“I do believe the only way we can end all preventable deaths and the suffering of millions is to provide decent health care to all.”
Hilary Benn, 2006
The next Grand Rounds will be hosted by Evan Falchuk at SEE FIRST (Insights into the Uncertain World of Healthcare). Evan’s theme is Health Care Reform.
How will it affect your life, your medical practice, your experience as a patient, as an insured, an employer, an employee, someone without insurance? What are your reactions to the politics, and what do you think will happen next? I’m asking for your candid views on health care reform seen from whatever perspective you bring. Medicine, politics, business, humor, left, right, center, up, down, you name it.
Health Care Reform has been a theme more than once in this Grand Rounds, i.e. February 10th at the Health Care Blog, and at Obama’s inauguration day (Ten Suggestions For Healthcare Reform) by Val Jones, MD.
The question is which health care reform? Because after all, this is an international Grand Round with bloggers from the US, Europe, Africa, Australia & Asia.
Probably, just as Google.nl (Dutch) already suggests the theme is meant to be about the USA health care bill of Obama, the future plan, and its costs (see Google Fig).
Recently the Patient Protection and Affordable Care Act (known as the “Senate bill”) became law on March 23, 2010 and was shortly thereafter amended by the Health Care and Education Reconciliation Act of 2010 and passed by both houses on March 25 without any support from republicans (source: Wikipedia). Please see Reuters and CNN for an overview of the March 2010 reforms and the year in which they take effect and the New York Times  for the effect per types of household (i.e. Fig. at the right)
The legislation will tighten regulation of insurance companies and is expected to extend medical coverage to more than 30 million uninsured Americans. As explained by Barack Obama in the CNN-video  below, it will take 4 years to implement fully may of these reforms, but some desperately needed reforms will take effect right away. For instance, having a child with a pre-existing medical condition will no longer be the basis for denial of coverage or higher premiums in the old system.
more about “Health Care:What happens when”, posted with vodpod
As a Dutch citizen, I simply can’t imagine that an insurance would be refused because my girl has asthma and I would to have pay a lot more because I happen to have a chronic disease. I can’t imagine that so many people (from a rich country) are uninsured.
As of January 2006 Our Dutch Health Care has been reformed as well. (Officially) there is no longer a fragmented system with compulsory social insurance for the majority and private health care insurance for people with a higher income. Now there is a standard insurance for all, where the insurers have to accept all patients, with no difference in premium, and no surcharges. Children up to the age of 18 years are insured for free.
Both employer and government will contribute to the Health Insurance fund, and the insured will pay a nominal premium for their standard insurance directly to the health insurer. People with a low income can apply for a care allowance.
To avoid that health insurers seek to avoid less healthy clients, insurers are entitled to compensation for expensive customers. Although not as ideal as conveyed by the Dutch Government in their commercial-like video  (a too central role for the insurers, considerably less covered by the basic health insurance) it still is a pretty good and affordable health care system.
It is often difficult to imagine how things work in another country unless you’ve been there or hear it through somebody else.
A Dutch correspondent in the US, Tom-Jan Meeus wrote a eye-opening article in the Dutch NRC newspaper  about the US health care.
When Meeus collected his first prescriptions from a US pharmacy, he had to pay six times as much for the same pills (same brand, logo, packing) as in the Netherlands. And he was even more surprised that the prices were negotiable. But he got used to the US health care system: he gets an expensive check-up each 2 months instead of the once yearly (when needed) doctor visit back in Holland. In this way his doctor safeguards himself against health insurance claims. Furthermore, his doctor “has to keep the pot boiling too”.
This man knows many influential people and has valuable inside information, i.e. about the health status (botox, psychoses) of some of the key players in the health care system. In addition, he was one of the doctors who thwarted Clintons Health Reform: his glory years. This friendly conservative doctor wants freedom of choice, for himself and his patients. When Meeus objects that this freedom of choice becomes a little expensive, the doctor argues that top health care costs a little (US doctors know they are “the best in the world”) and continues: “do you really think the health care becomes any cheaper when Obama subsidizes 30 million people to get insured? Hanky Panky, that is what it is.” But he knows a way to circumvent the rules. He cut the ties with two insurance companies that reimburse too little. “Perhaps, we can’t stop Obama, but we can undermine him. Why should we help people when we don’t make money out of it…”.
Hopefully not all the doctors think this way (I’m sure the blogging doctors that I know, don’t), but lets give a moments thought to two statements: That the US Healthcare is “the best” (as it is) and that the new health care system costs too much.
