Friday, September 4, 2009

NEJM Online Health Care Reform Center

The New England Journal of Medicine has created an online Health Care Reform Center designed to inform the ongoing U.S. national policy debate in both political and academic arenas. The Center features themed collections of more than 100 NEJM articles as well as links to relevant resources. Visitors to the site are invited to participate in discussions on a series of important health care policy questions. One such question is: "Which countries’ health care systems offer lessons for the United States? What are they?" To date, this discussion seems to have generated little interest.

Other industrialized countries as well as developing countries have designed a wide variety of systems to integrate the diverse functions of their health care institutions. In some cases, they offer natural experiments demonstrating the effects of ideological foundations as well as the strengths and weaknesses of diverse strategies. In the U.S. debate, there has been little reference to the valuable evidence available in international experience. The U.S. academic community has conducted no research programs on the complex social systems associated with health care in other countries, and influential professional associations such as the U.S. Academy of Management have generally rejected such research production as invalid on the methodological pretext that qualitative analysis lacks rigor. The American Medical Informatics Association (AMIA) tends to define research problems at the individual level of analysis (patient or care provider) and to advocate randomized controlled trials (RCT) or experimental methods applied to the study of social implications related to biomedical informatics; there is little place for system-level thinking. Where there should be an extensive body of interdisciplinary research on comparative national health care systems relevant to U.S. policy reform, there is none. Some of the reasons for this appear to be related to American "exceptionalism" and a fundamental ideological rejection of values related to collective social responsibility. (This is evidenced in the Academy of Management's widely held view that public health is unrelated to the problem definition of health care management as business process.)

Political opponents of health care reform have aimed substantial attacks on Obama's "public option" as an attempt to replicate a "socialist" system after the Canadian or British models. Politicians in both countries have been called upon to defend their health care systems in the face of often fanciful calumny. In an editorial published on August 24, the Canadian Medical Association Journal took a position arguing for a better informed and more logical debate considering lessons that could be learned from the Canadian experience. The Economist also published an article on August 20 entitled Keep it honest: Rationing is not a four letter word, pointing out the superior performance of the NHS in cost effectiveness when compared to the U.S. system, and deploring the impoverished and dishonest character of some "delirious" rants of the past few weeks heard from American politicians. Citizens of both Canada and the U.K. seem perplexed at the debate in the U.S.. Certainly a more thoughtful democratic process will be required for any meaningful reform. While policy makers around the world seek to create a forum on global health, the U.S. has lost its leadership role.

Recently CNN's Lou Dobbs introduced a series of reports on other national health care systems and the lessons that could be learned from these experiences. These brief reports provoked an attack on Dobbs from some political quarters accusing him of being a latent socialist, or even communist. Included in the series are Canada, Denmark, Japan, the Netherlands, Spain, Switzerland, the U.K., as well as vignettes on India, China and Cuba. The series seems to have been dropped from broadcast but some of the short vignettes have been moved to Anderson Cooper's 360 Blog Archive, where a number of the comments posted suggest that readers would be interested in learning more.