Cuban Health Care
Here’s a very interesting Reuters article on health care in Cuba. I don’t fully understand how the headline (“Health Care in Cuba More Complicated Than on Sicko”) jibes with the text of the article, since about the worst things the author can say about Cuban health care are that (1) the waits are a little longer than they were 6 years ago; (2) people have to bring their own towels to the hospital; (3) there are some shortages of basic medicines; and (4) there is political oppression in Cuba, which, while certainly true and clearly relevant to an evaluation of the Cuban government as a whole, does not seem to have much to do with its health care system per se. One fact in the story that really blew my mind was the following:
The average life expectancy of a child born in Cuba is 77.2
years, compared with 77.9 years in the United States, according
to the WHO. The number of children dying before their fifth birthday is
seven per 1,000 live births in Cuba and eight per 1,000 in the
United States. Yet the United States spends more than 26 times as much on
health, $6,096 per person a year, compared with only $229 in
Cuba, the WHO figures show.
UPDATE: I changed the original post to note the medicine shortages, which do strike me as a more substantive problem than the others the author of the article mentions.
Cuba’s totalitarian government is extremely relevant to evaluating its healkth care system. I suspect that the health numbers for Cuba are provided by the Cuban govenrment (or by WHO officials who are approved by the Cuban government) and thus are highlky suspect. With no free press to question Cuba’s healthc are system, of course it seems great!
I have no idea what the relationship is between the WHO and the Cuban government, although I’m sure you’re correct that the lack of governmental transparency makes the data suspect, at least as a prima facie matter. But that only goes to the question whether the health system is actually as good as many people claim; if it is as good as those claims, and the article offers few reasons to doubt them, the oppressiveness of the government, while abhorrent, does not undermine the significance of its health care accomplishments. And the latter seemed to be the reason the author mentioned it, not as a reason to doubt the veracity of the claims about the quality of health care.
On a more personal note, my family has several close friends of varying ages who have needed extensive medical treatment in Cuba. Generally, the care they have received has been very high quality and timely, although many of the descriptions in the article ring true: the hospitals are dingy and uncomfortable; there are some shortages of basic medicines; and the situation has deteriorated since Fidel began sending thousands of doctors to Venezuela in exchange for cheap oil.
Wouldn’t the more relevant comparison be with France, whose medical system was lauded by Moore as the best in a comparison that included ours, Cuba’s, and Canada’s. I have several students and friends who’ve thanked God for the French system when they got ill there. And isn’t it relevant that every attempt to scale back or eliminate national health care systems has been decisively repudiated by voters? Margaret Thatcher’s downfall can arguably be traced to her attempt to significantly privatize the NHS.
Moore’s ultimate point seems to me irrefutable: if you want to really reform the U.S. health care system, you’ve got to, at the very least, eliminate private insurance.
I agree that France (or Canada) is a better comparison for us. I was just blown away by Cuba’s aggregate health statistics given how little money they spend per citizen. Of course, the WHO statistics don’t measure quality of life, etc., but the infant mortality and life expectancy numbers, if accurate, are astonishing to me.
As far as I know, there is not a single country with a nationalized health care system that has avoided one of two problems–either the system becomes immensly expensive or the care received is substandard enough that people flee to any available alternative (including paying doctors illegally). Canada’s once-lauded system has seen nearly every mergency room in one major city–I think it was Toronto–shut down simultaneously, Candians crossing the border to get care in the US that is unavialble there, and a major lawsuit that challenged the criminality of not being able to pay doctors directly for their services (which was won by the plaintiff, although it may have been appealed). And don’t forget that those supposedly cheaper Canadian drugs are only cheaper because the Canadian government forces pharmaceutical firms to provide cheaper drusg or not do any business in Canada–which then raises the cost of drugs here (i.e., we’re paying more so the Canadians can pay less). While the current US system has its problems and definitely needs reform, there are few good models to emulate unless we can somehow pick and choose what does work elsewhere while rejecting what does not work better.
