May 2009 – Denialism

What is health care like in the UK, Canada and New Zealand?

Three systems widely cited as examples of universal health care are the so-called single-payer systems in the UK, Canada and New Zealand.

These systems I would describe as “socialized”, and rely for the most part on taxation for funding. The system in Canada for instance, uses taxes to pay for health care administered by the individual provinces, and provided by a mixture of private and public hospitals and health care providers. Private health care is restricted in Canada, but is available in some provinces under publicly-funded private organizations called P3s. Private health insurance is limited in Canada but is available.

The UK’s National Health Service (NHS) similarly uses taxes but 8% of their population still utilizes private insurance to augment their national health care services. Services from the NHS are entirely free of charge for residents, and prescriptions have a nominal fee regardless of the cost of the medication. The government is the primary employer of health care professionals, and general practitioners (GPs), act as independent contractors employed by the NHS who serve as gatekeepers into the health system. A GP manages your health care and decides if you can see a specialist.

The New Zealand system is more decentralized with funding of community health boards to serve the needs of the population, primary care since 2001 has been subsidized by the government through Primary Health Organizations designed to allow broad access to primary care for a nominal fee and hospitals and other health services are funded through taxation. They also have a single payer drug service to subsidize prescription drugs and users pay a nominal fee for prescriptions.

How satisfied are patients with these systems, and what is their quality of care?
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What is the cause of excess costs in US healthcare?

The question has come up again and again in our discussions on health care in the US and around the world, why does it cost so much more in the US when we get so much less?

The drug companies and their lobbyists are already out in force trying to make sure their pocketbooks aren’t hit by the inevitable reforms that are coming. In particular they insist drugs aren’t the problem in the US, it’s administrative costs! I would tend to disagree.

Based upon my experience working in the sytem, the main causes of excess costs I would hypothesize are the following (in order of importance):

An excess of cost in administration far out of line with most countries around the world.
Pharmaceutical costs – especially due to the effects of direct to consumer advertising (DTCA) encouraging use of more expensive, newer drugs (which is only allowed in the US), Medicare part D which forbids collective bargaining for lower drug prices, and a broken patent system that allows drug makers to patent and charge more for non-novel medications.
The absence of a universal system that prevents risk-sharing, and causes the uninsured to avoid treatment until problems are more critical, and more expensive.
Excessive reimbursement of physicians for procedural skills, rather than cost-saving physician roles such as primary care and family practice that emphasize early diagnosis and proper management of disease.
Excesses of cost caused by “defensive medicine”. While torts themselves don’t cause a great deal of monetary damage, the culture they create is one of paranoia in physicians who make decisions with lawsuits in mind, rather than the interests of patients and society
The excessive costs in ICU care, especially at the end of life, which may also be reduced by better EMRs with recording of living wills, and public information campaigns designed to inform people about the pain, invasiveness and futility of “doing everything” in the elderly.
The absence of an electronic medical record that is universal which causes redundancy in testing as patients see new doctors who then order redundant tests because sharing of information is so inefficient.

But these may just be my biased views based on my own limited experience. Let’s see what the data show. The McKinsey Global Institute has generated a report on this, and has broken down the data according to the individual costs in our system, while comparing it to that of other countries.

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What is health care like in France?

Here it comes. How dare I suggest the US could learn anything from France? By most assessments France provides the best health care in the world, with excellent life expectancy, low rates of health-care amenable disease, and again, despite providing excellent universal care, they spend less per capita than the US. Using about 10.7% of GDP and about 2000USD less per capita than the US they are providing the best health care in the world. To top it off, France’s system isn’t even socialized. That’s right. It’s yet another system that is a mixture of public and private funding that, if anything, provides the greatest level of physician and patient autonomy in making health care decisions. It is not, I repeat, not a single payer system. Doctors are largely self-employed, there is no big government authority telling doctors and patients what to do, just a progressive tax structure and requirements to pay into the system that fully subsidizes a functional healthcare system.

Start with the Wikipedia entry, if you can stand to read it try the WHO document on the structure of the French system, or various articles which all seem to agree the French system rocks. The few criticisms stem from it’s relative cost compared to the other European systems and perhaps overutilization by citizens. But no one asserts that it provides poor care, that it rations care, that it limits doctor or patient autonomy, or has poor resources.

