Comparative Medicine 101
US health care didn’t have to be this way
This is the first installment that takes a look at American health care by comparing it to another alternative. We’ll look at how we got here and what kind of quagmire we’re actually in.
I am in the largest public library in Talavera de la Reina, Spain, on a computer with an hour time limit for free internet. It’s my fourth day in the country.
The adjustment to the six-hour time difference and schedule of daily life — heavy, early breakfast; work; lunch at three p.m.; dinner around ten — has taken a toll on my waking countenance. In retrospect, I’m worried my yawning during various tours of the local ceramics scene may have offended the artisans.
I’m here as part of a fellowship with The Atlantis Project, which connects US-based premedical students with hospitals in foreign countries to shadow various doctors. The stated reasoning is to increase the exchange of international healthcare knowledge and give future doctors an appreciation of diversity in both culture and medical policy.
On top of that America’s unhealthily competitive and self-flagellating medical school applicants will do anything, pay nearly any price, to get an experience on their resumes unique enough to burrow its way deep into the mind of whatever creatures of myth sit on med school admissions committees these days. The Atlantis Project, a rather new venture, is thus tied to the history of higher-educational resume-farming, the latest permutation in the pay-to-play world of college-matriculation-as-key-to-social-mobility.
Our maternal mortality rate, as good an indication as any of a healthcare system’s basic functionality, is the highest in the developed world on average, and on statewide levels varies from levels of Canada-Netherlands-Scandinavia good to developing-countries bad.
But I digress.
As a mode of reflection and information, I’ll be writing here to compare my experiences in Hospital Nuestra Señora de la Prada and the Spanish healthcare system as a whole to my impressions of the American system and the hospitals where I’ve previously worked: Rhode Island Hospital, Hasbro Children’s Hospital, Miriam Hospital, University of Vermont Medical Center, and connected clinics. Call it comparative medicine.
First, some history.
The American healthcare system is, currently, the worst of all worlds. You have Randian free market fuckery for some parts — pharmacological companies, lately under investment-banker ownership (see Martin Shkreli, professional asshat), are thought-leaders in the arena of literally price-gouging people to death.
You have socialized care in others — American emergency departments (EDs) mete out free care for the desperate and destitute, yet cost far more to taxpayers than a decently accessible preventative socialized system would. Meanwhile, Medicare and Medicaid, perhaps the most cost-effective health policies available to us, are unfairly maligned and defunded by state- and federal-level partisan hacks whenever possible, thus further shunting the population toward the ED stopgap.
Finally, you have no care for a good portion of the population, either by choice (which frankly speaks to our country’s slipping educational standards) or not. The ranks of the involuntary uninsured would most definitely expand under the proposed GOP healthcare policy, a blue ribbon contender for the category of Most Blatant Attempt at Legalized Murder of American Citizenry in the 21st Century.
Our maternal mortality rate, as good an indication as any of a healthcare system’s basic functionality, is the highest in the developed world on average, and on statewide levels varies from levels of Canada-Netherlands-Scandinavia good to developing-countries bad. We spend the most on healthcare of any nation while getting humdrum returns. (I direct you to read the series of articles in The New Yorker by Atul Gawande on the various factors contributing to this conundrum.) We also don’t have enough doctors — the federal government seems unwilling to pay for more residency spots, which at the moment are the bottleneck keeping the professionally accredited population artificially low — and not enough doctors in the right fields, as the fee-for-service model currently favored unfairly rewards specialists and indirectly punishes preventative care. Nobody wants to be a gerontologist for the pay, but the country will need more gerontologists than it’s ever had as the Baby Boomers continue to get old and die.
In a similar vein, the vast cultural divide between urban and rural America is actively contributing to a healthcare shortage in the sticks. Doctors often have hopes of a lifestyle that to any millennial college grad on the outside of the profession seems baroque: marriage in their 20s (for “matching” in residency), a family, a house, a nest egg, maybe some cool cars or bicycles or some other expensive hobby. Almost no one that goes to American medical school — nearly all of them situated in ritzy cities or snuggly college towns that readily cater to the bougie dreams of future professionals — wants to be the sole doctor for a rural, hinterland town. Even though those are the communities that are being ravaged the most by economy- and opioid-induced or -exacerbated hopelessness, doctors have lives outside of their work, and unfortunately those lives demand urban modernity more than morality may demand a commitment to help the suffering.
