From The Floor
Analyzing Our Healthcare System: Is the Grass Greener?
Are other heathcare systems really better than ours? Here we provide an in-depth analysis from a nurse who was raised and educated in France.
PART ONE: THE PROBLEM DEFINED
In Summer 2003, nearly 15,000 French people died from a horrible heat wave that ravaged the country. The shocking number of fatalities caused French citizens to demand to know how their government could stand by while so many died. France’s President at the time, Jacques Chirac, ordered an investigation and assured the people that corrective action would be taken. The Institut national de la santé et de la recherché médicale (INSERM), similar to our National Institutes of Health (NIH), was ordered to investigate and provide a detailed report on the deaths.
The INSERM researchers came to several startling conclusions. The first was that many of the elderly deaths could have been avoided with two simple items: water and an air conditioning unit. President Chirac promised to have air conditioning units installed in all government-run assisted living and other facilities caring predominantly for elderly patients. This promise remains unfulfilled. Second, the INSERM researchers postulated that too many physicians took their 30-day vacation in August, the month when the most heat-related deaths occurred, which may have played a role in many of the deaths.
All these individuals had healthcare plans, and many were in healthcare facilities when they died—not a heyday for socialized medicine!
This example is no more dramatic than the testimonies of Americans whose health plan failed them or who experienced horrible consequences due to lack of healthcare; these stories are often referred to by supporters of universal healthcare, such as California State Senator Sheila Kuehl, the California Nurses Association (CNA), AARP and Michael Moore. Given the opportunity, both sides can provide heart-wrenching accounts, yet how do these examples advance the much-needed discussion on the state of American healthcare?
What makes this discussion such a challenge is how emotionally and politically charged it has become. If you are not in favor of the universal healthcare lobby, then you are labeled as heartless or a supporter of the evil healthcare/insurance lobby; however, if you show support to universal healthcare, then you are labeled Socialist, Communist and so on. How do we debate this very real concern in a civilized, informed manner?
As a French native who has lived a good portion of my adult life in the United States, I often compare and contrast the very disparate systems of these two countries. In addition, I read the written word like it will disappear tomorrow and have accumulated extensive knowledge and information on the health systems of various other nations. Therefore, I am very passionate about this debate, and have garnered much information to share with my readers.
No Such Thing As Free
An important term to clarify is “free healthcare”—a favorite of the pro-universal healthcare lobby, including those in favor of SB 840 (advertised as a single-payer system for California). However, healthcare is not free. For example, the French, Canadian, and British systems are paid for with taxes. In Canada, they pay 48 percent of their income and, in France, in addition to income tax, they have a healthcare tax called “taxe sur la valeur ajoutée” or TAV, which is an added tax on nearly everything under the sun—food, car repair, goods, etc.—in short, a consumption tax levied at each stage of production, based on the value added to the product at that stage. Most of the solutions offered for the United States require some kind of tax. How do you think we pay for Medicare?
Proponents for universal healthcare often compare our system to that of France, Canada, Great Britain, and Australia. However, in France and Australia, for example, if a citizen wants state-of-the-art treatment, they obtain supplemental health insurance. That’s right—they pay money out of their pocket to a separate health insurance company to augment the nationalized system. At present, the Canadian system prohibits the use of supplemental insurance; numerous patients and physicians have challenged this law and it is currently before their Supreme Court.
Others suggest that we need to cut out the middleman, health insurance companies, to reduce costs while allowing doctors to collect their fair share. Others say that if we got rid of the estimated 12 million plus illegal aliens, then the money we have already allocated would be more than sufficient to care for citizens and resident immigrants alike. Let’s not forget the malpractice attorneys, because there are many who believe that one sure way to reduce costs is to limit malpractice awards, citing the fact that fewer physicians are practicing as OB/GYNs because the cost of malpractice insurance is prohibitive.
