I remember that among other things I had told them that if they were English, or Dutch or Danish, or from New Zealand, they would have to wait months, if not years, to have that type of surgery. I also told them that the intervention was done in one of the finest hospitals of the world and free of charge, a privilege that not all the Americans are entitled to. I did not elaborate further because they were not interested and did not care on policy aspects of their case and the ramifications of policies in place. Interestingly enough, the day that my fellow countryman had surgery coincided with ground rounds in our department. That day the speaker eloquently talked about Medicaid Program Running in Place and falling short of expectations.
My point in bringing up this story is that many times we argue about unimportant issues instead of addressing the core of the problem in health reform. The above case was a live case of how effective Medicaid program perhaps in many cases is. That person’s life changed for better. He became free of pain and independent again after years of suffering. He became again an active member of society and able to provide for his family. His quality of life improved tremendously. The program did not discriminate based on ethnic, nationality, race or other and was an example of perfect equal access. The Medicaid pays less (or at least closer to the cost incurred) than any commercial plan does, and this can also be considered as a gain in efficiency. On the other hand, I am pretty sure that that Medicaid, Medicare, CHIP programs or even the employer based health insurances have lots of problems and anyone can find arguments to make the case against them. All depends on the point of view and what is being achieved by discussing such issues. On the ground rounds that day I suppressed inside me the urge to contradict the speaker based on the case. Many times skilled presenters or speakers make their case by bringing up arguments and making them colorful and palatable to the audiences often being to general. I believe, that any time we consider and try to engage in policy analysis we ought to do it along keeping in mind the true policy problem and its recognition, identification of its causes (immediate and root causes), and what would be the appropriate policy measures to remove such causes.

Although the authors comment on the NYT article about access to health care technology in UK and USA is correct and supported by solid data, I believe that it missed that target, too. It may be true that in US people incur higher costs than in UK when they seek health care services and that may deter the demand and access. However, lack of co-payments or coinsurances does not necessarily mean that access to health care services is better in UK. In all countries with nationalized health systems people may not pay any money but long waiting times for health care procedures denote poor access that ultimately affects health status and quality of life of people in similar way like co-payments or high deductibles do in US system. Again comparing which system generates higher welfare loss is difficult and arguable and at the moment not as important as recognizing it as a problem. It may be true that the resentment of Britons waiting months for hip replacements, cataract surgery, or other procedures for non-life threatening conditions and those for cardiac bypass or other procedures for life threatening conditions, whose miserable quality of life is prolonged by policies in place, may be less in magnitude than the resentment of 50 million Americans that go without health coverage for some time during the year. Or is it? Or it may be true that the man/woman months with disability and pain and suffering due to chronic diseases in the waiting lists compounded by suboptimal quality of life and lower productivity with negative economic repercussion per number of population in UK may be lower than the same indicator in US, but that does not mean that health reform in UK has been successful so far. My concern and worry relates to the fact that by engaging ourselves in such discussions we may lose focus and may add to the confusion in defining the real policy problems, identifying their cause, and selecting the proper policy alternatives. Nobody can deny that regardless the fact where the access is worse, the main policy problem generated by NHS in UK and health system in USA is the loss of population health stock in both countries due to limited access to care. Again, it is irrelevant in which country it is worse as long as both countries need serious revisions of their policies and radical changes in view of their reforms.
The second issue I wanted to discuss relates to the use of concepts that policy analysts are so found of and use so frequently. QALY, cost-effectiveness, opportunity costs, etc., have are often used to justify some rules and regulations in the equally inefficient NHS as the US health system against the use of advanced medical technologies. From a public policy perspective, measures that tend to deprive population in need of advanced technological tools that have been proven to restore the health status of the sick or ease the physical and psychological pain of the subject or the family, remain counterintuitive, counterproductive, illogical, and impractical. The rich will aggressively pursue any advanced technological opportunity when it comes to saving or even improving the quality of their lives (justly, without any regard to costs effectiveness, opportunity costs, or QALY results). Experience tells us that the poor will also do the same but the effects will be detrimental for them.

