FACT CHECK: REPUBLICAN PARTY STATEMENTS ON HEALTH CARE REFORM

PREAMBLE: Normally we would not presume to comment on an election issue in the United States. However, this principle is based on the assumption that Americans will place their vote based on accurate information regarding the candidates and the issues that are important to them. It is for this reason that, in this issue of Global Perspectives, we make an exception. We are providing this “fact check” because Republican Vice-Presidential candidate Paul Ryan, in his apparent zeal to prevent the successful emergence of universal health care coverage in the United States (as intended by the Patient Protection and Affordable Care Act of 2010), has been making negative references to the comparative performance of universal health care in Canada: these statements by Ryan are demonstrably misleading.

Ryan appears to make it up as he goes along, more in the manner of a carnival barker than as a candidate for the second most powerful national political post in the world. His superficial grasp of health issues seems prone to confuse and mislead his own voter base and the electorate as a whole, even about the performance of health care in his own country. Perhaps this may be expected of a candidate who, after obtaining a general undergraduate degree, then (aside from working briefly as a short order cook in a McDonald’s restaurant) went almost directly into career politics. In our view, the U.S. can and must do much better than this. The core issue is integrity: it is disturbing to think that this callow individual could hold the reins of power in the event that a sitting President passed away.

One of the campaign consequences of this candidate’s glib views on health care (whether this be in the United States, Canada, or anywhere else for that matter), is that it renders it virtually impossible for Republican Presidential candidate Mitt Romney, to discuss health care policy with any coherence, even though this is arguably his most notable success in public office (as former Governor of Massachusetts).

Ironically, because the Patient Protection and Affordable Care Act has been dubbed by Republicans as “Obamacare” (even though similar to the system now in place in Massachusetts) Romney must toe the party line.

No strength of character therefore has been exhibited by either candidate: one (Ryan) is ignorant and cavalier with the facts, while the other (Romney), despite knowing better, has been effectively muzzled by his own party. Surely U.S. Presidential and Vice-Presidential candidates should be morally stronger than this?

However, at least the facts of the matter can be set straight. In the following brief review we take note of: recent assessments of US health care performance against other countries (including Canada), and the main features of the Patient Protection and Affordable Care Act as upheld by the US Supreme Court in June 2012.

Reference:
Bryn Weese. Toronto Sun (on line) First posted Monday August 13, 2012.
http://www.torontosun.com/2012/08/13/romneys-pick-likes-canada Accessed September 15, 2012.


INTERNATIONAL HEALTH CARE COMPARISONS RELEVANT TO THE U.S. PRESIDENTIAL ELECTIONS

The health care system performance of six developed nations on several key parameters, was recently (2008) ranked by the Commonwealth Fund, a respected American foundation that promotes better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

The countries included in this exercise were: Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Notably the United States ranked 6th (last place) overall, and 6th in 5 out of 9 specific parameters; these include: safe care, access, efficiency, equity (fairness), healthy lives, and health expenditure per capita. Of the remaining parameters, it ranked 5th each for quality of care, coordinated care, and patient centred care. Its only first place ranking was for right care.

Contrasts with Canada are indeed relevant. In particular, for almost half a century, Canadian health care has been guided by the principle of universality (access to core services for everyone) within provincial systems of single payer public administration, with relatively minimal roles for private insurers.

By contrast, alone among developed countries, U.S. health care until now has been dominated by private administration and financing. The high cost of health insurance for those not included in employer-funded plans has resulted in almost 50 million people lacking coverage: insurers denying coverage for pre-existing conditions, and setting caps on life-time payments regardless of medical need. In other words, most health care in the United States is allocated on the ability to pay.

A systematic review of 38 studies reveals that Canada’s system achieves more favorable outcomes when compared with the U.S. predominantly private for-profit system, at less than 50% of the cost.

For more comprehensive global comparison there is the World Health Organization (WHO) landmark study, in 2000, of health systems performance in almost 200 countries. WHO's assessment was based on five indicators: overall population health; health inequalities within the population; overall health system responsiveness (combining patient satisfaction and how well the system acts); distribution of responsiveness (how well people of varying economic status find they are served by the health system); and the distribution of the health system's financial burden within the population (who pays the costs). The findings were both relevant and revealing: France was found to provide the best overall health care followed by Italy, Spain, Oman, Austria and Japan. The United Kingdom ranked 18th, Canada 31st, and the United States 37th (most expensive system in the world). Australia’s performance was ranked 32nd. Most European countries ranked higher than Canada, Australia and the United States.

Dramatic changes are now taking place in the US: under new legislation (the Patient Protection and Affordable Care Act of 2010 to be fully phased in by 2020) of the Obama administration, the US will begin to close the gap on universality and other deficiencies will be addressed. The legislation was upheld by the Supreme Court on June 28, 2012, against challenges by 26 states, several individuals and the National Federation of Independent Businesses.

CONCLUSION
The above brief review of salient facts notwithstanding, as amply demonstrated by the distortions of information evident in the Republican Presidential campaign (see Preamble), there will likely be ongoing political obstructionism from “Tea Party” extremists that will impede progress towards universality.

Background References
The Commonwealth Fund. A Private Foundation working towards a high performance health system. http://www.commonwealthfund.org/About-Us.aspx  Accessed September 15, 2012.

American College of Physicians. Position Paper: Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Ann Intern Med 2008;148:55-75. http://www.annals.org/content/148/1/55.full#T1  Accessed September 15, 2012.

White F, Nanan D. A Conversation on Health in Canada: revisiting universality and the centrality of primary health care. J Ambul Care Manage 2009; 32,2:141-9. http://journals.lww.com/ambulatorycaremanagement/Abstract/2009/04000/A_Conversation_on_Health_in_Canada__Revisiting.9.aspx

Guyatt GH, Devereaux PJ, Lexchin J, et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine 2007;1,1:E27-36. http://www.pnhp.org/PDF_files/ReviewUSCanadaOpenMedicine.pdf  Accessed September 15, 2012.

The World Health Report 2000 – Health systems: improving performance. Geneva, 2000 http://www.who.int/whr/2000/en/whr00_en.pdf  Accessed September 15, 2012..

Supreme Court of the United States. National Federation of Independent Business et al vs Sebelius, Secretary. Health and Human Services et al. Certiorari to the United States Court of Appeals to the Eleventh Circuit. No 11-393. Decided June 28, 2012. As cited in the Washington Post: Full text of the Supreme Court health-care decision. June 28, 2012. http://www.washingtonpost.com/wp-srv/politics/documents/supreme-court-health-care-decision-text.html  Accessed September 15, 2012.

SUPPLEMENTARY NOTES
The Patient Protection and Affordable Care Act (passed in 2010) core provisions come into effect in 2014 e.g., ability of insurance companies to deny coverage for pre-existing conditions ceases. All provisions are to be phased in by 2020. The Act supports a system far more complicated administratively than in Canada as it remains based on a multitude of insurance providers and gap-filling programs. It will take many years to fully implement, but does have the prospect of bringing the US into line with the principle of universal coverage that has been in observed for decades in all other developed countries.

Readers interested in further information on the Patient Protection and Affordable Care Act in the U.S., as upheld by their Supreme Court, a summary of its key features is available at the following site.
Senate Democrats http://dpc.senate.gov/healthreformbill/healthbill04.pdf

Wikipedia has also been updated on this topic although their full article is much longer and history more detailed http://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act