The American crisis
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3375 (Published 19 August 2009) Cite this as: BMJ 2009;339:b3375
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
It is a rather appalling state of affairs that while the USA, the
most powerful country on Earth is practising "democracy"
- with lobbyists in Washington like HMOs and medical insurance companies
spending millions on campaigns to prevent desperately necessary health
reforms - millions in the US are without access to ANY health care of any
description. The NHS has many faults, but millons without access to basic
healthcare is not one of them.
Competing interests:
None declared
Competing interests: No competing interests
Des Spence (American Crisis BMJ 19.8.09) sneers at
private patients
in the UK who "choose to squander their money in the misguided pursuit of
choice".
Surely it is precisely this lack of choice in the British
version of the
National Health Service which is responsible for so many of its worst
features.
A system dominated by a government monopoly and lacking any
meaningful element of choice or competition is bound to be inflexible,
and
unable or unwilling to respond effectively to patients who feel they have
a
genuine grievance.
Americans appear to be well aware of deficiencies in their own
system, but
it is not surprising that so many of them are suspicious of President
Obama's
proposal to forcibly introduce a monolithic government-run service
modelled
on the British NHS.
Lack of choice is one of the prime characteristics of a
dictatorship. Choice
and competition can only flourish in a democracy. Americans are
instinctively
aware of this, and Spence's condescending article can only help to confirm
their suspicions.
Competing interests:
None declared
Competing interests: No competing interests
Editor
We all know that BMJ columnists are paid on a similar scale to
bankers but in Des Spence' case this week I feel that he has earned a huge
bonus.
At every opportunity I shall plagiarise his contribution - 'The NHS
is a proud embodiment of the proclamation that all our people are valued
and will be treated equally.'
Yours sincerely
Steve Ford
Competing interests:
None declared
Competing interests: No competing interests
I applaud Des Spence's defence of the NHS, but it is a shame that he
feels it necessary to claim that "this is not socialism". The very things
that most of us value about the NHS - its universality, equity, and the
provision of personal good through public solidarity rather than private
self-interest - are the essence of socialism, and his own description,
"all our people are valued and will be treated equally", is as good a 10
word definition of socialism as I have seen.
Ideologues in the US and elsewhere may treat socialism as a dirty
word, but it was the source of the NHS, and those of us who support the
results should at least recognise where the means originated. Nye Bevan
and his comrades were proud of the NHS, and the NHS should be proud of
them.
Competing interests:
CJ is a member of the Labour Party - whether or not that counts as socialism is a moot point.
Competing interests: No competing interests
The major obstacle preventing the legislation of a universal and cost
-effective health care insurance for the americans, is the ideological
incarceration that prevents either side from honestly appraising the merit
of the opposition’s proposals. Democrats will not appraise the validity
that tort reform and competition across state lines will bring down cost.
Republicans on the other hand are rigidly anathematous to a public health
insurance plan which would ensure universal coverage while robustly
competing with private health insurance corporations. Having worked as
psychiatrists in the NHS and have relatives in Canada, it has been very
frustrating to see such strident and un-informed demonization of these
laudable (albeit imperfect) systems. To use the fear of rationing to
prevent universality, thus leaving the care of the uninsured and the
underinsured to the goodwill of charities and neighbors is unconscionable
in a civilized country like USA.
Competing interests:
None declared
Competing interests: No competing interests
Since all of our feelings are ambivalent, it’s no surprise that love-hate
relationships are so common. No matter how hard we try to have pure feelings,
it’s impossible. Let’s accept ambivalence as a fact of life, and reconcile
ourselves
to the painful, embarrassing inevitability of love-hate relationships. And let’s
learn to appreciate love, even if it’s sometimes tinged with hate.
Competing interests:
None declared
Competing interests: No competing interests
My father was a young GP in Portsmouth at the inception of the NHS in
1948.
He was a great supporter of the Health Service, and proud of his ability
to
look after the poor in the “slums” of our part of town.
I am a Stanford-trained Physician Assistant, practicing in the United
States. I
provide federally-funded medical care to a few of the 46 million
uninsured.
My patients are the working poor, the homeless mentally ill, recent
immigrants and migrant workers who build our houses and pick our fruit,
and senior citizens who do not have adequate coverage for their needs. I
have a very hard time obtaining the services they need outside my own
primary care efforts – they must scrabble for cash (which they seldom get)
to
pay for medicine, consultant evaluations, optometry, and dental services;
there is no domiciliary care; and hospitals kick them out in the middle of
the
night if they are able to walk.
I am currently in England looking after my mother at home. She is
90, and
she is dying, but she still gets incredible care. Nurses pop in four
times a
day, the GP visits three times a week, PT and OT are provided, and a night
nurse sits with her every other night while I get some sleep. All her
medicine
and supplies, including a state-of-the-art hospital bed, are free. They
have
also gone out of their way to provide comfort and support to me. It is
compassionate, practical, and makes clear economic sense. Does that sound
like the Republicans' absurd “death panel” to you?
