Myth 2: stop socialising so much
A distrust of what is called ‘socialized medicine’ is the principal argument made by the right against any solutions to US health care issues which involve an attempt at universal coverage and any governmental intervention in healthcare. A quote that captures this thinking is as follows.
“Socialized medicine is a bad idea. It stifles innovation and leads to rationing of services”.
(There are, unsurprisingly, many more intemperate quotes that fit here, mainly ones that articulate a bizarre and irrational hatred of Canadians (who are almost universally a thoroughly charming group of people in my experience) and which are only on a nodding acquaintance with English as she is spoke (even as she is spoke over here). But beyond the amusement of counting how many (sics) I can insert into eight lines of purple prose, the value of quotation is questionable.)
The argument though depends upon following being true to hold water.
1) First that healthcare innovation is greater in the US than countries with socialised medical systems (i.e. the rest of the west)
2) Innovation is the same thing as good quality care
3) That America has no rationing of care – or at least better access than elsewhere.
In addition, implicit in the argument is that the same problems of access and rationing occur in all socialized systems (and effectively because this is attributed to excessive government control, that all socialised health systems are large government bureaucracies.
It is worth testing each of these facts to check the argument.
First the suggestion that all socialised medical systems are essentially the same and are effectively large government bureaucracies is nonsensical. While all share some degree of social solidarity as an underpinning principle, variation is manifold. For example provision may be via a single monopolistic provider or a range of competing providers; healthcare professional may be employed by or contract with the state, or they may have no legal relationship with the state at all; funding may be through tax, social or individual insurance; there may or may not be rationing of services via waiting times; if an insurance-based system the insurance may be administered by the state or by private companies; insurance premiums may be paid by employers, employees or all citizens. I could go on. Therefore, tarring all socialized healthcare with the failings of one system – as an inevitable consequence of a healthcare system that is socialized is not only a failure of logic (a is bad, a is an example of b, therefore all b must be bad- by way of analogy replace ‘a’ with “Carlton Palmer’, ‘b’ with English midfielders, and then consider the vision of general footballing loveliness that is Paul Scholes), but also shows an ignorance of the diversity of socialised systems. (I would just like to point out that the above paragraph is the first occasion in the history of the English language that the words “vision of loveliness” and “Paul Scholes” have been used in the same sentence unironically).
The view that socialised medicine necessarily prevents innovation seems fallacious and dependent on a behavioralist view of the incentives to deliver innovation – i.e. you’ll only do it if there’s a buck in it for you. This seems to misunderstand doctors, scientists and health professionals. My reviews of research into the levers for improvement in healthcare point to intrinsic motivations such as altruism and professionalism being a much clearer driver than payment. Whether there is more innovation in the US is a moot point. It is certainly true that American’s are more interested in and optimistic about the development of medical technologies, and it is also true that the proportion of government non defence research expenditure spent on health is higher in the US than in the rest of the west (but the second highest level of expenditure is in the highly socialised UK) . What seems undoubtedly true is that American healthcare is much quicker to adopt expensive technological innovations (rather than necessarily innovate – there is a subtle difference here) and that this leads to increased costs. See for example this article.
Whether this necessarily adds up to better care is questionable. Wennburg (cited op cit), amongst others, has argued that innovation is prone to overuse and excess cost. “Lurking behind the variation in patterns of care are often huge hospital investment in expensive technologies that are directly tied to their economic stability”. In other words, heavy capital investment in expensive technologies can only be supported by making heavy use of the machinery in order to charge a bill and gain a return on capital employed. Typically this investment has been made in diagnostic machinery. A fellow Fellow of mine is working out of Brown University in Rhode Island. Rhode Island is the smallest state in the union (in area at least) and has a population of about 1.25 million. It also has 45 MRI scanners. When he asked why this was he was told
“marketing. Hospitals are not considered cutting edge unless they have their very own MRI.”
Essentially this means that working 8 hours a day – weekends excluded - with one scan every 20 minutes, there is sufficient capacity for every Rhode Islander to have a scan every month. This might be considered a tad excessive. In a rational market, the organisations with under-utilised machines should drop out of the market – BUT GIVEN THE UP FRONT COSTS OF INVESTMENT IN THE MACHINERY THEY CAN’T AFFORD TO. So the only option left under this hyper-expensive PR strategy is to get as much return on the asset as possible through very high levels of referral. This inevitably inflates costs. Hard to think of a nicer example of supply-induced demand – but of- course the supply itself is responding to a cultural myth about the thrill of the new. For a succinct expose of the fallacy that quick adoption of new technologies necessarily means better quality healthcare please check the writing of Paul Krugman here .
This argument also collapses because it assumes that socialised medicine is incapable of innovation. In fact the one part of the US healthcare system that is most socialised, the Veterans Administration, has, recently, one of the best track records in true innovation (i.e. genuinely developing better quality services – not just being too hasty in paying a lot more for new products that are only slightly better than those that pre-exist). This is referenced in the economist’s article above (in terms of its use of IT – which having seen demonstrated is genuinely impressive), and in terms of its adoption of quality improvement techniques, and transformation of its model of care (which not only got of higher quality but became cheaper too. Good references for this are contained here. If you have Pub Med or Medline you can find a plethora of papers in peer reviewed journals.
The stifling innovation argument is wrong both in its logic (innovation necessarily equals better care) and in its fact (socialised systems innovate – and may innovate more wisely). The next post considers the charge of rationing.
“Socialized medicine is a bad idea. It stifles innovation and leads to rationing of services”.
