We’re from the government, and we’re here to help.

   Everyone knows that this statement is generally untrue. It’s a whopper, right up there with “the check is in the mail” and “I’ll respect you in the morning”?   When is this true? Ironically, most often, when members of the armed forces are conducting operations ordered by their Commander-in-Chief (humanitarian or combat missions).  When is this not true? Well….

    As a group, proponents of health care reform advocate a greater government role in the provision of health care.  The more limited proposals advocate some combination of greater regulation and more extensive participation (e.g. expanding Medicaid).  More ambitious proposals would produce explicitly or functionally socialized health care. As we deliberate about the options, it is worth remembering that the US government in already in the business of health care,

    Not only is the US government already in the business of health care, it in fact runs 3 large health care systems in parallel.  The first is the military health care system, which in fact is a hybrid system of military hospitals specializing in the care of combat casualties and an HMO that specializes in procuring care from the lowest bidder (and if you have any friends in the service, you can ask them how it works).  The second is the Veteran’s Administration, which is one of the largest, if not the largest, vertically and horizontally integrated providers of health care on the planet.  The third is of course the Medicare system, which has been a growing force and shaping healthcare since its inception.  Only a few visionaries predicted the role that Medicare would have in shaping health care when it was proposed.

 

We can infer how well the US government would run any national health care system by examining the military and VA systems. As Medicare straddles the public and private sectors, let’s leave that quagmire for the future….

   The physical plant of the VA system is highly variable.  It is an interesting mix of older, obsolete hospitals, and a few dazzling, beautiful, modern facilities.  How about the care rendered? Highly variable.  VA hospitals associated with good teaching hospitals typically generate excellent care (1). That said, there are a host of failures that have generated scandals of greater or lesser proportion over the past few decades.  Most involve poor outcomes (2), while others involve an inability to supervise research on human subjects adequately (3).  The declining veteran population and an intense desire to provide the best care possible has produced a variety of internally generated initiatives to improve the care in the VA system over the past 15 years.  On the whole, most outsiders would agree that the VA system has improved dramatically, and that most VA hospitals do an at least adequate job of caring for their patients.  In all of the above, the VA system mirrors the private sector.

   Ironically, many (likely most) veterans who have the means to obtain their health care elsewhere do so.  While the VA system may be good, it is clear that the private sector is better, so much so that the vast majority of vets that can afford to get their care outside the VA system.  To be fair, in many instances, the VA hospital is geographically so remote from the majority of the veterans it serves that the cost of going outside the system is less painful than the trip to the VA.  Perhaps the greatest virtue of the VA system is that it provides consistently good care to our indigent veterans, for whom its very existence is a godsend.  Some outside critics of the VA system have long argued that it should be closed; and that care for our veterans would be better provided (or at least more budget efficient) by merging them into the parallel Medicare program.  Opponents of these proposals argue that vets have specialized health care needs that the private sector is not generally oriented to deal with.  There is merit to both sides. 

   Government run health care programs refer to their beneficiaries with a variety of terms, including subscriber, beneficiary, recipient, customer, and sometimes even ‘patient’.  What I never hear used to describe them is ‘captives’, although this term comes closer to describing their situation than any of these others.  Let’s go over it. Military: for the wounded, it’s the military system (the finest of its kind ever, anywhere); for their families, it’s Tri-care, which is care from the lowest bidder.  In general, military families lack the means to go outside the system.  For Medicare, the drop-dead age is 65.  You can go outside the system at your own cost, but you must opt in or out by 65, no matter what.  Only the VA system permits its participants to freely move in and out of the system.  This is likely a consequence of the fierce representation they benefited from in the past.  What about in the highly touted English and Canadian systems?  In England, private insurance is becoming more widespread as the performance of the NHS continues to decline. Like veterans in the US, people with the means to do so will pay money out of their own pocket to get away from their free government healthcare.  The English are a disproportionate percentage of the world’s medical tourists.  In Canada, it was previously illegal to seek health care outside of their system.  While this seems outrageous to US citizens (‘Americans’ in the vernacular), it makes sense at the societal level, as compulsory participation vested the entire populace in the performance of the system.  That someone sued and won the right to obtain health care (using their own money) outside of the system indicates Canadian health care is at least floundering.  Canadians are captives no longer.  Why do government run systems strongly desire or insist on a ‘captive’ population?  There are likely many reasons, but perhaps the most important is fiscal planning.  Health care paid for with tax dollars requires careful fiscal planning; and unlike the private sector, is highly limited in its ability to expand to meet surges in demand.  The long wait times in both Canada and England for almost every operation are in part a consequence of the long lead time of the fiscal cycle and the reluctance of the political leadership to ask the populace to pay more for health care.  Demand (need)for CABGs may go up steeply, but most elected officials lack the courage to raise taxes accordingly.  The performance of centrally planned health is thus at its worst in when they face an unpredicted surge in demand (and predicting the future of health care is not even close to an exact science).  The almost effortless ability of the US health care system to scale-up and compensate for the shortfalls of the Canadian system reflects the adaptability of the private sector.  It is worth speculating that smaller countries with smaller systems with clean government (e.g. minimal corruption) will outperform their larger counterparts.

