USA Health Care Reform – the view of an outsider

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http://www.chron.com/disp/discuss.mpl/ap/washington/6733920.html
http://www.chron.com/disp/discuss.mpl/nation/6733642.html
http://www.chron.com/disp/discuss.mpl/special/immigration/6732122.html

The Democrats were able to push the health care overhaul legislation in the Senate and could overcome its first major obstacle. With this the so called sweeping measure supposed to guarantee medical coverage for all Americans will be debated to complete the legislative process. The division on this historic reform is now a total vertical and horizontal with Obama like minded democrats on one side and the rest-majority of whom are the Republicans on the diagonally opposite side. The normal American precedence of Senate conducting its business through unanimous consent is absent in this case that is evident with the 60-39 procedural vote.
How it would ultimately undergo in its final shape is anybody’s guess.

I am a visitor to the Unites States on a holiday from Hyderabad, India for the last few weeks now spending time between San Francisco and Houston, where my son and daughter live respectively. Ever since I got here, I have been keenly following the Health Care Reform initiated by President Barack Obama. Not being from US, I am initiated into following this by the extensive coverage in news papers and campaigns by power groups, self professed opinion makers and to no small measure, by the public response in media. The more I followed this, I noticed that, as the Health Care debate moved to the floor of House of Representatives, and now in to the senate debate, most of the initial “forward-looking” proposals appeared to have either been diluted or were missing completely from the final draft that made it to both the houses. Lobbying by Doctors, hospitals, Insurance Houses and other health care providers, ensured they applied their pressure tactics to dim the prospects of progressive proposals. This pressure doesn’t seem to be abating, and looks like it is all set to continue until the Senate’s decision. This is of course on the expected lines since the whole reform rotates round one central theme – the financials involved.

In my professional life I have been an Advisor - Public Private Partnership (PPP), to Emergency Management and Research Institute (EMRI). EMRI is a unique (and successful) Indian PPP Model, initiated in the state of Andhra Pradesh, India for providing Emergency Response Services, through a toll-free telephone number 108 similar to 911 in USA. Now it has a network of 4000+ ambulances providing the services in 10 states catering to 350 million populations. From making a call to transportation to emergency treatment to 24 hours hospitalization, everything is free of cost-which amounts to roughly $12 to $15 per trip and totally borne by respective state governments. For the developed world, this may not see out of the ordinary, but to put things in context, India is a country where close than half of its billion plus people sustain on less than a dollar a day.

While a lot has been said about this bill, in my opinion the bill does not address ways and means to improve Delivery of Health Services to Vulnerable Segments. The proposed Medicare is a laudable measure probably in one way because it would take care of millions of uninsured including the senior citizens. However majority of other provisions including Medicare also rotates round costs. The health care bill itself is typically named as ‘‘Affordable Health Care for America Act’’ when discussed in the House of Representatives and as “Patient Protection and Affordable care Act” when introduced for discussion in Senate emphasizing “Affordability” rather than “Availability, Accessibility and Acceptability”. It aims to provide affordable, quality health care for all Americans and reduce the growth in health care spending. It aims to provide more security and stability to those who have health insurance, insurance to those who do not, and lower the cost of health care for US families, US businesses, and US government to put in Obama’s own words. The emphasis everywhere is on affordability, costs, insurance and business.

While these are important, it is time the US looks at Health care from the more important perspective of “Availability, Accessibility and Acceptability”-all in patient’s angle.

Has the Health Care Plan of President Obama made adequate safeguards for making available and accessible round the clock health care facility that any individual in USA irrespective of his age, ethnicity, immigration status and income? In my experience as a health care professional, with the intention of making health care available to the poorest of the poor in India, it is the fear rather than the pain that threatens a human being and unless the fear is driven away by way of right kind of medical intervention when needed, the health care reform has no meaning at all. The definition of a medical emergency varies for an individual to individual and may be completely different as compared to a doctor or an insurance company. No individual can be denied access to the facility which stems from a perception of medical emergency.