The Canadian System
Many point to Canada as a system worthy of emulation, but it is far from perfect. I was once shocked to hear news announcements on Canadian TV pleading with citizens to only use the Emergency Rooms in cases of real emergency since they had to close several due to a lack of doctors, many of whom were on a trip to Toronto. Later, I learned that even though the government (unlike in France and Great Britain, for example) does not own the hospitals, they do provide major funds. So each month, as the hospitals’ money decreases, certain treatments are delayed and, in some cases, ceased until the next month’s allocation.
It is also important to note that all these nations, including Canada, Great Britain, France and Australia, have nursing shortages that make ours look like a walk in the park. Others point to the “excessive” salary that doctors make as one of the causes of our current healthcare problem. If those doctors didn’t expect to make $200,000 a year, then our healthcare system would have so much more money to invest in actual care—right?
When looked at objectively, our system is not so much bad as faulty. I know all the “SICKO” fans were led to believe that even Cuba has better healthcare than we do. When Mr. Moore, a noted “expert” in healthcare (NOT!) was asked to choose which system we should emulate, he suggested Canada as a model. Just to put things into perspective, as of July 2007, Canada has a population of 33,390,141; in Los Angeles County alone, the population is estimated at just over 10 million with the total population of California estimated at 37,700,000; in the United States, our population is more than 300 million.
You may wonder why these figures are important to know—the answer is simple. Take baking a cake—let’s say you have this to-die-for Devil’s Food Cake recipe and you know that it yields eight servings, but you want to make it big enough to serve 80 people. Even though you know it’s 10 times the size, you can’t just multiply the recipe by 10, since the portions of liquid and solids will not necessarily mesh and the end result will not reflect the taste, consistency or quality of the original recipe. I believe it is the same with a healthcare plan or system we try to emulate—we can’t just use a multiplier to figure out how to expand it or how to ensure full coverage—this would be futile and could leave us in a worse position than we think we are in now. However, this does not mean that I think that the status quo is the way to go. Nearly everyone agrees that something needs to be done—the question is what?
What are we to do about fixing our current healthcare challenge? We need to take a critical look at our system and identify what works and what does not, and we must try to avoid the desire to point fingers and play the blame game. Most importantly, we must be willing to make some sacrifices if we want to see our nation develop some kind of coordinated healthcare system.
PART II: WHAT SACRIFICES ARE WE WILLING TO MAKE?
Many people believe healthcare is a right guaranteed under our Constitution, thus making the government responsible for providing healthcare coverage. If this is the case, then what are we willing to sacrifice for this scenario to become a reality? When I think about the differences between the French and the United States’ healthcare systems, I am reminded of two critical aspects that are like day and night: expectations and repercussions.
Heroic Measures to Prolong Life
Americans expect their healthcare providers, especially physicians and nurses, to go to extreme lengths to save a life. Nowhere is this expectation greater than in NICU. I remember the first preemie that I ever took care of here in the U.S. She was way “undercooked” as we say in NICU, born under 500g (imagine a pound of butter, if you will), but this did not stop the entire healthcare team from doing everything humanly possible to keep her fragile body alive until, many months later, she matured enough to breathe, eat, and live on her own. No one found it odd that we were willing to invest millions of dollars to save this one fragile life, even with the knowledge that she would probably go on to live with many chronic disabilities due to her extreme prematurity.
In France, as a rule, an infant born under 500g is not given any heroic measures, nor does the family expect it. Instead, the family and infant are given a room where they can spend what time remains, and only palliative measures are taken to make sure the infant does not suffer. This does not mean that the French value the lives of their loved ones any less than Americans, it simply illustrates different levels of expectations. In France, there is no expectation that a 97-year-old man will undergo aggressive treatment to prolong his life, while in the U.S., there are many who expect this will always be available.
Other Cultural Differences
Just as the French don’t expect heroic measures, they also rarely sue doctors, nurses or other healthcare providers for malpractice. This does not mean that their healthcare providers are more competent, it’s just that lawsuits are not a cultural norm in France. When I was once asked to lecture to a team of doctors on the U.S. versus French healthcare systems, I was jokingly warned by my host not to dwell too long on malpractice since they didn’t want me to “teach” the doctors about what they viewed as a very American idiosyncrasy.