   Is there any evidence of inability to meet surges in demand within the systems run by the US government? You bet. The recent scandal involving severely wounded Iraq war vets is exactly that (4). Same with the lawsuit by the growing number of vets regarding a variety of service shortfalls(5). Of the two, the Walter Reed failure is the more compelling example.  It involves care for the kind of problems that are unique to the military and veteran’s systems (e.g. the aftermath of blast injuries). Bluntly, real heroes from the wars in Iraq and Afghanistan were compelled accept enormous delays in care. Worse, they lived in conditions that would be condemned as cruel and unusual in most US jurisdictions if prisoners were subjected to them. Be certain: in the worst cases, casualties at Walter Reed were housed in conditions worse than those at Gitmo. The Walter Reed scandal is nothing less than a ‘failure to discharge a blood obligation to veterans who are inarguably entitled to the best we have.’

   How did this happen? News reporters have lots of answers.  I have a few ideas.  Please remember, I’ve been wrong before, and I’ll be wrong again.  First, no one expected the large number of survivors of otherwise devastating injuries from our present wars. No one.  This war is generating veterans who have survived horrific injuries and are manifesting previously rare combinations of cognitive and emotional sequelae.  Second, while there have been dramatic improvements in prostheses, reconstructive surgery, and rehabilitation; little or no thought was given to ramping up ‘prototype’ care into wartime production.  No planning = no resources.  These long waits were indeed for fantastic care that is available nowhere else.  Third, and by far most important, no one cared until the cameras showed up.  Like many failures, it did not happen over night, but via the gradual erosion of performance in the face of escalating demand.  Those in the midst of it could not see clearly what the cameras did.  This cognitive blindness is a common feature of failures.

   Service in the government, whether uniformed or not, produces enormous pressure to conform and accept the performance of the system, whatever it is. This is true whether you work in the US army, a VA hospital, the DMV, or England’s NHS.  Do you really believe that any physician, nurse, physical therapist, or anyone in the military chain of command aspired to the Walter Reed failure? Obviously not.  It is certain that everyone involved did the very best they could with the resources at hand, and that those who received care got the very best available anywhere.  There was no lack of dedication or competence. The sad truth is that everyone at every level in these systems regards themselves as nothing more and nothing less than a cog in a great machine.  They regard themselves in this way because it is true. Sadly, those who are being punished for this scandal are being punished for doing their jobs as they had been expected to and taught to by the system they were working in.  If you rock the boat, you kill your career advancement and jeopardize your pension.  In every instance, the power to garner more resources was above their pay-grade.  There are other reasons as well: I don't know them all.

   In my eyes, the real failure is at the highest political level, and on both sides of the aisle, where leaders have engaged in the magical thinking that they could fight a major war with nearly budget neutral health care for their casualties.  Wars generate unforeseen need for major expenditures.  Every combat commander in the US military has access to large sums of money to acquire resources at need and without the usual encumbrance and delay associated with government oversight.  There has been no such fund created for the care of our combat casualties.  Why not? I’m serious: the greatest responsibility for the Walter Reed scandal should be borne by the members of the congressional committees charged with overseeing the military health care system.  Those congressmen who are grandstanding for the press? The lady doth protest too much….  If you don’t see this clearly, you’re part of the problem.