For a rebuttal of Robert’s view, particularly the demonstrably false notion that national healthcare is less efficient than our crazy-quilt of private insurance companies whose combined bureaucratic weight is crushing primary care givers and whose sole purpose sometimes seems to be to deny coverage, see the following comparative study:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=482678
Robert is wrong. The first fact to keep in mind is that the US has the most expensiev health care in the advanced world (measures as $ per person) and yet has some of the worst outcomes. The problem is that people keep arguing based on anecdote, not sound statistics! Don’t get be wrong: some single-payer systems do have problems– the UK and Canadian systems tend to have waiting lists (though, if I were one of the 45 million uninsured, a little wating list wouldn’t bother me so much!). But the French system does not have this problem, and it is STILL far cheaper than in the US.
The basic issue is quite simple: single-payer systems embody social risk-sharing, whereby the young and healthy subsidize the old and sick, knowing that they will be simililarly be helped in their time of need. Insurance companies on the other hand want actuarial insurance– each person pays according to risk. Now, that’s a great deal for for the young and healthy, but it leaves hangs the less fortunate out to dry. What they do is engage in adverse selection– weeding out those “bad risks” through higher premia or outright refusal. Single-payer systems don’t have this problem, as they are not obliged to make profits.
Here’s an interesting article from Slate concluding that:
“A closer look reveals the counterintuitive possibility that high infant mortality in the United States might be the unintended side effect of increased spending on medical care…”
Among other causes, “better and more affordable medical care actually has worsened the rate of prematurity, and likely the rate of infant mortality, by making fertility treatment widespread.”
http://www.slate.com/id/2161899/
I won’t weigh in on the insurance stuff — other than to say that it is possible to have a universal system while maintaining private insurance, several European models do just that, moreover a combination Medicare default/ private insurance if you want seems to me the most doable politically in the immediate future.
But regarding infant mortality:
It’s important not to let this statement live too long because the highest infant mortality is found among groups that are less likely to be using fertility services — African American women. The core, seemingly intractable infant mortality rate has nothing to do with fertility services.
In addition, fertility services are usually not covered by insurance, which in turn causes many couples to compensate by transferring more embryos to avoid another round of expensive fertility treatment.
So the moral of the story is: The infant mortality issue is mostly disconnected from fertility services, but if you want to reduce fertility related multiple births that contribute to a higher infant mortality rate, one way is to mandate coverage for IVF so that couples aren’t incentivized to transfer a higher number of embryos to maximize the chance of a positive outcome.
It should be pointed out that we have known for years that Cuba has great health care. Proportionately for the US this is a scandal of mammoth magnitude.
The poor care of the rescuers has also been known to those of us who have been involved with 9/11 compensation from the beginning. Basically, some kind of mathematical model was applied where you were better off dead than sick. Especially if you were a rescuer. The government allotted so much and that was it. Unless someone demonstrated and then more money came in.
The other shameful fact is the treatment of Cuba by the US because of the expatriated Cubans in Miami. They were miserable to the people when they were in power and are still trying to produce misery in exile.
The fact that Christian leaders were weak to help shows how nationalist Christainity is in this country rather than Christ-like. As long as they were Communists we decided it was okay to be un-Christian to them.
Like most Salon articles, I found the piece referenced by Mr. Molloy to be long on hype but short on substance.
Keep in mind that the infant death rate in the US is the worst among the industrialized, affluent nations of the world.
If fertility technology was the culprit or even a major contributing factor, one would have to ask why it wasn’t also factor in countries with comparable living standards but lower mortality rates.
Also, without the raw numbers, the fact that the number of fertility treatments doubled between 1996 and 2002 is meaningless. Unfortunately, the Institute of Medicine report containing the data cited by Salon was behind a paywall.
Perhaps it’s apropos of nothing, but Cuba has the 17th highest suicide rate in the world. (The U.S. is 46th.) There could be many reasons for that rate, including the possibility that mental health care in Cuba is not as good as the country’s medical health care.
Russia has the highest rate, with ## 2 through 9 either former Soviet states (e.g. Lithuania) or Soviet satellites (e.g., Hungary). Japan is #10, and surprising (at least to me), Cuba is sandwiched between Switzerland (#16) and Austria (#18).