As with most health care systems, the more you read about it the more you see how the system reflects the values of the country. But these should be universal values.
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What is healthcare like in Germany?

What better argument for universal health care can you make than that of Germany? By far one of the most successful systems, it has had some form of universal health care for almost 130 years, and is currently one of the most successful health care systems in the world. It is again, a mixture of public and private funding, with employers providing most of the funding for health care by paying into one of several hundred “sickness funds” that provide health care funding to their employees. Germany is widely regarded as having excellent access, short wait times, care with the best technology and pharmaceuticals available, and this again while spending 10.7% of GDP (US 16%) with per capita spending of ~3.3k USD (approximately half of that in the US).

The German health care wikipedia entry is a good starting point, and it’s always fun to try to translate German web pages and try to make sense of Google translations. But I’ve found several good articles describing the system including several articles in the MSM like this NYT piece which refers to Americans as having an “… immature, asocial mentality [that] is rare in the rest of the world,” one for travelers, and one for those looking for German jobs. The consensus seems to be that Germany rocks when it comes to health care.

Let’s talk about how it performs and how it works.

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Denying AIDS – A book by Seth Kalichman

Seth Kalichman is a better man than I. Kalichman is a clinical psychologist, editor of the journal Aids and Behavior and director of the Southeast HIV/AIDS Research and Evaluation (SHARE) product, and he has devoted his life to the treatment and prevention of HIV. Despite a clear passion for reducing the harm done by HIV/AIDS, to research this book he actually met, and interviewed, prominent HIV/AIDS denialists. I confess I simply lack the temperament to have done this. To this day, when I read about HIV/AIDS denialists, and the the 330,000 people who have died as a result of HIV/AIDS denialism, I see red. I think violent, bloody thoughts.

The HIV/AIDS denialists, like Celia Farber, object to being called denialist, a quote from her in the book:

Those who wish to engage the AIDS research establishment in the sort of causality debate that is carried on in most other branches of scientific endeavor are tarred as AIDS “denialists,” as if skepticism about the pathogenicity of a retrovirus were the moral equivalent of denying the Nazis slaughtered 6 million Jews.

To this I would reply that the HIV/AIDS denialists like Duesberg are worse than holocaust deniers. Holocaust deniers are anti-semitic bigots and horrible people sure, but the HIV/AIDS denialists are responsible for an ongoing campaign of death. Because people like Duesberg have convinced morons like Thabo Mbeki of their pseudoscience, hundreds of thousands of people are dead.

This is why I see red. Denialist is about the nicest thing you could call the likes of Farber and Duesberg.

Kalichman’s book is well-written, timely, thoroughly researched, and to his great credit he uses my definition of denialism. Ha! How could I help but love this book? The fact that he pursues denialism from a psychological angle, and interacts directly with the critical denialists behind this story make it a profoundly important study and resource in understanding not just HIV/AIDS denialism, but all forms of denialist pseudoscience. This takes a very patient, very dedicated person. I would have lost my temper, lost my patience, or lost my mind to have delved so deep into this madness. Not to mention, I’m not very forgiving or nice to people I perceive as being so detrimental. It’s a personality flaw, I recognize it. That’s why we’re lucky to have people like Seth Kalichman.

Let’s discuss some of Kalichman’s findings below the fold…
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What is healthcare like in the Netherlands?

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The Dutch really have it together on health care, they have a system that has been proposed as a model for the US to emulate. In stark contrast to many other European systems, it’s actually based entirely on private insurers, rather than a single-payer or entirely national system. Yet the Dutch system is universal, has far superior rates of satisfaction with quality of care and access, and still costs a fraction of what we pay for health care per capita in the US. How is this possible?

You can read the Wikipedia entry on the Dutch system or read about it on their Ministry of Health’s English webpage or watch the short film on their reforms below.

So, how does the Dutch system work?

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What’s health care like in Australia?

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To start off some balanced discussions of what universal health care looks like around the world, I thought I would begin with Australia, a system that we could learn a great deal from.

In the US system, we do not have universal healthcare, we have mostly employer-subsidized healthcare, private insurance and medicare covering people’s health expense. We also lack a universal electronic medical record, our main recourse for responding to poor care is lawsuits, and we have a high disparity in services available to those with money and those who do not. We still manage to spend more on health care per capita than any country in the world, while being ranked 37th in the world by the WHO, 72nd in the world for healthiness of its citizens, and 19th among industrialized countries (last) by the Commonwealth fund. We have a very poor infant mortality rate, which is only partially explained by our willingness to treat more premature infants than other countries, and is mostly a result of poor health care infrastructure in several of the poorer, Southern states.