Here is an example: Ten years ago, my 5 day old grandson developed yellow patches in his eyes. For a first time parents, even a minor blemish is an emergency, as a parent would agree. On contacting the pediatrician on duty my daughter was advised to bring the baby the next day morning to the hospital since there was no ‘emergency’ according to him. Doctor’s view is different from patient’s point of view. What shocked me was that the parents had no choice to accept it because their insurance plan and the medical system did not allow them to take their child to an alternate Doctor other than the Doctor with whom they registered through Insurance. And to prove the point here, the lab test revealed next day that child’s ‘Bile-Rubin’ percentage was around 20, which was on the higher side according to doctor and hence needed treatment. However no treatment was provided, in the absence of instructions from concerned insurance company for the next 24 hours until the child’s condition further deteriorated. Finally through a highly complicated admission procedure, under pressure from parents, the child was provided in-patient treatment. The above is an illustration to say that in America, everything pertaining to Health care is dominated by Insurance Companies and everything is measured by money and time. Unlike in developing countries, availability and accessibility of the Health Care is not patient’s choice but that of Insurance Company.

And has the health care bill proposed by President Obama address this? The concept of Availability, Accessibility, and Acceptability does not exist in the health care system as it exists now-nor does the new bill seem to provide adequate safeguards. In the Insurance driven health care scenario now and in all probabilities in future too, the choice to choose a particular kind of treatment is not that of patient or even doctor but that of insurance company-private or public managed.

Health Care facility of patient’s choice is more important than alternate plans. Health Care basically has to be divided in to three categories namely, Primary-Secondary-Tertiary. Most of the medical problems that require health care fall in to the primary category. Only few in tertiary category and the rest are secondary. Any society cannot call itself developed if it does not take total responsibility every citizen’s primary health care issues. This cannot and should not be passed on to the private sector except at the choice of the patient. Secondary care can be shared by the government and the private sector, where as for tertiary care there can be a free market competition between government and private in provision of services. Whoever can afford may be allowed at their choice to choose a private care whether through insurance or otherwise but everyone irrespective of affordability or not shall be entitled to government health facility.

For example in the southern Indian state of Andhra Pradesh, where I live, for the 85 million population- most of whom live in rural areas, there are a large number of Primary Health Centers (PHC) and Community Health Centers (CHC) at as many places as possible, to take care of Primary Health Care free of cost to all. For the secondary care, there are adequate numbers of Area Hospitals though in absolute numbers these are lesser than the PHC and CHC. For tertiary care there are Specialty and Super Specialty Hospitals at all identified places. These are all a part of the Government Public Health System and provision of health care is free of cost to every citizen. In addition, a core part of the health system is the Fixed Day Mobile Health Units – which are actually fully equipped mobile hospitals in the form of an Ambulance which aims to provide primary screening to identify high risk health problems. It has facilities like Lab investigations, Medical investigation, Distribution of drugs and immunizing the children. Preventive and curative at all levels are the objective of this government run system.

The Rajiv Aarogyasri Community Health Insurance Scheme (Named after Rajiv Gandhi, former Prime Minister of India), is a unique Community Health Insurance Scheme being implemented in Andhra Pradesh provides financial protection to all poor families (this number is almost equal to that of the additional number of beneficiaries proposed in the forthcoming US Health Care Legislation in the whole of USA) for the treatment of serious ailments requiring hospitalization and surgery. The entire cost of treatment is borne by Government. The choice to choose the hospital and doctor totally rests with patient.

When the world looks at America, it expects it to be a world leader in the true sense of the term. It expects its President to show the world what it means to be the leader of the free world. India where people live in abject conditions -is still able to provide Availability, Accessibility, and Acceptability in health care. Its time America and Americans do a thorough soul searching and ask themselves what they need from health care? Is the need for a new health care bill or a new health care system? You don’t know what you don’t know – till you know what you don’t have.If revolutionizing the American Health care System is not made possible now, when a forward looking progressive President is in office, it means forever it cannot be done and it is time to make it happen. (END)