Hybrid Health Care

By J. Daniel Beckham

Hybrid Health Care

Government-run health care is not the answer; neither is capitalism: Let's keep working on our mixed-breed system.

I was in Kingston, Ontario, in 1999. It's a beautiful place located on the crystal clear waters of the St. Lawrence River. We went to Fort Henry for the evening's sunset ceremony, which included martial movements of kilt-clad bagpipers. While it was a little unsettling to realize that the old cannons on the fort's walls were still pointed toward its American neighbors to the south, the most memorable part of the evening occurred early on. The master of ceremonies welcomed all and concluded with an announcement that, judging by his tone and delivery, he made routinely before each evening's ceremonies. Canada is, he proudly proclaimed, according to the World Health Organization, the globe's healthiest nation. To this, the overwhelmingly Canadian crowd responded with an approving and prideful roar.

Odd, I thought. Not necessarily inappropriate: People often cheer for much less. But I couldn't imagine such a thing happening back home. It would have been like opening a baseball game in Baltimore by reminding the fans that Johns Hopkins was rated the No. 1 hospital in the nation.

In late October, the Vancouver-based Fraser Institute released its 14th annual report on hospital waiting times in Canada. The report held some interesting revelations. Canada's health care is, as everyone knows, a nationally run program providing care to all. But apparently it does this at a very slow pace. According to the Fraser report, the average wait for hospital treatment is 17.9 weeks across 12 specialties and 10 provinces. If you need hip replacement surgery, the wait time in British Columbia now averages 52 weeks. These wait times have been rising steadily despite record levels of spending on health care. Canadians are responding to long wait times in the same way their cousins in the United Kingdom have--by seeking care in "private" (nongovernment) clinics and by turning to providers outside their national borders. In Vancouver, a private company called Timely Medical Alternatives contracts with American hospitals and physicians to provide care to frustrated Canadians. As those in Florida know, it's a practice Canadians have pursued on their own for decades during their winter migrations south.

Wait times are not the only health care challenge facing Canadians. Recent documentaries and films have profiled patients in Canada's hospitals whose experiences might lead them to happily turn themselves over to American providers--including those who are part of investor-owned chains.

The Canadian Plight

For those not interested in experiencing Canadian health care firsthand, they may be able to pick up a video of The Barbarian Invasions, which won two awards (including best screenplay) at the 2003 Cannes Film Festival. The film, about a son's struggle to help his cancer-stricken father, opens with a scene in a Montreal hospital: Patients, doctors and nurses are packed into a crowded ward, yet we understand that the government has directed that a floor of the hospital remain empty.

The son manages to bribe the hospital's manager and the boss of the hospital employee union to let his father have a private room on the empty floor. The father needs a PET scan, nearly unavailable in Canada, so the son takes him to Vermont. A friend of the son's who is in Baltimore states, after examining the scan, that the father will have a better chance if he heads to Baltimore for treatment.

The father, however, proclaims that he voted for socialized medicine, and he's prepared to accept the consequences of it.

John Graham, director of health and pharmaceutical research at the Fraser Institute, writing in January 2004 for Tech Central Station, a Web site dedicated to the interface between free markets and technology, suggests that "the father speaks for too many Canadians, who often wrap their national identity up in nationalized health care. For this reason, Canadian politicians have not had the courage to give Canadians more health freedom. However, the pain and inhumanity caused by the Canadian health care system are starting to make even the most nationalistic of us reconsider the amount of control over health services that we've ceded to our governments.

"This movie tells us a lot about the consequences of government monopoly [of] health care. The hospitals are poorly managed, the doctors and nurses confused, the unions who really run the show thuggish, the patients all but ignored."

In his review, Graham adds that Quebec was just recovering from a streak of violence by health worker unions. The government had contemplated outsourcing some services to private contractors, and this set off riots in which a children's hospital was vandalized and politician's offices covered with pig manure.

Looking for Answers

Today, Canada exists as a vast living laboratory for government-run health care. What's happening there is obviously important to those who provide and receive health care in America. Judging by conversations I have with physician and hospital executives, there's a growing spirit of surrender here in the United States.

Even among some of the nation's largest and most preferred health systems, there's a pervasive sense that anything is likely to be better than "this." "This" is continuing downward pressure on Medicare reimbursement, growing vulnerability to laws and regulations tied to government reimbursement, mounting piles of paper and, at the level of the individual physician practitioner, malpractice exposure that threatens to bankrupt even the most scrupulous. The pressures on consumers are also increasingly onerous, with growing numbers seeking employment as much for health care benefits as for wages. And as life expectancies continue to stretch out, the elderly and their children face the prospect of watching a lifetime's worth of accumulated assets chewed away by medical bills.

In addition to the services that government programs reimburse, there is, as every hospital executive and physician knows, a raft of services that are mandated but not funded, such as antidumping rules that prohibit hospital EDs from refusing care. The reality is that America already provides universal health care through its patchwork of public and private programs. It's a long way from ideal, or even adequate. The question is, "How does it function related to the alternatives; in this case, Canada?" The United States did get some feedback on the dramatic impact that regulatory oversight and constraint can have when in the 1980s providers in New York found themselves pressured by the state's health commissioner. What followed was a period of underinvestment and decline in facilities that New York is only now recovering from. For a while, New Yorkers, like Canadians, were making their way across borders to get their health care.

Despite the pessimism, it's clear that America's health care industry is not sitting still and that its motion is in the direction of substantial improvement and growth. The past decade has seen an unprecedented investment in health care infrastructure--including sparkling new facilities, many of them designed from the onset with comfort, safety and productivity in mind. Large investments have also been made in wiring hospitals with information systems that link physicians, nurses and hospital managers in ways that are unrivaled in the world. And, in growing numbers of hospitals, there has been a fundamental shift in culture and attitude from paternalistic bureaucracy to patient-centered service. It's worth noting that these changes have occurred absent the kind of massive infusions of capital that were represented by the Hill-Burton Program that funded much of American health care's early growth. Rather than wring their hands, many hospital executives have articulated a simple imperative for their organization: "We've got to figure out how to make money on Medicare."

The American approach does appear to be more expensive. But it's also faster for most of the population. Wait times, while they exist in some specialties, are almost nonexistent in others. The development of new technologies and their diffusion also appears to move much more quickly in the United States. While significant disparities exist in practice standards and outcomes, these appear to be trending toward uniformity. This trend promises huge gains in quality and cost effectiveness, but it's not clear what the long-term impacts of standardization will be on innovation. Nor is there readily available information that profiles the current state of outcomes and innovation in Canada or other nations.

Our Hybrid System

It's common to see the comparison between Canadian and American health care as a government-run universal health care program versus a freewheeling capitalist-run program. While the first assertion may be true, the second is way off the mark when it comes to describing the American system. It really is a hybrid with upward of 50 percent of the health care in America paid for and regulated directly by the government.

How it got that way and how it operates today is the result of compromises at the interface between government and free enterprise. Early in his presidency, Teddy Roosevelt, the product of the fruits of American capitalism, saw conglomerates and trusts poised to roll over everything in their path, including government. He pulled out his big stick and pounded them down to size. It's the American way. Keep the government and private enterprise in a balanced state of tension, and progress tends to happen--often messy but infused with the energy necessary to maintain forward momentum. As the Englishman Alistair Cooke once commented, "You can always count on the Americans to do the right thing once they've exhausted all the alternatives." The choice for American health care is too often for the sake of politics and simplicity framed in terms of polar opposites: national health care on one hand or capitalism on the other. There is a third choice and that's to keep working on the hybrid we have, despite its messy uncertainties.

Originally published in Hospitals & Health Networks Online