Not surprising, William. Life in Cuba is grim, notwithstanding the public health system. There is not a lot of hope, especially among young people. For a good sense of the emptiness of life in a stagnating socialist economy, I recommend Pedro Juan Gutierrez’s Dirty Havana Trilogy (not for those who are offended by explicitly sexual prose, but a great book nonetheless). In fact, my uncle often says that the only reason the suicide rate in Cuba isn’t even higher is that it’s so hard to find the things you need to kill yourself.
I am sure this is “anecdotal” and therefore not worth much in some eyes, but I had the privilege of living under a single payer system in Italy for three years. I will admit that a single payer system will function and provide good fundamental medicine, but at a cost.
It is more than just long lines. Although, I think people short sell the impact of these. I had a Lt working for me who tore his ACL. He was properly diagnosed. Cast with a 30lb full leg plaster cast and sent home – “stable” – awating his surgery 5-6 weeks later – next available. He was basically immobile, could not leave his apartment and couldn’t work. Other people had to shop for him and cook for him and check in on him two or three times a day, and he was miserable. After much complaining, I got him air-evac to the States – surgery two days later – back at work in Europe in two weeks with a lightweight cast.
Or our babysitter who was hit by a car – multiple compond fractures to the legs. Not only did family and friends have to bring towels, but bottled water, and toilet paper. It was lovely visiing him in his room in August, in 95 degree heat, with no air conditioning.
People in my Wing would rather wait a week or two to fly to the nearest US Military Hospital in Turkey than brave the Italian system – which frankly was adequate, but antiquated. As one Captain told me – I thought I was inside a Norman Rockwell painting of a doctor’s office in 1936.
Mind you, this was in the wealthy Northern part of Italy. And oh, by the way, the Italian system is regularly among the world’s best, while we air conditioned, toilet papered, fiberglass cast wearing Americans are fair to middlin.
It is not just about outcomes and minor inconveniences. It is about having choices and a system that is responsive to patients as consumers.
As for Cuba – its wonderful healthcare doesn’t seem to be enough to keep some people from taking dinghys through shark-infested waters to come to our miserable country – go figure.
Sean — I’m sure I know more Cubans who have sacrificed much to come here than you do. And, to the one, I can say that they come here despite our health care system, not because of it.
By the way, isn’t the military’s medical system government run? I guess that would make it a single-payer system, right? Go figure.
I’m curious about when Sean H was in Italy; we found Italian healthcare to have problems, but almost the exact opposite of what he found.
I doubt if anyone believes for a secon that it is better to live in Cuba than the US. What is significant is how much better life is in Cuba than in most poor countries.
Why we will not help Cuba is beyond me. Is the constituency in Miami that powerful?
I think we may be able to get past what some people seem to think is a moral requirement that Cuba be a failure in every way by saying that DESPITE being a politically and economically backward country, Cuba has a remarkably good health care system.
As for the United States, the health care system is broken in every way. I am an executive for a major insurance company. The reason I write under a pseudonym is that I support a single payer system, a position which is as you can imagine rather unpopular at work. I sometimes blog about this.
Insurance companies are vilified in the US and there is a common assumption that if one could only eliminate them most everything else would fall into place. In fact, rather like a dysfunctional family, everyone is part of the problem.
There is no “market” for health services, in the sense that there is a market for automobiles. One cannot get price and performance information about doctors and hospitals. There isn’t much of a market mechanism to keep prices down, so they go up. The purchasers of insurance are not the members but their employer groups. As Minion put it, one pays for one’s level of risk. It is really shared by the people in the employer group (the company) as well as individually. Employer groups (especially small businesses) can get priced out of the market simply because someone gets sick. So these businesses (and large ones too) try to move health costs to the consumer by reducing benefits whenever possible to get their premiums down. Some of these benefit reductions and cost shifting go under the usual dressed up names like “consumer driven health plans” and “health savings accounts”. Consumers have gotten used to the idea that insurance (the coverage of unforeseen risk) and free health care are the same thing. We don’t, as a society, take care of our health and we over utilize doctors. Finally, there are the insurance companies. Because they can’t (in our “free” market) be put in the position of having people only buy insurance when they are sick, they have to be strict on pre-existing conditions and other things. They have to set all kinds of conditions for coverage, not only because the employer groups demand it, but because this is the nature of making expenses predictable.