(There are, unsurprisingly, many more intemperate quotes that fit here, mainly ones that articulate a bizarre and irrational hatred of Canadians (who are almost universally a thoroughly charming group of people in my experience) and which are only on a nodding acquaintance with English as she is spoke (even as she is spoke over here). But beyond the amusement of counting how many (sics) I can insert into eight lines of purple prose, the value of quotation is questionable.)
The argument though depends upon following being true to hold water.
1) First that healthcare innovation is greater in the US than countries with socialised medical systems (i.e. the rest of the west)
2) Innovation is the same thing as good quality care
3) That America has no rationing of care – or at least better access than elsewhere.
In addition, implicit in the argument is that the same problems of access and rationing occur in all socialized systems (and effectively because this is attributed to excessive government control, that all socialised health systems are large government bureaucracies.
It is worth testing each of these facts to check the argument.
First the suggestion that all socialised medical systems are essentially the same and are effectively large government bureaucracies is nonsensical. While all share some degree of social solidarity as an underpinning principle, variation is manifold. For example provision may be via a single monopolistic provider or a range of competing providers; healthcare professional may be employed by or contract with the state, or they may have no legal relationship with the state at all; funding may be through tax, social or individual insurance; there may or may not be rationing of services via waiting times; if an insurance-based system the insurance may be administered by the state or by private companies; insurance premiums may be paid by employers, employees or all citizens. I could go on. Therefore, tarring all socialized healthcare with the failings of one system – as an inevitable consequence of a healthcare system that is socialized is not only a failure of logic (a is bad, a is an example of b, therefore all b must be bad- by way of analogy replace ‘a’ with “Carlton Palmer’, ‘b’ with English midfielders, and then consider the vision of general footballing loveliness that is Paul Scholes), but also shows an ignorance of the diversity of socialised systems. (I would just like to point out that the above paragraph is the first occasion in the history of the English language that the words “vision of loveliness” and “Paul Scholes” have been used in the same sentence unironically).
The view that socialised medicine necessarily prevents innovation seems fallacious and dependent on a behavioralist view of the incentives to deliver innovation – i.e. you’ll only do it if there’s a buck in it for you. This seems to misunderstand doctors, scientists and health professionals. My reviews of research into the levers for improvement in healthcare point to intrinsic motivations such as altruism and professionalism being a much clearer driver than payment. Whether there is more innovation in the US is a moot point. It is certainly true that American’s are more interested in and optimistic about the development of medical technologies, and it is also true that the proportion of government non defence research expenditure spent on health is higher in the US than in the rest of the west (but the second highest level of expenditure is in the highly socialised UK) . What seems undoubtedly true is that American healthcare is much quicker to adopt expensive technological innovations (rather than necessarily innovate – there is a subtle difference here) and that this leads to increased costs. See for example this article.
Whether this necessarily adds up to better care is questionable. Wennburg (cited op cit), amongst others, has argued that innovation is prone to overuse and excess cost. “Lurking behind the variation in patterns of care are often huge hospital investment in expensive technologies that are directly tied to their economic stability”. In other words, heavy capital investment in expensive technologies can only be supported by making heavy use of the machinery in order to charge a bill and gain a return on capital employed. Typically this investment has been made in diagnostic machinery. A fellow Fellow of mine is working out of Brown University in Rhode Island. Rhode Island is the smallest state in the union (in area at least) and has a population of about 1.25 million. It also has 45 MRI scanners. When he asked why this was he was told
“marketing. Hospitals are not considered cutting edge unless they have their very own MRI.”
Essentially this means that working 8 hours a day – weekends excluded - with one scan every 20 minutes, there is sufficient capacity for every Rhode Islander to have a scan every month. This might be considered a tad excessive. In a rational market, the organisations with under-utilised machines should drop out of the market – BUT GIVEN THE UP FRONT COSTS OF INVESTMENT IN THE MACHINERY THEY CAN’T AFFORD TO. So the only option left under this hyper-expensive PR strategy is to get as much return on the asset as possible through very high levels of referral. This inevitably inflates costs. Hard to think of a nicer example of supply-induced demand – but of- course the supply itself is responding to a cultural myth about the thrill of the new. For a succinct expose of the fallacy that quick adoption of new technologies necessarily means better quality healthcare please check the writing of Paul Krugman here .
This argument also collapses because it assumes that socialised medicine is incapable of innovation. In fact the one part of the US healthcare system that is most socialised, the Veterans Administration, has, recently, one of the best track records in true innovation (i.e. genuinely developing better quality services – not just being too hasty in paying a lot more for new products that are only slightly better than those that pre-exist). This is referenced in the economist’s article above (in terms of its use of IT – which having seen demonstrated is genuinely impressive), and in terms of its adoption of quality improvement techniques, and transformation of its model of care (which not only got of higher quality but became cheaper too. Good references for this are contained here. If you have Pub Med or Medline you can find a plethora of papers in peer reviewed journals.
The stifling innovation argument is wrong both in its logic (innovation necessarily equals better care) and in its fact (socialised systems innovate – and may innovate more wisely). The next post considers the charge of rationing.
posted by Exiled in mainstream at 3:21 PM
1 Comments:
I remember President Clinton listing American achievements. He included splitting the atom, a feat first achieved by Lord Rutherfor, a New Zealander working in Cambridge, England. Perhaps he confused his Cambridges.
As far as innovation is concerned Americans would do well to remember that those great American innovations in health care like antibiotics, monoclonal antibodies, CT and MRI scanners were actually invented in Britain, where socialized medicine stifles innovation.
Post a Comment
<< Home