   Are elected officials held responsible (‘accountable’ in the PC jargon of modern health care) for the failures they cause in health care? No. There is no better proof of this than Cook County, Illinois, in the year 2007.  The newly-elected president of the Cook County Board of Commissioners (Todd Stroger Jr) is in the process of fulfilling a campaign promise to balance the county’s budget without raising taxes. He’s accomplishing this by gutting its public hospitals and clinics, the vehicle by which the county has provided care to its poor for decades.  Tens of thousands of people rely on this system (>25,000 admissions/yr and over 100,000 clinic visits a year).    A huge number will be compelled to seek health care elsewhere.  This constitutes an enormous indirect but explicit tax on all of the other health care providers in the region.  Hospitals and clinics already on the brink of economic failure will erect substantial barriers for these patients, mostly in the form of limited availability of service and long delays. What will happen to these patients?  Some will die.  No one knows how high the body count might ultimately be. Political agendas will generate wildly different guesstimates.  It’s not hard to imagine that it might surpass 9/11 or Hurricane Katrina. Heck, over time, it might surpass both of them and the body-count from Iraq too.  The mayor of Chicago, Richard M. Daley, has said almost nothing, even though most of the dead will be Chicagoans.  The governor, Rod Blagojevich?  He’s in the mist of a budget standoff with his legislature, backing a proposal that has been unanimously rejected by both parties.  Local congressmen?  Our famously liberal Rahm Emanuel has been almost completely silent (at least in public).  Ironically (and to her credit), only the liberal Jan Schakowsy, whose constituents are likely to be least affected, has made any moves to deal with it.  There is no outrage. Why not? Two reasons.  First, the vast majority of people don’t have enough health problems to understand this disaster or have much empathy.  This is human nature, and a partial explanation for the failures of all collective health care (e.g. the NHS).  Secondly, the poor, many of them made poor by their health problems, will constitute most of the casualties.  While it is true that in general, most people don’t care about the poor, this may be especially true of politicians. The poor are neither a vocal constituency nor generous contributors to political campaigns. 

   The sad reality is that our elected leaders can make decisions about health care that have predictably disastrous consequences for large numbers of people, and its not even worthy of the local news. There is no reason to believe that any national health care system would be any different.  Indeed, whether it is the heroes at Walter Reed or the poor of Cook County, the bureaucratic distance between our elected officials and these scandals insulates them from any blowback. Is this the kind of health care we aspire to for everyone?

We’re from the government and we’re here to help? Ha.

**********************************************************************
P.S. -Mitch Keamy understands all of this deeply, and has written about it previously, in an article published in a newsletter whose title was something like ‘If you like the VA, then you’ll love nationalized health care.’  He has vastly more insight into the political considerations than I do.  I expect to hear from him about these…..

1. http://www.thedailystar.com/news/stories/2007/03/08/jpschumer03075.html

2. http://www.charlotte.com/109/story/105322.html

3. http://www.ahrp.org/infomail/0403/13.php

4. http://www.washingtonpost.com/wp-dyn/content/article/2007/02/17/AR2007021701172.html

5. http://www.cnn.com/2007/US/law/07/23/veterans.lawsuit.ap/index.html

Comments

[shomama]

why are anesthesiologist so adamantly anti-nationalized health care? Is it because they are worried it may poke a hole through their artificially inflated salaries? There must be some of you that believe health care is a HUMAN RIGHT. I especially liked how you conveniently excluded medicare/medicaid from your analogy of how bad it would be if the government ran things. Last time I checked, being poor with medicaid is better than being poor with a shitty HMO (I've had both myself). Just because the government has done a bad job running the VA or Walter Read doesn't necessarily mean that it would do a bad job running a national health plan. And maybe if the government did run our health service there could finally be some accountability from the people, the citizens. As it stands now the insurance companies are only accountable to their shareholders. I'm a med student going into anesthesiology. I hope that the field will not be full of republican idiots!

[Mike O'Connor]

First, I'm deeply grateful for the personal attack. Nothing inspires me to be more rational or considerate than the absence of both in others.

Socialized medicine and health care for the poor are both highly attractive to physicians as a group, myself included. While most people have a dog in this fight, my attention has been and remains centered on how to generate better health care across the spectrum, including the indigent. The question to ask and answer is: what it the best way to do this?