No one among high officials of the ministry of health in any country can tell to the families of severely ill people that they can’t get those new treatments because the cost-effectiveness studies show that they are not worth the money spent, or that with the money needed to treat their dear ones, the government would provide some primary care services that would improve the lives of some other people. It would be completely senseless. I personally have been in those shoes. I was working in the Ministry of Health of my country and was part of the group working on health policy development and reform implementation. The time could not be more interesting and challenging from a professional and life experience point of view. It was immediately after the fall of the communist regime and on into economic transition. Overzealously during those years, I have tried to assimilate the palatable concepts like cost-effectiveness, priorities, opportunity costs, importance of primary care versus hospital care, and other cliché teachings, all courtesy of World Bank, UNICEF or other UN branches, and other big donors’ consultants. Given the importance of the moment, our lack of exposure to such arguments and debates, the level of knowledge we coming from clinical field had in these matters, poor economic situations of the country and the pressures that come with it, we were in real danger of brain washing and subsequent indoctrination. Nevertheless, when it came to meet real people in pain and suffering, all those teachings meant nothing. I could not set myself free off the thoughts that for more than half a century people in my country, like in all ex-communist countries of Eastern and Central Europe, were deprived of the rights to make choices they wanted and had to accept what the government provided. The resentment of people enduring the consequences of having no choices was, perhaps, one of the factors that brought the demise of those systems. During those years, experience taught me a great lesson: the conclusions of some cost effectiveness or cost opportunity studies meant nothing unless policy analysis took into consideration the public welfare in all its dimensions. No matter how poor people are and what the costs will be, they will pay anything to have the best care possible when their life will be in serious danger.

I still can’t say whether my past experience and teachings were worth or not. But certainly I feel very fortunate that I quickly realized that the scope of my work as a policy maker in the Ministry of Health of my country was making the best of health care services available and accessible to all, i.e. the opposite of what teachings were telling me. This was by intuition. Later on, after I moved to USA, I became convinced that it is an achievable goal. Just, you make the system efficient. Therefore I strongly I argue against the archaic ideas of rationing as pillars of health reforms.

The third thing that I would like to discuss is that of rules or regulations within health systems that health policies can’t define in detail. Even in the ideal circumstances of a sound health policy and an efficient health system, there always will be some counterintuitive and counter productive rules and regulations conceived by inexperienced bureaucrats and/or politically motivated officials that will jeopardize the flow of patients and reform outcomes. Few years ago I read on the internet about the health policy to be adopted by Blair government (sometime during 1997 I believe) where the long waiting times of patients in UK were claimed as some sort of policy tools to make sure that surgeons will continue to have their job security. That excerpt from the NHS white paper (that I can not find anymore) shows the shortsightedness of bureaucrats who do not see public policies as serving the interests of the entire population against various powerful groups’ interests (surgeons for example who due to their knowledge and skills become powerful upon sick individuals). The case of the English lady needing Avastin in the NTY article falls in this category of issues. These issues are less important from a public policy perspective. Journalistic work, consumer associations, and other similar sources will reveal these problems and hopefully they will be solved.

In conclusion, the core policy problem in UK or USA is the unmet demand of population for health care services (more specifically diagnostic and treatment services). Usually this is the case in all countries where health reforms have failed. In UK and USA such market shortages are not due to lack of capacity as it may be the case in low income and some developing countries. In fact, both UK and USA have excess capacities in place. Consequently, market shortages must be the result of a particular state of individual behavior reflected by demand and supply of health services. The question is what is that specific behavior that is causing the market shortage? What are the factors that sustain this behavior? Can these factors be removed? Where is that Governments in both countries are missing? Answers to these questions in that order will give clues on the immediate cause of policy problem generated by such health systems, the root causes of such problem, and the proper policy alternatives to make health reforms successful. These, I think, should be the main lines along which policy analysis discussions should be done.