Wednesday, January 28, 2009

Health Care Isolationism

In his farewell address, former President George W. Bush warned against a retreat into isolationism in response to the global economic crisis—ironically, exactly the opposite theme of the first ever farewell address by George Washington, but then the Bush White House never really did irony, did it?

Still, the US claims to be a leader in globalization, preaching the benefits of economic integration among nations as a force for peace, prosperity and human rights.

Except when it comes to health care. With the US Congress poised to embark on an all-out push to expand and reform coverage in this country, all ideas are on the table—except for ideas directly tied to the experiences of other nations in providing health care to their citizens.

Consider the Congressional Budget Office’s pre-emptive analysis of different health care reform options. The 196 page narrative, accompanied by a series of “scores” of the costs and savings of different proposals, was an initiative of Peter Orszag, who now heads the White House Office of Management & Budget and so will remain a key figure in the health care debate.

The paper offers a number of creative analogies to help understand ways to predict the impact of different policies on the markets, consumer behavior and overall costs. Our favorite: an analysis of the potential impact of insurance mandates looks at prior experience with mandates for vaccines, seat belt use, auto insurance purchase, and income tax payment. (We certainly didn’t know that only 86.3% of tax liabilities were actually paid. Maybe the current rate of insurance coverage isn’t so bad…)

Anyway, amidst all those creative and thoughtful analogies, there is one thing missing: data derived from experiences with universal coverage in other countries around the world. In the 196 pages, we could find just one reference to an international health care system as a model: a study of changes in the availability of medical services in Quebec after universal coverage was adopted in 1970. (We always felt that Quebec should not merely separate from Canada, but join the United States. Perhaps CBO supports that view as well?)

Americans, of course, pride themselves on doing everything in a uniquely American way. And, as Atul Guwande discusses in a recent article in the New Yorker, there really isn’t anything unique about America pursuing a unique version of health care reform. Guwande—a regular contributer to the New Yorker but also a member of the Clinton health care reform team back in 1993-94—points out that every other country to adopt universal coverage did so in its own fashion, evolving out of existing and decidedly local systems already in place.

But we submit that there is more to it than that. Despite what seems to us to be a growing consensus that the US health care system is failing on almost all fronts, it remains politically foolhardy to suggest reforms based on other countries’ models.

After all, if one presidential candidate can accuse the other of being a socialist based on a tax plan that would raise taxes on those making more than $250,000, who would be brave enough to advocate a health system modeled on that of France or the UK or even Japan—much less our neighbors to the north in Canada. (One exception: one of the leading candidates to run the US Medicare and Medicaid agency, Institute for Health Care Improvement CEO Donald Berwick, describes “American exceptionalism” as one of the problems in the way of health care reform.)

So, frustrating though it may be for biopharma companies that operate internationally—many of whom see valuable models and cautionary tales across the globe when it comes to health systems—it seems clear that, when it comes to the politics of health care reform, no one wants to import anything from outside the US.

Except cheap Canadian drugs, of course.

image by flickr user thephotoholic used under a creative commons license.

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