In theory, nationalized health care or socialized medicine create a perfect safety net, and establish a baseline of care for everyone in a society. On a small scale, it is very likely that this model works, and works well. Scaling it up and keeping it going is vastly more difficult than most people appreciate. Centrally controlled health care resembles the federal government's response to Katrina more than anything else. That's its nature. We all may believe that it could be done better, but there is no evidence that this is the case. Advocacy in defiance of all available evidence is either prescience or religious fervor: only time will tell.

Health care systems are like the proverbial elephant: your view of what you're dealing with is highly dependent upon where you happen to have hold. Insiders have widely disparate views of how these systems perform, but in most instances, they seem to be inferior to what exists in the US already:

Canada:

http://socglory.blogspot.com/2007/08/canadian-doctor-describes-how.html

England:

http://nhsblogdoc.blogspot.com/

Read the description of the Canadian system: in most instances, our public hospitals provide better care(but once again, have abandoned cancer treatment and the management of chronic disease). This matters, as once you scratch away the veneer of propaganda, these systems become less attractive. Adapting the Canadian or English models might make things worse for everybody; there is no evidence to suggest that they will be superior.

And of course, my post above advances the hypothesis that the US government struggles to provide adequate care on a smaller scale.

I remind you that I am employed as an academic. Outside of our local public hospital, the one I work at has provided more care to the poor than anyplace in the city, in some years, more than all of the other hospitals in the city put together. The consequence has been that my salary has been meager for most of my career. If you care, my counterparts in England and Canada are presently compensated more handsomely than you might imagine.... because anesthesia everywhere is more demanding than you might think.

If this problem were easy to solve, we wouldn't be having this discussion. Make no mistake: everyone wants to solve this problem, but have different visions of what constitutes an acceptable solution. As is often the case, our system may be bad, but all of the alternatives are worse.

[mkeamy]

Hi shomama. Thanks for coming by. While I think inflammatory ad-hominem attacks (look it up) are not conducive to a decent discussion, I'll give you the benefit of the doubt that you didn't simply come around to expiate some anger you've got at something else, but that you're asking a serious question. I have grave concerns about the whole healthcare finance system either way; private or public. (I am one of the author's co-authors, by the way; he may be the smartest guy I know...) anyway, the public financing option has the defects that you mention; excessive profiteering, de facto rationing, and overwhelming beaurocracy. A federalized system will have problems with resource allocation (matching need to supply) a politicized rationing system (everyone can't have everything they want) and perhaps a politicized delivery system (do you want to work for a George Bush right wing zealot-appointee placed in charge of your hospital?)For an example of a resource allocation mismatch as a consequence of government manipulation, you need look no further than the critical shortage of primary care doctors which is the consequence of a lopsided medicare compensation system that differentially rewards proceduralists.
Every path is fraught with risks now, although most feel something must be done to address mounting access to care issues in this country... Interestingly, I read (and just re-read) Mike's post-I didn't see any discussion of physician income there? Are you projecting some other feelings of your own onto this post? For a great discussion of physician income issues, which seems to be on your mind, go to Kevin MD's blog, where there is a link to a letter written by the (liberal) Princeton healthcare professor Uwe Rinehardt, in responding to a New York Times op ed piece attacking physician incomes, also with a link.

As for accountability, read Mike's post "Hiding the Bodies" Do you think that a government that could pretend global warming doesn't exist for seven years will be publicly accountable? I don't.

Anger is a very difficult emotion if you're going into anesthesia; it'll eat you up!

Cheers and good luck.

[shomama]

mkearny:
First off, there is no need for me to look up ad-hominem as I am well aware of its meaning. Perhaps you should look up the correct spelling of bureaucracy.

I'm glad for the discussion. I have been reading your blog for some time now and really enjoy it. I found your piece on the pre-op interview enormously inspiring and touching and I have actually tried to incorporate that thinking when I do pre-ops now.

I'm sorry if my comment seemed angry. I did not intend to disrespect any of you and clearly you all have much more experience than I do. However, it seems that everywhere I look anesthesiologists in particular are adamantly opposed to a single-payer system. I can't seem to understand why that is so. I thought that perhaps since anesthesiologists are so well paid, they fear losing that income. That is the reason I brought up income. I am not "projecting" other feelings so you can spare me the $.50 psychology.