A single payer system would eliminate questions about who is covered and could provide a basic level of coverage for everyone. Private insurance could provide extra coverage or frills (like private hospital rooms). (It wouldn’t be America if it weren’t possible for people with more money to get something extra; maybe to Sean’s point private insurance could provide a hospital room with two air conditioners.) But there would have to also be a mechanism to keep costs down. Medicare has been proposed by some for this, since it has a cost control mechanism (“just put everyone on Medicare”.) But Medicare in fact is part of the dysfunctional system. It is subsidized by private insurance in the United States and is constructed to fit into, not stand alone against, the screwed up system.
Our private system provides massive profits for all sorts of interest groups. As people more and more revolt against the madness of what we have now, different interest groups will want other interest groups to take on the financial burdens of reform. Our “free market” simply isn’t working and the logic of insurance itself requires as a point of fact the largest possible risk pool in order to work most efficiently. Right now we treat it as just another consumer product. But is it? This is an excellent area to talk about the intersection of morality and the economy.
If you read my last post again you will see that i did not in any way defend our current system–I pointed out that it needs reform. But I do not want to see a single-payer system for the reasons i stated and the reasons that subsequent poster shave mentioned. More to the point, froma realistic standpoint of what is politically possible in this country there will not be a single-payer system anytime soon. To advocate that–no matter how strongly you believe in it–is to fight a guaranteed losing battle that will leave things exactly as they are. Incremental changes (the picking and choosing I mentioned) have a much better chance of actually being enacted.
Eduardo,
You are right. The military system is – or at least was – pretty much socialized medicine. And I lived under it from my birth – as a military brat – and most of the last 25 years. Let me tell you about that.
It is a good system. But I will tell you right now there are things that military people put up with that I doubt many Americans would.
For example, each of my children were delivered by doctors who neither my wife nor I ever laid eyes on before they walked into the delivery room. They were good, competent doctors, but when we mention this to civilian friends and family, they are shocked given that these were routine births and not emergencies. Until the last twelve years – when force levels dropped and more money was put in the system and much of the system was privatized – you absolutely had no choice of physician. If you belonged to X Squadron, you saw Dr X. Getting out of your assigned doc was very difficult. It typically took a week to a month to get a routine appointment – which is why all the active duty people went to sick call. Medicines – you got what they had. Unless you could show that you had a history of allergies or some other problem with a med, you got what was on the shelf even if there was something more effective, but expensive. The docs were careful about this, because they had to justify going to an outside pharmacy.
Above all – there were strict limits on liability due to sovereign immunity. Military members can’t sue at all, and family members had to go through the Fed Tort Claims Act. Having sat accross the table from a family offering them $60K for a dead child, I can tell you the limitations are real.
It may be that a single payer system is what will be needed to control costs and assure access, but its proponents should be honest about what it will involve and what will be lost.
There will be more limited choices period. Doctors – medicines – treatments – you name it. You name me any activity run by the government that offeros more choice than a private enterprise counterpart.
The medical profession will be more highly regulated, and limited. You will also have to consider whether physicians can operate outside the system. Most places with socialized medicine don’t allow, or severely limit this.
Services will have to be dictated by some sort of centralized bureacracy – just like HMOs now – that will decide who will be treated and how. Someone will have to decide if the recovering alcoholic gets a new liver – it will just be a government bureaucrat instead of an insurance company.
Liability limitations will have to be included. Where will the trial lawyers be on that?
The bottom line, I think is that a single payer system will work, but it will operate about as well as the best government bureacracy runs – which is at best is merely adequate.
You want to know the downside of a system like the military one – just look at the whole Walter Reed fiasco.
