By Dr. John M. Livingston | Medical Policy Adviser
Over the past seven years and since the Affordable Care Act’s passage, I have listened without interjecting myself into the debate about the efficacy of moving forward with Medicaid expansion, Idaho’s Statewide Health Innovation Plan (SHIP), and access to health care to those on the margin.
This year the debate surrounding healthcare will begin with a discussion about the merits of government-run systems.
A December 2018 Wall Street Journal article by Dr. Scott Atlas reminded me of what may be in store as the Idaho Legislature again debates these issues. Below I have reviewed many of Dr. Atlas's observations and statistics.
The same arguments made five years ago about access to care, quality of care, cost of care, and allocation of scarce medical resources will be made again.
Through the years, obfuscations and dissimulations of facts have been presented in the press and at legislative hearings. I even heard that because one Idahoan did not have Medicaid,he had to have his leg amputated—this argument was put forth by the head of the Idaho Hospital Association, who had never himself been directly involved in any type of clinical decision-making process that would necessitate such a procedure.
If any physician bore witness to such a situation—seeing another physician or hospital deny services to an indigent patient with the above-described outcome, and did not report such negligent behavior to the State Board of Medicine—the witnessing physician would be held accountable by the institutions where he practices and by the state board.
Presenting such fraudulent and deceptive arguments in the course of political debate only lead to hysterical decision making, which almost seems to be the norm today.
I would like to dispel some other arguments you will hear this legislative session in favor of government-run healthcare delivery systems.
Last year, I heard a prominent Idaho physician state, during testimony before a legislative committee, that the United States ranks near the bottom of nations in the developed world in infant mortality and that we were the only country in the group that did not practice single-payer medicine.
Both statements are false.
In the United States, our infant mortality was 5.9 out of 1,000 live births, meaning about six babies died out of every 1,000 delivered. That figure appears high in comparison to European countries, Australia, and New Zealand.
But in the report, the World Health Organization pointed out "that it is common practice in several western European countries to include only those infants who survived a certain period of time … infants that don't survive that time are completely ignored when compiling statistics." The British Journal of Gynecology determined a 40 percent variation and 17 percent false reductions in mortality rates of infants!
Premature births—the primary cause of infant mortality—are more common in the U.S. The chance of surviving a premature birth is also higher in the U.S.
The cause for prematurity is multifactorial but is 68 percent higher in the U.S. than Britain and 200 percent higher than Ireland and Finland. The issue regarding the last two countries may in part be due to the definition of prematurity.
In many countries that utilize single-payer systems, the decision whether to take care of a premature baby may be an economic one and a baby may be allowed to die instead of deploying scarce medical resources that have alternative uses.
When all these factors are considered the U.S. has the third best neonatal fatality rates and trails only Sweden and Finland.
Life expectancy was also a figure quoted by the physician before the legislative committee. The U.S.has life expectancies for men and women of 76 and 81 years, respectively. That’s five years lower than France and Germany—if immigrant populations are not figured into the calculus.
But here again, the figures need to be inspected carefully. In countries with homogeneous genetics and healthy lifestyles, life expectancy is much better.
Other significant factors that affect life expectancy include overweight and smoking. The Lancet reports that, using body mass index (BMI), the U.S. has a higher obesity rate than any other developed country.
Smoking carries with it a 10-year loss in longevity. The U. S. has the highest rate of smokers on a per capita basis than any other developed country.
Non-illness causes of death—accidents and violence—which are immediately fatal have nothing to do with healthcare quality. Some 66 percent of deaths among Americans younger than 24 years of age are not caused by illnesses. For men between 20 and 24 years of age, 84 percent of deaths in the U.S. are caused by homicide and accidents.
Looking at disease processes that cause the most morbidity, mortality, and disability, the U.S. has far superior results—cancer, heart disease, diabetes, high blood pressure, early access to life-saving surgery, earliest access to new drugs and diagnostic technology all lead to better outcomes.
Wait times for patients with chronic debilitating diseases are far shorter in private systems—think weeks and months in single-payer systems like Western Europe and our own Veteran’s Administration and Indian Health Services.
And in every country with a centralized healthcare system, there is some form of privatization moving forward that is addressing the limitations of the government-controlled systems—so much for the idea that these countries only provide healthcare via the government. By the way, in Canada, where the government runs the entire healthcare system, more than 50 percent of people in British Columbia carry some form of private health insurance.
When pricing mechanisms and unfettered markets are allowed to function—conditions we have not had in this country for 30 years—prices will come down without impacting outcomes. Again, this is exactly what is happening worldwide even in single-payer-dominated countries.
Instead of presenting such false arguments in the press and before legislative committees, we should be exploring how to decrease costs. We should seek to open markets, encourage transparency, and improve access for everyone, not just those in the gap, but also to those who already pay high premiums but forego going to a healthcare provider because they can't afford the co-pays and deductibles.
I wonder if any of them have had a leg amputated because of a lack of access—an economic incentive not to be seen by a doctor?