There are other changes we might expect if we were to move to a nationalized, universal or socialized healthcare scheme. These changes would include the acceptance of some form of a national health identification card: a real-time, transportable, electronic medical record for use in diagnosis and treatment. These types of cards make great sense and are already in use in many of the countries that have a nationalized, universal or socialized healthcare program. Such a card would allow all of our medical and pharmaceutical history to be readily available, eliminating the patients’ responsibility to provide their entire health history and pharmacopeias, which can be harder to recollect as we get older. One of the greatest barriers to adopting this is the reluctance of Americans to enact a national ID card system. This almost uniquely American aversion to a national ID is difficult for the French to understand, as government intrusion is much more common in France.
Better for Nurses?
It has been postulated that universal healthcare would usher in an era of better nursing care and a better nurse work environment. Whether or not this is the case is yet to be proven, but one only needs to read the daily reports from England, Canada, Australia and France to see that their healthcare plans are facing monumental challenges and, in some cases, the nursing profession seems to be imploding. Sign up for an Internet clipping service and select keywords such as “nurse” or “nursing”—you will be surprised to learn what challenges our profession faces in other countries.
Another area that is rarely discussed is the state of medical research. It is a long held belief that the U.S. “out researches” the rest of the world in the arena of medicine. Pundits point out that our nation is responsible for approximately 75 percent of all new medical and equipment research and development and that this success rate can be directly linked to our free-market approach to healthcare.
For example, at a recent meeting of health insurers in Pasadena, the head of the Canadian Medical Association cited that, on average, it takes five years for the Canadian medical establishment to adopt new medical and pharmacological technology. In short, the product was available in the U.S. for at least five years before it made it into mainstream Canadian healthcare. In addition, Canadians often must wait for life-saving treatments. A recent Canadian Supreme Court decision that stated “access to healthcare did not mean access to a waiting list,” which came in response to a lawsuit where Canadians were suing the government to allow them to access treatment in the U.S. for procedures such as hip replacements, cancer treatments, etc.
Cash Only System
Many opponents of the universal healthcare scheme fondly refer to the “good old days,” pre-World War II, prior to the rise of the large health insurance companies, when doctors collected directly from patients. These individuals argue that if we adopted a system reminiscent of this period, we could cut our healthcare costs down to nearly nothing. In addition, the consumer and doctor would be allowed to return to a more personal, one-on-one relationship—the way, they argue, that it was intended to be all along.
Supporters of this model hold a strong belief that it will enable physicians to have a greater impact on the care they provide, and that patients would have a better idea of what their healthcare costs truly are instead of what they are presented with in today’s insurance scenario.
When I was a nurse in Columbus, Georgia, I remember one such physician who not only accepted cash, he practiced the barter system with his patients who were cash poor but had wonderful products or services to trade. Some doctors eschew insurance all together and claim that, by not accepting insurance, they reduce the number of employees from five per full-time physician to two. Physicians can, in turn, spend more time with patients, and thus provide better quality of care.
Going cash-only is not as farfetched as it may seem, but there are indeed barriers to such a system, and a critical need to raise awareness that such an option exists. In addition, patients would need to be made aware that there are urgent care clinics that accept the self-pay or uninsured patients, and that the ER is not their only choice.
Contrary to universal healthcare propaganda, self-pay patients are not necessarily playing with fire. When a person is basically healthy, without a chronic or catastrophic illness, paying for a $60 check-up once or twice a year is an acceptable alternative to $100 plus monthly health insurance premiums, deductibles and co-payments. It is an option many entrepreneurs and employees at small startup companies choose since they are too small to leverage a good benefits plan or are often deemed uninsurable by health insurance companies.
Perhaps we could develop a health insurance program for catastrophic and chronic illness and have everyone pay into this program. Therefore, when confronted by a pregnancy, broken leg, bout of pneumonia, cancer or some other costly illness, the cost would not bankrupt the individual when they access the care and treatment they need.
Is Health Insurance Different Than Auto Insurance?