We first have to find out whether the money was well spend before the health care renewal.
1. According to the Organization for Economic Cooperation and Development (OECD), the US spent 15.3 percent of its GDP on health care in 2006 and this number is rising. As you can see this is far more than the other countries spend.
This trend was already visible in the early eighties: the last 10-20 years the US spend far more money on health care than other rich countries..
And although the U.S. Medicare coverage of prescription drugs began in 2006, most patented prescription drugs are more costly in the U.S. than in most other countries. Factors involved are the absence of government price controls (Wikipedia).
Perhaps, surprisingly, the higher health expenditure hasn’t lead o a higher life expectancy. (78 years in the US versus 82 years in Japan in 2007). The differences are huge if one plots health spending per capita against life expectancy at birth.
Just like the international comparison, higher health care expenditures in different parts of America don’t result in a better health care for all this extra spending. Miami spends 3 times as much money per person health care than Salem (Oregon). Many doctors in Miami, for instance, perform a bunch of tests, like ECG’s, after chest complaints, because they have the necessary devices, not because all these tests have proven useful. Despite all expensive tests and treatments, Miami (and comparable great spenders) has the worst death rate following a heart attack.* [ source, video in ref 5 and the Organisation for Economic Co-operation and Development's Health Data 2009 site.]
And this is how the US health care works: simply more treatments and tests are available, but the incentives are wrong: physicians are paid for the quantity of care not the quality.
Just like the doctor of Tom-Jan Meeus, who did a two-monthly unnecessary check-up.
Or as the internist Lisa Bernstein suggests in the New York Times :
For instance, if an asymptomatic, otherwise healthy, patient comes to me wanting a whole-bodyto make sure they do not have something bad hiding inside of them, I would decline and educate him or her that there is no data to show that this test has any significant benefit to offset the potential radiation or other harm and the major medical societies do not recommend this test.”
Mind you this is the situation before the current health care reform.
But there is another thing not yet addressed: the expectations of the US-citizens. Americans (and more and more Europeans too) want those check-ups and screenings, because it gives them a (false) feeling of security and because they feel they have the right. That is why it is so difficult for people to give up unnecessary CT-scans, PSA-screening and mammograms.
One reason why Americans have a higher risk for certain diseases (diabetes, overweight, cardiovascular diseases) might be their lifestyle. And lifestyle is something you can change to a certain extent and can have great effects on your health. Lifestyle is also something you can learn. You can learn to enjoy good food, you can avoid the 3 times daily coca cola and it can be fun to do some exercise or for children to play outside. But still some people rather have a pill to stay healthy or undergo all kind of (poor performing) tests to see how they’re doing.
Am I exaggerating?
No. This is reality. A few days ago. I saw Letterman in his show  telling Jamie Oliver (on his crusade to change the US diet habits) that “he believed diet pills were the only successful way to lose weight in the U.S. and that he expected humans to ‘evolve to the point where 1,000 years from now we all weigh 500-600lbs and it will be OK’ and that “If you would go to doctor they would be happy to give you as many pills as you need and you weight 80 pounds”
Do I fail to see Lettermans warped sense of humor?
Does he really belief this? And, more important, does the majority of Americans believe this?
For here is much to gain, both in health and health care costs.
* As far as I can tell these are only associations; other possible reasons are not taken into consideration: busy live in a metropolis or the population composition might also play a role.
Main References (all accessed 29 March 2010)
- NY-Times (2010/03/24) How Different Types of People Will Be Affected by the Health Care Overhaul.
- CNN.com (2010/03/23) Health care timeline (including video)
- Ministerie van VWS: The new health care system in the Netherlands
- NRC (2010/03/20) Tom-Jan Meeus: Mijn dokter won ook van Clinton (Dutch; subscription required).
- Laika’s MedLibLog (2009/09/10) Visualization of paradoxes behind US Health Care.
- Laika’s MedLibLog (2009/09/25) Friday Foolery : Maps & Mapping.
- NY Times.com (2010/03/27) health/27patient.html?src=twt&twt=nytimeshealth.
- The dail Mail UK (Last updated 210-03-25). Simon Cable. Don’t cry Jamie! Now David Letterman lectures Oliver and says his healthy eating crusade won’t work in America
- Wikipedia Commons: Healthcare spending as %25 GDP
- Unemployed single mother, from the NY-times, Ref 
- Animated graph: International health data changing the parameters produces different graphs (2 shown). The data for the graph can be found in the Organisation for Economic Co-operation and Development’s Health Data 2009 see ref 
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