The ACP just released a position paper on health care access. It’s a comprehensive analysis of our system compared to those of other developed countries. It’s a fair and sober as long as you start from the view that what’s needed in the US is a single payer system.

It says it wants to learn from other health care systems in the developed world. It’s full of interesting data that anyone interested in the issue should peruse. This is its conclusion:

The main lesson of this article is that many countries have better functioning , lower cost health care systems that outperform the United States. We must learn from them.

What would you guess we should learn from them? How about establishing a top down national health care program? This report was prepared under the aegis of the leadership of ACP. How much input the college got from its membership is not known to me. I was not asked to comment, though I have had a minor leadership position in the organization. No one else I know who belongs to the college was asked for an opinion. I suspect, but cannot know for sure, that the leadership of the ACP is quite a distance from its rank and file and that its members had little input to the group that put the document together.

There are some things we can learn from other countries that are not in this report. To begin with, many of them have a rate of growth in their cost of medical care that exceeds ours. This is what health care engineers either ignore or gloss over with fantasies about impossible cost savings. The most important health issue is not access, but a cost growth that persistently exceeds that of national income. If you live in a house and your rent annually goes up faster than your income you’re going to have to move sooner or later. All the nations in the developed world are going to have to move (from their medical house) soon.

Another lesson that can be learned is that if the birth rate is less than replacement, you’re going to have to move out of your medical house even sooner than you thought. Every country in the developed world except the US has a birth far below replacement.

Isaiah Berlin wrote a famous essay, “The Pursuit of the Ideal.” In it he shows how the search for perfection always ends badly. Every issue that is important is seen differently by different people. If you have the “perfect” system the only way you’ll get it adopted is by force. Consider the ACP’s recommendations which are abstracted below.

Provide universal health insurance coverage to ensure that all people within the United States have equitable access to appropriate health care.
Federal and state governments should consider adopting one of the following pathways:
Single-payer systems, which generally have the advantage of being more equitable, with lower administrative costs than systems using
private health insurance, lower per capita health care expenditures, high levels of consumer/patient satisfaction, and high performance on
measures of quality and access. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.
Pluralistic systems, which can be designed to assure universal access while allowing individuals the freedom to purchase private supplemental coverage. Such systems are more likely to result in inequities in coverage and higher administrative costs.
Congress should encourage state innovation by providing dedicated federal funds to support state-based programs to cover all uninsured
persons within the state.
Cost-sharing provisions should encourag patient cost-consciousness without deterring patients from receiving needed and appropriate services.
Develop a national health care workforce policy for the education and training of an adequate supply of health professionals to meet the nation’s health care needs, including primary care physicians.
Redirect federal health care policy toward supporting patient-centered health care that builds upon the relationship between patients and their primary care physicians and the patient-centered medical home.
Support initiatives that provide financial incentives to physicians for the voluntary achievement of evidence-based performance standards, to encourage quality improvement and reduction of avoidable medical errors, and incentives for systems performance that encourage comprehensive and continuous care coordination and prudent stewardship of health care resources.
Support an interoperable health information technology infrastructure with federal funds to assist physicians in acquiring technology that will enhance delivery of evidence-based patient-centered care.
Reduce administrative and regulatory burdens, such as multiple and duplicative physician credentialing forms and multiplicity of types of insurance forms, and their attendant costs.
Encourage public and private investments in all kinds of medical research, including research on the comparative effectiveness of different treatments, to foster continued innovation and improvements in health care.

If you survived all this and are still here you’ll notice that these recommendation while they seem great at first reading are in practice impossible and in some cases mutually contradictory. They are utopian, full of either errors or unsupported assumptions, and seem disconnected from reality. Do its authors really think the single payer system they want will “reduce administrative and regulatory burdens”? They repeat the crazy belief the the federal government can run a medical system with less administrative costs than the private sector. See my post of Dec 4, 2007.

But this report is Socratic in comparison to the editorial that follows it. Written by the editor of the Annals of Internal Medicine its last paragraph reads thusly:

“Successful national health care systems have taken several routes to paying for health care, but they share one essential characteristic: The government guarantees that every citizen will have health insurance. They have solved a problem that grows worse every day in the United States. Why do Americans tolerate a system that leaves one sixth of its citizens with poor access to basic medical care? When will we elect leaders who will erase this stain on our national character? Perhaps the example of other countries will motivate Annals readers to join ACP in demanding decisive action on universal coverage.”

It’s hard to be so emotional and get so many thing wrong in so few words. I don’t know what problem the editorialist thinks foreign countries have solved. It’s certainly not cost. Just before writing this I was in the hospital providing the best care I can to patients without health insurance including dialysis to undocumented foreign nationals. I guess I am a collaborator in staining the national honor. Not having medical insurance is not the same as not having medical care and anybody who writes about this issue and purports not to know this is disingenuous at the Olympic level. “A stain on our national character.” This sophomoric and melodramatic outburst trivializes a serious issue. The demand for medical care is endless. The cost of this care can only be contained by rationing by delay or rationing by price. If you want the former go for the single payer system. If you’re for the latter you won’t get elected. Or we can ignore the whole enterprise and sink under the weight of ever increasing costs.

Also note the position of moral superiority from which the editorial is proclaimed. Anyone who is not for universal coverage is not only wrong but is tainted the stain on our national character and must be a very bad person indeed. When you have the key to the truth you can brook no opposition.

The perfect being the enemy of the good it makes sense to try to fix one thing at a time. The ACP sets no priorities they want everything now. If you have a list of goals and meet just one of them you’ve done a great job. Medical care in the US for all it’s strengths could be a lot better. It will only get better if we realistically analyze its problems and set goals that are not overwhelming or utopian. The ACPs recommendations fail both these criteria.

For some interesting view of medical care to or north see here and here. Also see the video below. The US is a safety valve for the poor to our south and the affluent to the north. The Academy Award winning movie The Barbarian Invasions (largely set in a Montreal hospital) depicts hospital administrators and unions as corrupt, the physical plant to be decrepit, and physicians as ignorant of their patients problems and their names. I don’t know how accurate this portrayal is, but presumably the French-Canadians who made it have some experience with their medical system.