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Tuesday, April 6, 2010

Getting a leg up on health care


LONDON — The signature by U.S. President Barack Obama of his health care bill was welcomed by most people in Britain and Europe. Many thought that the provision of health care for those not covered by insurance or whose insurance could not be renewed because of an existing health condition was long overdue.

The arguments of the "Tea Party" opposition — that compulsory insurance infringes on citizens' freedom and amounts to socialist medicine — strike most Europeans as wrongheaded and suggest that the Sarah Palins of America lack human sympathy and are living in a past that they mistakenly idealize.

No Western country has yet found a perfect solution to the problem of providing adequate and affordable health care for an aging population at a time when new, expensive treatments are being developed. Demand could not only outstrip supply but also burden younger members of society with costs they are unwilling to meet.

The Obama health care proposals can be criticized because of their cost, but they are surely better than continuing with the previous system. The American legal system encourages patients to sue doctors and hospitals when anything goes wrong. As a result doctors, if only to protect themselves, order diagnostic procedures that may be unnecessary.

The insurance system operating in the United States is also too costly. The average cost of health care in the U.S. is higher than in any European country without necessarily delivering better results. The burden is likely to increase as Americans get older and live longer. This problem may be particularly acute in America, but it exists in all countries. Various details need to be considered, such as setting limits on damages payable when procedures go wrong and exposing ambulance-chasing lawyers.

Also necessary is to limit the power of professional doctors' bodies to act as a cartel and keep "up" the costs of medical treatments. As the Japanese know, the Japan Medical Association is adept at lobbying and, like its equivalents in other countries, often seems a law unto itself.

Prices of drugs have to be controlled and the use of generics over proprietary drugs encouraged, but this has to be done in a way that does not inhibit research by pharmaceutical companies, which must be able to cover their research costs through patent protection over a limited period.

Although difficult to strike the right balance, it is essential that the relationship between drug companies and hospitals and medical practitioners is adequately supervised to prevent corrupt practices.

Medical ethics, in particular the Hippocratic oath, need to be an important part of all medical curriculums. Doctors inevitably face ethical dilemmas over abortions and how to treat the dying. The need to keep costs under control must never be allowed to influence ethical decisions.

Hospital administration is an important element in cost control. In Britain it is widely believed that the growth of health service bureaucracy has undermined efficiency and added unnecessarily to costs. Too many targets can lead hospitals to overlook their primary responsibility of patient care.

A major effort is being made in Britain to computerize patient records. This could bring improvements in ensuring that care is given speedily and effectively, but there is the danger that a patient will be seen more as a number than as an individual. Medicine remains an art as well as a science.

The debate about whether and how much a patient should pay, other than through taxes or insurance, for medical treatment will continue. Some argue that the patient should pay toward initial consultations to avoid frivolous misuse of practitioners' time and that hospital meal costs should be borne by the patient. Others argue that the only right and fair answer is that health care should be free at the point of delivery, as it is under the British National Health Service (NHS).

In Britain, private hospitals and specialist consultants, funded largely through private medical insurance plans, thrive alongside the free NHS. Consultants generally work part-time for the NHS in state-run hospitals but also have separate consulting rooms. They are not supposed to discriminate in favor of private patients.

Many patients of London consultants come from abroad. In London, top private hospitals and medical consulting rooms on Harley Street treat large numbers of Arab patients. The British system may be invidious, but it is probably better than that operating in some other countries where patients, regardless of their financial circumstances, are expected to top up the fees provided by the government by making side payments. Some give gifts to consultants to ensure the best treatment.

To the cost of health care for the elderly must be added the cost of providing them physical assistance and home help. How much care should be provided and how it should be paid for have become important political issues in Britain.

The Scottish and the Welsh governments aim to provide such care free, but the costs of doing so in England would be huge, and at a time when public finances are strained it would be hard to justify.

Both the Labour and Conservative parties have declared that they will not make cuts in the NHS budget. This will mean even larger cuts in other budgets and may well be unsustainable. There is certainly a good deal of waste in the health service bureaucracy that should be squeezed.

It is essential that there be an informed debate in every democracy about how best to deliver nondiscriminatory health care to all, how to achieve savings and cost efficiency in health services, and how to cover costs without placing too great a burden on taxpayers.

Hugh Cortazzi, a former British career diplomat, served as ambassador to Japan from 1980 to 1984.


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