Friday, April 2, 2010

Bad Ideas and Health Care Reform

Nope, I'm not going to be writing about Obama's recent success in passing health insurance reform. I'm cautiously optimistic about its impact, but those events have predictably brought up the subject of health care reform in Canada once again. As a general rule, newspaper columnists and pundits are not experts about anything and will typically provide - at best - some sort of conventional wisdom that doesn't bear scrutiny. David Olive's column about "five bright ideas to save the Liberal Party" is no exception. He posits, indeed, a health care "renaissance" as one such idea:
Skyrocketing health-care costs are a fixation of governments from Japan to France, all facing the same demographic challenge of an aging population as we do, but not content as we are in passively watching health-care costs gobble up 40 per cent of our economy by mid-century, likely sooner. Health care is perhaps the one major field most stubbornly resistant to reform in both quality (medical errors are rampant) and cost-efficiency. At least in its big cities, China is far ahead of North America in electronic medical records, which cut down on errors and costly duplication, and make “distance care” more practical.

As to the breadth of coverage, our imagined comprehensive Medicare coverage is anything but. It lacks the universal dental care of Britain and state-funded prescription-drug provision of France and Japan.

Just as caregivers have little incentive to rethink treatment, patients have little reason to adopt a healthier lifestyle of proper diet and fitness. A reinvented Medicare would impose means-testing and co-pays to provide that incentive. As part of that overhaul, universal care would be made truly comprehensive by embracing dental health and pharmacare extending beyond the seniors now receiving it.
Setting aside the general vagueness and lack of specifics in this "idea", it betrays both all-too-common simplistic thinking about these issues. Medical errors are rampant? I'd say they happen and are to a small extent unavoidable. As I wrote in the fall, there are numerous approaches to improve communication and cut down on errors, such as the addition of universal checklists to the OR. I'd hazard a guess that electronic medical records would play - at best - a small role in "cutting down" errors. We have many computer-based records systems as it stands, but in my admittedly limited experience paper charts are easier to flip through to find what you're looking for. I'm not sure where the duplication comes in either; if the past, oh, 30 years or so have shown anything, it's that computer infrastructure is expensive, high maintenance, and certainly not cheaper than paper.

Olive is quite right that we lack universal dental coverage (which I understand the UK doesn't have to the extent he implies) or prescription-drug provision... though drugs for certain chronic conditions and cancers are. He probably should have discussed drug costs in more detail, however, as if there's anything "unsustainable" (a common media refrain) about our system, it's drug costs - most of which are privately paid.

His last point is simply morally unjustifiable. On one hand, I'd say that good health is its own reward, and while there's no shortage of people who make bad choices (e.g. NEVER start smoking), there are many more whose jobs facilitate a sedentary lifestyle and it is a simple effect that people with low incomes and limited educations have the worst health outcomes. Another sizeable group of "frequent flyers" for health care suffer from genetic predispositions to different diseases. In short, Olive is advocating that sick people be punished for their poor health status, under the supposition that this will give them an "incentive"... not to be sick. I guess. I'm sure those with type 1 diabetes or rheumatoid arthritis would be happy to pay nominal co-pays if it would rid them of their conditions once and for all, but that's not how things work. I'm not aware that such incentives actually work anyhow, apart from having the documented effect of driving people with low incomes away from seeking health care. And that's a bad thing.

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