The Social Lens of Social Medicine

By Jim McVeagh 16/11/2010


Tim Parke, the Clinical Director of Auckland Hospital Emergency Department, has written an opinion piece in today’s Herald, extolling the virtues of state health care. “Universal” health care, as he calls it. That word immediately alerts me to the socialist thinking that will be behind the article. The most obvious aspect of state health is that it is not universal at all, except in the sense that it offers the same baseline service to all comers. This baseline service is often very inadequate, meaning that those who cannot afford private health insurance, are forced to endure a far lesser standard of service than their wealthier counterparts. This is why health outcomes for lower income groups are worse across the board. Of course this problem occurs in private health systems as well, but at least it is more clearly spelt out there. It is also much easier to rectify (although looking at Obama’s appalling health care bill, one would be forgiven for thinking addressing health access imbalances was something difficult).

Being forewarned about the social lens that Dr. Parke is about to employ in his article, it is easy to spot exactly where it is being used. Dr. Parke poses three questions and then proceeds to answer them with socialist filters that invalidate each argument he makes. Take his opening question:

How does the New Zealand system of large public hospitals, subsidised GP networks, ACC insurance and small private hospital contribution perform relative to highly privatised US healthcare?

He immediately proceeds to quote OECD data. I have often blogged on the dangers of using international comparison data to draw conclusions about the effectiveness of health systems and interventions. It is rare for the data methodology between countries to match. Dr. Parke mentions US infant mortality without once considering that the US count all still births and late-term abortions in their mortality statistics. Some countries do not even include babies that have died less than 24 hours after birth. Typically, the US fares badly in life expectancy for the simple reason that their weighted infant mortality drags it down.

Besides the obvious problems with direct comparison of data, one must also point out that in the list of comparison data that Dr. Parke uses (Life expectancy, heart attack, stroke, cancer, trauma, breast cancer, infant mortality and premature death) only breast cancer has a direct correlation with quality and access to health care. It is also the only statistic where the US do better than NZ. All other stats rely almost entirely on social factors such as diet, exercise and living conditions. It is any wonder that the US – a nation of obese, junk food consumers who think that “exercise” is a word that describes a school homework book – fare badly in most of these stats?

If you are really looking for a statistic that measures the true effectiveness of a health system, then you need to concentrate, not on the total population, but on the portion of the population whose health is significantly affected by the healthcare system, namely, the elderly. A standardised quality of life assessment for 75 – 80 year olds would almost certainly reveal that the US elderly have far better QoL than a similar group in any other country. Most are covered by either medicare or private insurance. Access to health care is relatively unrestricted in comparison with NZ.

In New Zealand, access to public health care is heavily restricted to the “most needy”. The upshot of this is that an elderly person with hip arthritis must wait until they are in constant pain and virtually immobilised, before they will get their hip replacement. That person’s musculature will have severely atrophied and their ability to recuperate and re-mobilise will have been severely curtailed. All too often the scenario is that, instead of a decade of good life following a hip replacement at 75, the elderly person suffers pain and decreasing mobility for 3-4 years, gets a hip replacement, mobilises poorly and ends up a year later in a nursing home, dying a year or two after that. That is the real face of public medicine.

Not content with meaningless comparison data, Dr. Parke goes on to ask two Straw-man questions. The first:

Are public hospitals inherently unsafe compared with private facilities?

He is, of course, quite correct to suggest that the flurry of press anecdote about bad outcomes gives the false impression that private facilities (that are rarely mentioned) are safer than the public facilities. He is also completely correct to suggest that part of this is due to the higher levels of complexity of patients that gravitate to the public hospitals. Of course, part of this increased complexity is entirely self-inflicted by the difficulty in obtaining timely elective surgery, allowing patients to deteriorate and become more complex in their pathology.

But this is not the real problem with this question. The real difficulty with this point is that it is not a question that any serious debater of these issues would formulate. No-one who knows anything about medicine thinks for a moment that public medicine is inherently less safe than private medicine. What they think is that public medicine is inherently less human.

No-one who has spent a night in a public health facility and, then, in a private one would have any doubt in their mind that the private facility is infinitely nicer. I am not here talking about better food or nicer decor. I am talking about the attitude of the staff, particularly the doctors. Public health tends to drive doctors to become task orientated (seeing the patient as a set of disconnected problems). State doctors derive no income from patients directly. While this can be a good thing, it typically eventually leads to busy doctors who see patients as a nuisance. There are some terrific doctors in the public health system who are superb with patients, but there is no doubt that the system lends itself to disinterested, arrogant doctors.

You may think I exaggerate here, but I have seen a good number of senior registrars go out into private practice and suddenly metamorphose from complete assholes to pleasant, caring practitioners who can’t do enough for their patients. Financial incentives are a wonderful thing.

And talking of money, we come to Dr. Parke’s second straw-man.

Why should taxpayers be forced to cover people who don’t make health provision for themselves and their families?

Why should this be a Straw Man? Firstly, it is because, apart from the odd libertarian, most of us don’t mind helping the poor to have access to health care. There may be a lot of resentment generated by welfare payments, but the vast majority of us are comfortable with health. More importantly, though, state funded healthcare is not the only workable model for helping the poor to access health care. There is absolutely no reason why the taxpayer could not fund a basic insurance policy that the person can choose himself. The matter of free choice is vital, and is the reason why Obamacare will fail. If people can choose their own policies, competition drives down price and pushes up benefits. If you have a state run insurance, like ACC, it is usually both expensive and inadequate.

There is much to dislike about US healthcare. Millions of uninsured without access to healthcare, absurd litigation and massive costs. None of these problems are an inevitable consequence of a private health system. The first represents a failure of US government, who continue to insist that a state-run insurance scheme is a viable answer. The second is also a failure of US government to curtail the ridiculous excesses of the lawyers. The third is the inevitable consequence of the first two failures – over-servicing of medicare patients and a deeply ingrained defensive medicine, that over-investigates everything for fear of legal action if a problem is missed. The US could make it’s health system the envy of the western world if it had the will to. In the meantime, New Zealand will undoubtably keep viewing its health system through the socialist lenses of organisations like the UN and the OECD and pat itself on the back for its wonderful system.

And individuals, particularly the elderly, will continued to be disserviced by it.

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