I believe the original post makes a cohesive argument. And you both clearly acknowledge that the current system is broken; on this we can agree. But here is my point: How can the systems the original poster mentions be that terrible (i.e. Canada and England) but still rank above the United States in most ratings of health care. Furthermore, what about the French system, which is widely considered the best health care system in the world? Could the money we are pouring into this senseless war be better utilized to create a health care system modeled after the French. And not even the French...America has a history of ingenuity and creativity. Can we not come up with a national health system that provides adequate care to all its citizens without compromising on individual access or wait time. And one that doesn't grease the pockets of insurance companies. So the alternatives are not worse. They can be better.

The original poster claims that at his public hospital the poor are cared for without a problem. While I find this rosey picture hard to believe, he might want to consider visiting other county hospitals, like those in Los Angeles or New York. Patients waiting for hours without care or as was seen in LA, those who can't pay are put in a cab and sent to "skid row" sometimes with their IV still in place and only a hospital gown across their backs.

[Hank Roberts]

Do you respond to questions here? It's not clear.

Curious about whether the government's done the right thing as you see it in dealing with this news:
http://origin.mercurynews.com/breakingnews/ci_8439887
http://ap.google.com/article/ALeqM5i8B3EkgPbRHRxqB6l6BG6ZL1bn9QD8V69MQG0

[Mike O'Connor]

First, the obvious observations:
This is a disaster for these patients.
In a perfect world, this should never happen.

Truth: It has happened before and will happen again.

Now it's time for the less obvious....

I've spent a lot of time in the past ten years reading about, studying, and thinking about failure, especially recurring failure. Failure recurs when previous response to it was ineffective. Response is ineffective if it is predicated on an incomplete or incorrect understanding of the cause of failure.

Truth: In medicine, we have eradicated all (or almost all) of the simple failures. Those that remain defy our understanding, not our will. This is a critical insight: those problems which fester in medicine defy simple solutions, no matter what the pundits, politicians, regulators, and various experts say. More on this tangent in another post...

Wild Speculation: While these news stories point to re-use of syringes and vials, this is at the least an oversimplification. Further, my speculation is that there was minimal or no re-use of vials, and that all of the syringes that were re-used were glass, not disposable plastic. Hence the real problem: the processing of re-usable instruments in health care, including all surgical instruments, glass syringes, and endoscopes.

Fact: The processing of re-usable medical instruments is a logistically daunting and technically difficult undertaking in which minor failures have major consequences. It is profoundly more difficult to accomplish than outsiders appreciate, and failures far more common that casual newsreaders might believe. It is a problem that plagues all of health care, from its most prominent institutions to its most obscure. It almost certainly happens for more often than it makes the news. Like all recurring failures in medicine, our understanding of this phenomenon is poor, which is why it continues to happen. My colleague Richard Cook has been intensely interested in understanding this problem; unfortunately, there is no external funding available to do so. As for this response: it will be ineffective, as all previous responses have been, and it is likely we could have this dialogue 5 or 10 years from now, just as we could have had it 5, 10, or 50 years ago.

This area represents a real opportunity to make progress on patient safety, but it would take a substantial investment in a study by a competent investigator. There is no money forthcoming, and there are only a few investigators competent to understand this problem. Absent real understanding, progress on reducing the incidence of this disastrous complication will not happen.

If you're interested in the lab and understanding safety and failure, visit the homepage:

http://www.ctlab.org/

For more stories about failures associated with the processing of instruments:

http://www.newsobserver.com/215/story/181586.html

Canada:

http://www.thestar.com/News/Ideas/article/301896

England:

http://www.bio-medicine.org/medicine-news/Contaminated-Surgical-Instruments-Increase-Risk-Of-Infections-12072-1/

[Hank Roberts]

Thanks Mike O'Connor, that's helpful.
I've read (in a biofilms article) that it's actually impossible to sterilize the hollow inside of a colonoscope, they make a best effort. I'd wondered, seeing the lab with the problem did colonoscopies, if it could be transmission via the instrument rather than via the anesthesia injections. (And just now Google turns up quite a few hits, biofilm contamination seems to be a hot issue with a lot of research)