Gene, I lived in Italy about 12 years ago. If you lived in or near Rome, or one of the other big cities, I know their facilities were better – a buddy of mine worked in the embassy and he said his experience was better than mine. Like I said, I think it was a good system, with good care providers. That being said, I did not find it to be better than the US system. I could live with a system like that, but I really think many, if not most, American’s won’t.
In support of Sean’s statement on liability: A friend of ours whose husband was in the Navy had an ectopic pregnancy that was first misdiagnosed and then the procedure to correct it was botched. She was left unable to have any more children and unable to sue. Not a situation most civilians would tolerate.
Sean, you might be surprised to learn that increasingly, a woman’s own obstetrician does not promise to deliver babies that are anything other than pre-scheduled. With the birth of my last child (two years ago), I went into the last two weeks of my pregnancy knowing that if I went into labor on either of those weekends and many of the nights in between I would be delivered by a doctor I had never met. My two doctors shared call with two other groups and whoever was on call did the delivery. I was told that right from the start and I got used to it. The exigencies of practice and the desire for a saner lifestyle mean that fewer and fewer doctors practice according to what you might perceive to be the normal civilian model. It’s only going to get more like that. Ironically, removing health care from a more market centered approach is the most likely thing to reverse that trend.
Robert, I don’t know who your friend consulted, but the federal government, including the military, permits civilian tort suits. Indeed, most such suits are claims for medical malpractice against health care providers.
Robert,
It is probably true that the interest groups involved in our health system will prevent the establishment of a single payer system. But I can tell you as an insider that tweaks won’t solve the problem. The system itself if broken. You speak of “socialist” systems becoming too expensive or in the quality of care declining. Both are happening with our system already.
For those who have a religious belief in the efficiency of the “free market”, the free market does not operate in health care in the United States. The information necessary for the market to operate (costs and quality) is not available to the consumers of the product. If making this information available is the tweak you are speaking about, you realize that this would require a massive amount of regulation, because the holders of this information will not release it unless they are forced to by law. I would argue that if we had the political will to do this level of national regulation, it would be equivalent to having the will to set up a single payer system.
Remember, though, that the political key in our economic system is always going to be to answer the question “what about me”? If a role is found in a single payer system for the private insurance companies (perhaps in the provision of non-risk services such a claims processing or cost control), they may not be as resistant as you think. Physicians of course do not want their reimbursements to go down. They think that a single payer system might do this, but they also think that the free market would do this as well; hence their iron lock on comparative information of price and quality. I think that we could leg into a single payer system if we could provide the requisite guarantees. I certainly don’t see service quality going down if we do this and I don’t see how the system could become more expensive that it is and will continue to be now.
I would only add this to what unagidon said: A single payer isn’t necessary to assure universal access. Right now, we have a single payer system for the elderly that functions alongside private insurance. There’s no reason that can’t be replicated. People who are happy with their private insurance and private insurers who are able to prove to their clients that they add value can keep the status quo.
And yes, doctors want the best of all possible worlds: regulation that protects them from insurers but that doesn’t constrain their own ability to set price to their patients, all the while blocking initiatives that would provide greater information to consumers. Right now, if insurers serve one important function it is that they have information. That they aren’t allowed to act on it is a testament to the political power of providers.
Barbara,
You are right, civilians can sue if they do it right – under the FTCA. She may not have been able to use the FTCA if the medical care was provided overseas. Then she would be limited to an administrative claims process. Also, the time limitations on federal claims are very strict, as are the formal processes. Also, it was my experience as a federal attorney that we were much more willing to defend against claims than insurance companies. As a result, many claims get dropped because attorneys don’t have the patience or money to spend years in federal courts – particularly since those courts are almost always less generous than their state counterparts when the plaintiff prevails.
Barbara and Sean,
Thanks for the information on suing … I do not know the legal specifics of my friend’s case, only that she informed us that she was unable to sue (which may have only been her perception–but it was not really the best moment to question her further).
Please check out this article:
Who’s Really ‘Sicko’
In Canada, dogs can get a hip replacement in under a week. Humans can wait two to three years
http://www.opinionjournal.com/editorial/feature.html?id=110010266