 non-VA patients from across the country. The patients were randomly selected males aged 35 and older. Based on 294 health indicators in 15 categories of care, they found that overall, VA patients were more likely than patients in the national sample to receive recommended care. In particular, the VA patients received significantly better care for depression, diabetes, hyperlipidemia, and hypertension. The VA also performed consistently better across the spectrum of care, including screening, diagnosis, treatment, and follow-up. The only exception to the pattern of better care in VA facilities was care for acute conditions, for which the two samples were similar.
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Like Uwe Reinhardt, I do not advocate for a socialized system. However, I think there is much we can learn from the ones we know about. They, sometimes, offer better care and, sometimes, offer much cheaper care, while still offering quality care.
I watched a bit on TV recently on the health care system in Switzerland, which is a form of national healthcare (how’s that for avoiding the word “socialized”.) using private health insurance companies. If the report was accurate, I would be quite happy with a system like that.
One of my big problems is that I don’t trust government, or many (most?) people in government. (One anecdote of supporting evidence as to why here). I find that far too many government employees forget they are pubic servants and act more like public serpents.
The survey is interesting. I’d like to see a larger sample size. But, the more I think about it, the more I remember incidents of people I know getting crappy care from provate doctors, clinics and hospitals. Too many anecdotes to mention. VAs have to worry about a congressperson, Senator or some other public official coming down on their head if they screw up with the wrong person at the wrong time.
In the 70s, the VA had an awful reputation. I think the big change was they they instituted an electronic medical record system that works pretty well and they make it a point to track things. They then hold people accountable if they dont meet practice guidelines.
Steve
Accountability is important. I’ve read reports that doctors tend to not report other doctors. My sister used to be the lawyer for Tennessee that went after doctors licenses when when they messed up. Often the doctor already had a pretty bad track record before they came to her attention. I know several doctors. If you ask their opinion of another doctor, you get a lot of hemming and hawing if the doctor you’re asking about is sub-par, but rarely a clear statement.
Yes, accountability is essential to a high quality health system. And, yes, all too often physicians are hesitant to propound negative assessments of other physicians’ performance. There are more than a few reasons for that hesitancy. For example:
– Medical decisioning is, quite often, made on incomplete data. Unlike many professions, physicians often must make a diagnosis and institute treatment based on probability rather than confirmed findings. Delay in instituting treatment can be worse than complications of the treatment. My son received two units of untyped blood (O negative) last week upon arrival in the ER with a ruptured spleen. He was in severe shock and the danger of waiting another 15 minutes for accurate typing and crossmatching would have endangered his life. The con of the transfusion is the increased risk of allergic reaction.
– Making a negative assessment and reporting that is the right thing to do and the benefits to the community are obvious. However, the physician so restricted remains in the community and has recourse to suits for defamation (even if easily defended it is expensive), can agitate other patients to sue for malpractice if they have minor complications, and in general can cause problems for the physician who made the negative assessment. All in all, more than a few physicians have seen the negatives that result from reporting negative assessments of performance and are very hesitant to get into that.
– When asked in casual conversation about another physician, I rarely provided an answer. Peer review and assessment of professional performance are very specific functions and involve detailed legal accountability for the persons involved. It took me over a year to write the DoD peer review and assessment directives back in the mid ’80s. Casual conversation peer assessments are fraught with legal, ethical, and other pitfalls. Even in cases where I had been the maker of a negative assessment that led to removal of a physician’s clinical privileges at a hospital, I would not discuss his many shortcomings with patients. I simply responded that the medical staff had recommended to the board of directors that he no longer be allowed to treat patients there.
– A physicians credentials (diplomas, certifications, etc) are property and, as such can only be removed through mechanisms meeting Constitutional standards. Licenses are somewhere between property and “privileges” and are a little easier to remove. Clinical privileges at a hospital are “privileges” and can be removed somewhat more easily but that removal is subject to legal challenges and all the problems that those entail.
All those factors aside, we physicians have not traditionally been strict enough in enforcing standards in our profession. That has improved in the past 40 or so years but has a long way to go. In our defense, I should point out that many other professions have taken little or no self regulatory actions. Attorneys are at about the same place as are physicians. Teachers pretty much leave regulatory oversight to the school boards, bankers seem to not care at all, real estate professionals seem to have little in the way of self regulatory oversight, I could go on but that seems unnecessary.
What I can tell you is that if your physician has clinical privileges at a JCAHO accredited hospital or treatment facility, his credentials have been verified by contact with the issuing organization (meaning that forged credentials are extremely unlikely). In addition, that hospital has an ongoing peer review and assessment process that is reviewed every two to three years and is deemed adequate.
The direct military health system is also a basically socialized system. Traditionally, it was an incredibly robust and effective system providing high quality health care to soldiers, their families, and retired military and their families. Sadly, continual budget cuts have cut into capability drastically. At this point, the system is badly stressed in providing care to active duty members and limited access for the other beneficiaries.
This brings up the weakest link in a single, nationalized system in that that system is at the mercy of politicians and their current desire to cut funds or increase funds depending upon which will get them reelected (their real job being to get reelected).
And these are the same politicians who like to talk about supporting the troops.
Steve
Pretty much. I started to list a bunch of other things our politicians do for us and then remembered that I have decided to attempt to be civil in my conversations. This does make it difficult to describe politicians but I really intend to make the effort.