Another option, currently in use in Massachusetts and under consideration in California, is a requirement that everyone must have insurance coverage (most likely a combination of public/private/employer coverage). Proponents of this system in California point to how well a similar mandated insurance program works for automobile drivers. However, I have not found the mandated auto insurance law to have a dramatic impact on my car insurance payments, which seem to increase every year, even though I have no accidents or violations. Just ask anyone who was struck by an uninsured driver how that mandated insurance law worked for them.
Of course, the obvious response is that we need to “put teeth” in the law so that more people will comply. Simple answer on the surface, but if any of my readers are following what our current Insurance Commissioner, Steve Poizner, is proposing in his plan to initiate more aggressive enforcement, I think you can draw a similar parallel to the challenges a mandate requiring everyone to carry health insurance may face.
An interesting aspect of health insurance is that it does not follow the model of most other types of insurance. For example, ask any auto or home policyholder if they expect their insurance to cover maintenance and they would, in all likelihood, answer no. We do not expect auto insurance to cover flat tires or tune-ups, and homeowners never expect their policy to cover a visit from the plumber or roofer. However, these same owners do expect their policy to cover damage caused by accidents or catastrophic events. Yet we expect our health insurance to cover our physical maintenance in addition to any chronic or catastrophic illness.
Perhaps, if we approached health insurance as we do other forms of traditional insurance and offer the opportunity to purchase coverage for chronic and catastrophic events only, it would be more affordable all around. Small employers could then provide some type of supplemental insurance that covers all the extra bells and whistles and deliver, once again, a benefit that would help employee retention and attract employees. Startups and small businesses might be able to provide insurance, or perhaps do as many nonprofits do, which is join into a pool and use this leverage to provide additional coverage to their employees.
Government Run Healthcare
Personally, I have many reservations when asked to contemplate government-based health insurance. One only needs to take a look at the current state of our Veteran’s Administration (VA) healthcare program to see what can happen. I remember how well the program was run when my ex-husband returned from Vietnam, but over time, as various administrations came and went in D.C., they each influenced appropriations for the VA. In the mid-to-late 1990s, the VA experienced massive reorganizations and budgetary constraints that have, in great part, led to the current condition it is in today.
As Governor Schwarzenegger tried to roll out his SB11 healthcare plan in California, weaknesses were quickly identified and attacked. At the same time, it was confirmed that Massachusetts’ mandated health plan will cause a large budgetary deficit for this state. The Governor’s plan could have resulted in deductibles amounting $20,000 per family—how many middle class families can afford such a deductible? While our state faces a $10 billion budget shortfall, how could we launch such a complicated healthcare program without causing an even greater budgetary deficit? Needless to say, the bill died.
Unions and other pro-labor groups express their concerns over the possible costs of such a program and what additional financial burden this may place on their members. We must also ask whether or not this program will be offered to all Californians. If this program is made available to anyone in California, will this include the undocumented individuals, temporary workers or visitors to our state?
Does this mean I oppose a universal healthcare approach? Not necessarily, but I’m not sure the programs being touted as the cure to our current challenges will solve the underlying issues. I also fear that, in pursuit of the so-called better programs in other countries, we may inadvertently abandon the strengths of our current system. Perhaps we shouldn’t throw the baby out with the bathwater and, instead, take time to truly analyze what we do right, look at where our flaws are and then develop a system that would serve as a better model.
We also need to ask ourselves what are we willing to give up in order to move to whatever new system our state or nation devises for us. As both nurses and citizens, in all likelihood, these changes will have a twofold effect for us, since we are both consumers and deliverers of healthcare. Everything, including our healthcare delivery system, needs to evolve to remain relevant, applicable and serviceable.
The question that remains to be answered is what will it evolve into—and if you are concerned about the direction the discussion is taking, be sure to educate yourself on the subject (and that means learning about all sides of the discussion) and don’t be afraid to join the fray. Without a doubt, this will be a most interesting ride.
Geneviève M. Clavreul, RN, PhD, is a healthcare management consultant and a former Director of Nursing.
This article is from workingnurse.com.