Thursday, July 21, 2016
Freedom versus control in a private vs. public health care system
This is my 12th year as a physician in the United States. I was born in London, grew up in Berkshire, and decided to become a doctor when I was a teenager. I remember being asked what I thought about the National Health Service (or NHS, the UK's government-run health system) during my medical school interview. That question is almost a rite of passage for anyone applying to medical school in the UK. My answer was an idealistic one, probably identical to what most people in England—if not Europe—would say. Health care is a birthright.
The NHS is a wonderful concept and immensely fair and just. Nobody should ever have to pay for medical care in their hour of need, right? I speak too as someone of Indian heritage, who has seen up close and personal how unexpected illnesses in relatives can completely bankrupt families, causing untold anxiety and stress. Surely nothing could be worse than that free-market extreme with no public system backup?
During medical school, I also worked for a couple of months in Adelaide, Australia, primarily in Accident & Emergency/Trauma in a major tertiary care center. I also did a stint with the Royal Flying Doctor Service going on airborne missions to the outback, mainly rescuing very sick indigenous (Aboriginal) people and bringing them back to the city. The system Down Under is an interesting mix of both public and private health care, but still with a solid government-run backbone for people who really can't afford insurance. However, at that time, even the thought of having to pay for health care at all still seemed very foreign to me as I began my career as a physician.
Before I came to the U.S. back in 2005 to start my medical residency, these were my views on the funding of health care. Fast forward to 2016, and my opinions have shifted rather dramatically in terms of what a health care system should look like and whether people should contribute more themselves. Looking back to when I first moved here, one of the things that first struck me about U.S. medical care was the sheer speed and freedom of it all. Patients appeared free to choose their physicians, were in more control over their care, and didn't have to wait so long to get things done. My jaw dropped when one of my first patients was admitted from the ER, and had already had most of their tests and scans done, including an MRI. They would then be seen by all of the doctors they needed to, including any necessary specialists, within a very short period of their hospitalization. These attending physicians would follow-up with them daily (unlike in the UK, where the vast bulk of the work is left to more junior doctors).
We can get into a debate about fee-for-service and incentives, but it's human nature that people and organizations work harder when they are incentivized to do so. Documentation was also much more thorough than the couple of lines that I was used to seeing scribbled in a patient's chart (True, a lot of this was for billing purposes, but it's still always good to be thorough). Since my very first week working as a medical resident, I've said, and continue to say, that a homeless person presenting with an acute illness such as sepsis or a myocardial infarction in America, will get better and more outstanding care than a rich person almost anywhere else in the world. There's a very common misconception overseas that patients in America are left dying on roads outside the hospital if they cannot afford care! This simply isn't true, and I learned it very fast. Clinical care in the United States is top-notch (albeit at a high cost). As are the central issues of patient dignity, patient rights, and accountability of any hospital or clinic to seriously address any complaints.
Physicians too in America, appeared to have a much better deal than in the system I'd just come from. They were more in control of where and how they worked, weren't restricted in terms of their career progression by the government, and were also compensated a great much more for their hard work (granted however, they also had a much higher debt burden). Despite the problems and changes in U.S. health care over the last decade, it remains the case that doctors here have an unprecedented amount of freedom in how and on what terms they work, compared to almost any other country.
Having all these different experiences over the years, if you were to ask me today, I don't believe such a centrally controlled system like the NHS is an ideal system to aspire to. It restricts patients and physicians alike. It is too much at the whim of transient politicians, with no medical knowledge, who can enforce a universal country-wide policy change almost overnight (such as a change in patient rights, physician scheduling, or even banning all doctors from wearing white coats and ties, which is what happened in the UK). Neither does a centralized system foster the best environment for innovation or individualized care. Go to any patient floor in a socialized system, and it often has a Soviet-style aura about it, with rows of patients lined up, little personal space, monolithic designs, and staff wearing the same uniform. The collective American psyche is very different from Europeans, and the consumer-driven mentality here probably wouldn't endear itself to an NHS-type system anyway.
With regards to funding, I don't think it's necessarily a bad thing for patients to contribute themselves for doctor visits and hospital stays, as long it is capped at a very manageable level for the individual, with absolutely no “surprise bills”. There's an argument to be made that if people in England are so willing to spend £30 ($50) for regular restaurant visits, haircuts and other entertainment—why not a small co-pay for a doctor visit? Anything that's completely free can easily foster an increasing culture of entitlement, reduced self-responsibility, and sadly sometimes abuse of the system.
At the other end of the spectrum, is the idea of caring for peoples' health from cradle to grave a noble one? Yes, it is. Should anyone be refused coverage because of a pre-existing condition or go bankrupt and lose sleep because of unforeseen medical bills? No, they shouldn't in any civilized country. Do many of the socialized healthcare systems produce better outcomes than us? Yes, they do. Is the high-cost system we currently have sustainable over the long term? No, it isn't.
Perhaps something in-between the two extremes would be best, like Australia, which gives tax breaks for people who take out private insurance, but still offers a public system as backup to anyone who needs it?
For this debate at least, I'm stuck between a rock and a you-know-what.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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