So we’re at a number of impasses, but healthcare being what it is, the whole system can’t exactly stop on a dime to sort its shit out. It’s doing important — one might say life-and-death — work, not only for the flesh-and-blood people it ostensibly serves but also for the economic titan it is an integral organ of. Healthcare currently makes up a sixth of the American GDP. For context, if projections for 2017 GDPs hold, that is roughly equivalent to the GDP of the entirety of Germany. The ACA in tandem with willing insurance companies, flawed as they are, keep this system, tumorous as it is, plugging away because the alternative would be apocalyptic: a lot of profits and livelihoods lost, a lot of anger, probably a lot of lawsuits, and certainly a lot of tragedy.
But it didn’t have to be like this. The first push for government-guaranteed health care in Western countries, at the turn of the 20th century as a response to the industrial and Communist revolutions, was a topic of frequent debate at the time. Capitalists, naturally, by and large balked at paying a dime for the wellbeing of another homo economicus, while labor generally supported it — except if the labor in question was doctors. Then they opposed it.
If doctors didn’t have the right to name their price, they worried their standards of living might be adjusted in ways they didn’t agree with, and so argued for the market-based model of medicine that emerged from the advances in industry the century prior.
This trend continued. In the 1950s, President Truman attempted to pass a government-provided healthcare system. The American Medical Association, the number one professional organization for doctors, mounted the most expensive lobbying campaign in American history at the time to stop this, and succeeded. When President Johnson tried this again during the Great Society reforms in the 60s, the AMA leapt back into action and outspent its previous record, utilizing the homely charms of one (I shit you not) Ronald Reagan to help explain to the nation why letting the government take over the medical industry was wrong and bad. Johnson, tricky as he was, managed to get Medicare (old people) and Medicaid (poor people) into law, and, with those, de facto forced desegregation in hospitals as Medicare and Medicaid funding were contingent on meeting certain civil rights criteria. Former president Truman and his wife were ceremonially made Medicare’s first recipients, one presumes in recompense for a dream not only deferred but also neutered.
The AMA, humbled and also learning that perhaps looking out solely for the financial interests of its constituents wasn’t sound public health policy, got behind the programs. Most recently, with the ACA, they, hospitals, and pharmacological lobbyists got drug price bargaining, which would be a step in a better direction in terms of affordable care, taken out of the legislation as the main carrot for their collective blessing. The AMA remains a relatively conservative force in medical policy today, though to its credit one that seems to be on the right side of the ACA repeal debate. After all, they can’t just roll over and concede wholesale the potential profits of those 22 million potentially uninsured to the mortuary industry .
Spain, on the other hand, has made the best out of a meager station compared to its neighbors. When the Spanish Civil War saw the rise and triumph of Catholic-supported fascism under General Francisco Franco, gone was any hope for women’s health care, scientific education, and any devolution of powers away from the leader’s cabal. When Franco finally croaked in 1975, the democracy that followed in 1978 made healthcare a constitutionally guaranteed right, and slowly worked to integrate hospitals into previously guaranteed social security systems. The transition was rough, and the compromises made were keenly felt by doctors and wider society, but by 1983 any citizen or resident of the country could go to a hospital, show identification, and get care, no strings attached. The high unemployment rates and minimal international investment were palliated by the knowledge that health was a right, not another commodity. However, much like the UK’s National Health Service, costs grew and government spending shrank. In 2009, in the wake of the Great Recession, patients were asked to pay for previously free services based on their income, while benefits and salaries were reduced for providers and spending in several specialist areas were cut.
But even with these changes, today the Spanish healthcare system is considered one of the greats.
In stark contrast with American models, healthcare professionals in Spain are paid an annual government salary, tend to work 7 hours a day (eight to three —and yes, that includes residents, so pick your jaw up off the floor), and receive benefits, including a pension. The money isn’t great, I’ve been told, especially with Spain’s progressive tax brackets, but it’s livable, especially when higher education doesn’t cost your future ability to own property and/or participate in the consumer economy like it does in the States. Plus, public transportation actually exists.
That said, these are two very different systems for two very different societies. The main concerns of Spanish health policy seem to be that its workers aren’t paid commensurate with their skills and experience, that the easy availability of health care might be serving as a disincentive to employment, and that the welfare state’s attendant taxation requires too much of the very middle class many health professionals wish to be/are a part of. As I said to an Intensive Care doc, though, compared to the American system’s potentially fatal flaws, those are some mighty fine problems to have.
So, with that out of the way, in the coming weeks I’ll compare a number of aspects of these systems. To name some ideas:
- how a hospital functions in its community,
- how the staff of said hospital relates to one another and is organized,
- what philosophy underpins these systems, if such a thing can be derived in some consistent form, and
- how the economic future of the countries these systems are housed within may affect them, and vice-versa.
Feel free to send questions along for me to answer about my present and past experiences spelunking in the viscera of these many-limbed beasts we call healthcare systems.
Hasta luego.
Nicholas Morley is based in Burlington, VT, albeit presently in Talavera de la Reina.