Australia’s system is not too fundamentally different from the mixture of employer and public based funding found here in the US. An outline of the health system is available from the Australian government and the Wikipedia entry is here. It’s spends about 8.8% of GDP on health care, compared to the US at 15.3% based on 2007 OECD data (or 9% and 16% respectively according to the Commonwealth fund data). Of that, about two-thirds is public, one third private expenditure. Let’s take a closer look…

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NHS has broken the cycle!

A few days ago I asked how do we break this cycle of news reports based on terrible misreading of the scientific literature literature. All these reports do is spread misinformation and undermine trust in scientific research.

Well, the British National Health System has the answer! Via Ben Goldacre, I’ve found my new, favorite website, Behind the Headlines at NHS. It’s the Snopes.com equivalent for shoddy science journalism. Every day they examine what health news is making the headlines, share it with scientific and clinical experts, and they report on the science in a way that’s actually accurate.

So, ignoring the question of why don’t journalists do their job correctly in the first place so we don’t need this service, I’m thrilled to hear of its existence. It seems inefficient though. First university PR departments and journalists have to mangle the science, then we need to have scientists put it back together again. We should just have scientists report on the literature, like at scienceblogs! Instead we have a bunch of incompetent boobs spoon-feeding the public total garbage without anyone writing in to complain when they turn in stories that are essentially complete fiction.

For instance read about Man Flu story at Behind the Headlines, then look at the Daily Mail article or BBC reporting that started this mess.

The authors of this dreck should be fired for journalistic incompetence, and the scientist she quoted (if indeed she was quoted correctly) should consider never talking to a journalist again as they make it appear that she doesn’t even understand her own research. The scientists too in this instance appear culpable as it seems they were happy to help spread completely simplistic, and I think frankly false interpretations of their data.

Luckily, the NHS is providing a public service to the citizens of the UK, and indeed the world, by replacing such nonsense reporting with thoughtful, considered articles that actually explain the science and inform the public.

Are Patients in Universal Healthcare Countries Less Satisfied?

A dishonest campaign has started against healthcare reform in this country and the first shot has come from Conservatives for Patients Rights (CPR), a group purporting to show that patients in universal health systems suffer from government interference in health care. To bolster their argument, they have a pile of anecdotes from people around the world who have suffered at the hands of evil government-run systems. The problem, of course, is that anecdotes are not data, it is impossible to determine the veracity or reasonableness of these claims, and there is no way, ethically or practically, to respond to claims against doctors in these systems.

And should we be surprised? Every other country in the industrialized world has universal healthcare. Some are government run, single payer systems, others are mixtures of private and public funding to guarantee universal coverage. I would be shocked if you couldn’t find a few people to provide testimonials about how they’re angry at their coverage. After all, Michael Moore made an entire movie about such testimonials against our system.

So what do we do? How do we find out the truth when the ideologues and financially interested parties have started a campaign to muddy the water with anecdotal attacks?

We look at the data of course. And surprise, surprise it doesn’t support CPR’s assertions that our system couldn’t stand some improvement.

During the next couple of weeks, I think we should talk about what healthcare looks like here in the US and around the world. Rather than a few horror stories, let’s take an in-depth look at what’s happening in universal systems, and whether or not we should consider a change.

Let’s start with an examination of some data from the literature on different experiences people have with these healthcare systems.
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The 111th Skeptics’ circle, featuring that creepy Sham-Wow guy

I have no idea what possessed Action Skeptics to use the Sham Wow guy to present this week’s entries, but it’s amusing. Check it!

In particular I like ICBS everywhere on this thermography nonsense, and Living better skeptically on yet another cancer quack. It’s very upsetting when quack modalities defraud people of hard-earned money. It’s even more upsetting when people encourage quackery to replace an legitimate and important screening procedure such as mammography or effective treatments for cancer. These people are the most dangerous kind of quack, if they continue unchallenged they will be responsible for the death of their victims.

I was also interested to see Tech Skeptics’ discussion of lazy journalism exposed. Apparently, journalism these days begins and ends at Wikipedia.

So stop by and say high to ShamWow Vince over at Action Skeptics.