In the US, I see the crude, greedy ignorance displayed by the
corporate
machine that is America’s feeble and embarrassing health care effort. It
is an
utter failure. I can not assure my patients of a decent standard of
medicine –
and for that reason I am planning to leave the profession for a while and
devote myself to helping the Obama Presidency in its courageous and
unambiguous push to rectify and humanize American medicine. I don’t know
what my patients will do, but I think my father would appreciate this
categorical imperative.
Competing interests:
Recipient of the American
Academy of Physician Assistants'
2009 "Service to the Underserved"
Award
Competing interests: No competing interests
American crisis and mission impossible
I was reading this article with interest. The crisis arises from many
competing interests. Having lived in Asia, the United Kingdom and the
United States, I have learnt how americans think and behave. It all comes
down to many of the following competing interests.
Individual states: Once upon the time, President Thomas Jefferson
said "The United States are". He used pleural instead of singular.
Essentially, the United States are a union of 50 small countries (states)
and some other jursidictions with their own state governments with
executive, legislative and judiciary branches. The state governments also
have control of reservist troops (National Guards). All states agree upon
only three things, i.e. same currency (dollar), single foreign policy, and
single armed forces. The similarities end here and everything becomes
different. Many americans do not trust the central (federal) government in
Washington D.C. and many feel that healthcare is not the responsibility of
the federal government. Many view the federal government as a necessary
evil and an evil necessity.
Trial lawyers: This group prospers on malpractice litigation, whether
the cases have merits or not. Lawyers can take malpractice cases to the
courts on contigency basis. Since the cost of defending the lawsuits is
very expensive, many doctors and liability insurance companies settle the
cases out of the court. If plaintiffs win, juries also award astronomical
amount of money. Trial lawyers have massively contributed to Obama's
campaign and Mr Obama makes no mention about medical malpractice tort
reform in his healthcare reform agenda. Surely, Mr Obama has to take care
of his trial lawyers. Trial lawyers have their lobbyists in Washington
D.C.
Medical professionals: This group badly wants medical malpractice
tort reforms since liabilty premiums have risen faster than inflation
rate. And they do not want to order many tests just to defend themselves
in case they are sued. Many malpractice insurance companies have fled some
states such as Florida because of massive jury verdicts. Even though
physicians have discussed this issue with Mr Obama's administration, Mr
Obama has deaf ears on this issue. It is not surprising that many
physicians have retired early or have left high-risk specialities such as
obstetrics and neurosurgery. Medical professionals also have their
lobbyists in Washington D.C.
Medical Insurance Companies: These companies always have a profit
margin of 20-30%. Even though they want to limit the benefits of the
patients when they are sick, the companies have no problems giving huge
bonuses and massive salaries to the CEOs. The companies do not like Mr
Obama's overhaul of healthcare system as they can become out of business
over time. So, they have their lobbyists in Washington D.C. to protest
against Mr Obama's plans.
Patients: Patients are divided. The majority of Americans are aware
of the faults in the current system, however, they do not like Mr Obama's
plan of eventually monopolizing the healthcare by the government. It is
not surprising to see many protesters at townhall meetings and anti-Obama
demonstrations. The elderly group especially are against Mr Obama's plan
for they fear the government will limit their access to healthcare and
that Mr Obama will ration their care. Many people are saying " When Obama
lies, grandma dies". Interestingly, the unions are also against Mr Obama's
plan since their have enjoyed very good healthcare benefits. Only the
truly poor and many illegal immigrants support Mr Obama's plan.
Pharmaceutical companies: They support Mr Obama's plan as they will
be able to sell more drugs when more people become insured. They also have
their lobbyists in Washington D.C.
Political parties: Democrats want more votes in the forthcoming
elections. First, they want to legalize many illegal immigrants as
permanent residents of USA. At present, they account for 12-15 millions.
They become potential voters after legalization process. Offering
universal healthcare to them is a strong incentive to the Democratic
party. On the other hand, republicans are traditionalists and they say
"healthcare is not the federal government's business. Mr Obama should not
interfere."
Small businesses: They account for 85% of businesses in USA. They
hate Mr Obama's plan for they will be forced to buy medical insurance for
their employees and at the same time, tax rates will be increased. Many
will have to shut down their businesses or will have to move overseas.
Taxation is anti-american and increased taxation can bring down USA in the
long run, they say.
There are many other competing interests I fail to mention. Given
those interests, Mr Obama's healthcare is like "a mission impossible". I
am afraid american crisis will go on.
Competing interests:
Currently Attending Hematologist/Oncologist at an inner city university hospital in Boston.
Competing interests: No competing interests