Prescribing reform.

Stransky, Martin Jan

The United States and the Czech Republic need to fix health care, and both countries must find a political middle ground.

Among established democracies, it is hard to find a country in which there is not a continual and often heated debate on health care. As health care increasingly chews up national budgets, legislators are reluctant to act because they know health care is a political and social landmine. In the United States, debate on health care reform has degenerated into angry shouting matches at town meetings, complete with citizens toting automatic weapons to protect their "rights" while protesting President Obama's "socialization." In the more socialist Czech Republic, the fall of the recent government was brought about in large part by public protest regarding the implementation of a mere 30 Kc ($1.70) co-pay fee for prescriptions and doctor visits, in an attempt to curb the country's world-leading average of 16 annual visits per patient to the doctor. (It worked.)

In most developed nations, health care spending is the single biggest inflationary sector and is thus threatening or ruining personal, business, and national budgets. In the United States, the inability to pay escalating insurance premiums, which have increased at three times the rate of wages in the past few years, is now the single leading cause of bankruptcy at both the company and individual household level. Though 90 percent of those who voted in the United States in the last election do have health care, it remains the only country in the developed world not providing universal health care for its citizens, leaving 47 million Americans uninsured, with one out of three Americans going without coverage at some point.

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Despite leading the world in health care spending--the United States spends 17 percent of its gross domestic product (GDP) on health care, or an average of $7,421 per year per citizen versus eight percent of GDP in the EU--the United States ranks 37th on the World Health Organization rankings of quality and efficiency in health care, making it the most inefficient country in the world as far as health care spending is concerned. This largely stems from the little-known fact that, in the United States, 50 percent of all money spent on health care is spent on 5 percent of the population, mainly to prolong life, sometimes for only a few days.

In the United States, death is the enemy; no one is allowed to die. If President Obama, other politicians, and the US medical establishment could succeed in putting physicians ahead of technology (How do I know it unless the test verifies it?) and pushing for a social realignment that would alter America's view on life, lifestyle, and death, billions would be saved without talk or need of any further reform. But this would be political suicide in the land and culture of the chosen.

For politics to succeed in any country, battles must be picked that can be won, even if they are picked from the middle or bottom of the list. The need to provide insurance to 47 million uninsured Americans strikes a justifiable and sympathetic chord in most American hearts. Control of rising insurance premiums--by far a much greater culprit in the US health care scenario of rising costs--is something harder for the aver age American to grasp. Hence, Obama has focused the debate in the United States on the need to create a "public" government-sponsored program for the uninsured, who--though they use emergency services excessively and do not participate in preventive medical programs--chew up only 10 percent of each health care dollar. For a country that requires citizens to insure their cars but not themselves, this will be a telling debate indeed.

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In Europe, the emphasis is not on avoiding death, but on living a good life and avoiding bad wine. Not having health care provided for you by the state is unthinkable, where socialist traditions prevail. At the same time, Europe and the United States share the same health care problems, like rising insurance/state premiums and the rising use and costs of medications and medical technology. However, Europe spends far less money on health care than the United States. Despite this, life expectancy in the European Union is actually longer than that of the United States. The Czech Republic spends $1,276 per person per year (about one-seventh of the aforementioned US total) on health care, with Czechs living an average of only a year less than Americans.

The Czech Republic presents a somewhat unique scenario in that no health care "system," per se, exists. This is because after 1989 full-fledged capitalism was unleashed on a socialist system, fragmenting the system while driving costs upward. To date, a definition of just what constitutes the "standard of care" for any given medical condition, as well as for accessibility to services, does not exist. These fatal flaws mean state insurers are free to interpret what they should provide while hospitals and providers are free to privatize based on local political and/or economic rewards.

The country has had 13 health ministers in the past 20 years--not exactly a recipe for coordinated policy. Absolutely no one has put forth a plan of what Czech health care should look like five or ten years from now, let alone next year. There continues to be a lack of central control and planning and a reluctance to stratify the system via the introduction of meaningful capitalist competition in a thriving private sector while shoring up the state safety net. This has left the chief players--doctors, hospitals, insurers and the Health Ministry--competing for political and economic turf among themselves, with the patient as the loser. The absence of central control has also allowed rampant corruption to flourish, accounting for up to 20 percent of all health care spending. One only needs to look at the property or vacation destinations of hospital and ward directors who are reimbursed under the table by drug companies to prescribe their drugs to see who is on the take and who isn't.

In the United States, Obama spoke on 9 September to a joint session of Congress and on television to the entire nation, saying "Health care is our main problem. Nothing else even comes close. " In the same breath, he outlined a plan with key goals, such as continuing existing coverage for those who have it, stripping insurance companies of the right to deny coverage via pre-existing medical conditions, placing a limit on out-of-pocket expenses, and guaranteeing insurance coverage for everyone.

In the Czech Republic, a much-needed leader pushing for health care reform has yet to emerge, though the last health minister, Tomas Julinek, did give it a try, until his 30 Kc co-pay shot him down. President Vaclav Klaus has yet to utter a single syllable about health care or corruption: the country's greatest scourge. Instead, he continues to focus the energies of his unbridled ego on denying the effects of global warming, attacking the EU and launching battles against the Constitutional Court when he does not get his own way.

Despite the differences in the approach to life and health, both the US and Czech scenarios have common underpinnings. First, there is much tension at the level of the common man regarding simple reforms--from the gun-toting town hall rebel in the United States to the Czech who refuses a 30 Kc co-payment. Though each views the role of government in opposite ways, their reactions are the same. Second, neither country needs to increase its health care spending for better health. Substantial improvements, as well as marked savings, can be found by influencing social values and by implementing changes within the system itself. Third, both countries are handicapped in that they reward health care providers based on quantity and cost of procedures and not quality of care or result. This drives up the cost of care instead of driving up savings (in the United States, pilot programs are addressing this issue). And fourth are the aforementioned runaway expenses of increasing medication costs combined with the pursuit of advanced technology.

The success of a society is ultimately measured by the status of its poorest and not by its richest. And that status is to the greatest extent determined by their health and by extension their health care. Health care is about fundamental principles of social justice and a nation's character. It seems that, on both sides of the ocean, be they on the free market right or the socialist left, painful adjustments toward a new center will have to be made.

Martin Jan Stransky is the publisher of Pritomnost and The New Presence magazines and practices medicine in both the United States and the Czech Republic as an assistant clinical professor in neurology at Yale University and director of the Policlinic at Narodni in Prague.