Monday, June 14, 2010

Hospital Rwanda

I can hold a grudge like no other. As a result, I have not done more than skim through the headlines of the New York Times in years. And I used to read the Times and several other papers, granted the electronic versions, cover to cover every day. In all fairness to the Times, several years ago I had a job that allowed me to read several papers a day. Now, particularly at this time of year when I’ve got wall-to-wall interviews day in and day out, skimming the headlines is about all I have the time for.

All of which is a long winded way of saying, I came across this article on health insurance in Rwanda which I had to stop and read. To the dismay of my colleague this means that last Tuesday’s election results get short shrift. My quick two cents on that, much ado is being made about nothing with regards to the appearance of the anti-labor/progressive positions taken by the White House and former President Clinton in stumping for Blanche Lincoln. They did their job in campaigning for the incumbent from their party, and one sitting in a fairly important committee chair. We can argue about whether that’s how it should be or not, but that’s politics. Don’t like it, vote and convince the people you know to vote and hold elected officials accountable for the positions they take. Which is most likely what’s going to happen to Senator Lincoln. Back to Rwanda.

139th out of 181. 139th out of 182. 141st out of 190. That’s where Rwanda ranked on the IMF’s 2009, World Bank’s 2008, and 2009 CIA World Factbook list of countries by GDP. The United States ranked number 1. 92% of Rwandans have health insurance. 85% of Americans have health insurance according to last year’s annual report by the Census Bureau. Why is it that Rwanda can figure out how to bring near universal health care to its population for $2 a year and we can’t, or more to the point won’t, figure out a public option? Right, politics. Something Blanche Lincoln is learning cuts both ways.


Hendricks said...

Would you be willing to receive all your medical treatment in Rwanda?

the silent type said...

If I was Rwandan or lived in Rwanda, yes. Last I checked that's how most people receive their healthcare, in whatever country it is that they live in. And that my friend, is the point. If I was Rwandan I would have a greater chance of being covered by health insurance. Would you be willing to give up your health insurance, assuming you have any, if you needed to be hospitalized for an extended period of time? How about if you had to take a number of expensive prescription medications for the rest of your life? When you are, we can talk about me taking the illogical step of flying halfway across the world for medical treatments that are available to me at home. Provided I have insurance that is.

Hendricks said...

My point, blithely implied, was that you seem to be attributing moral or medical superiority to Rwanda on the basis of the percentage of its population covered by insurance. I phrased my post as I did to challenge the belief that there is an equivalency between the quantity and the quality of health insurance, as well as the relation between health insurance and actual medical care. Perhaps I should have said "Would you rather be a sick Rwandan in Rwanda, or an equivalently sick American in America?" Given the wide disparities in life expectancy, infant mortality, childhood mortality, and maternal childbirth mortality, one can draw simple conclusions that America provides a higher standard of care to more people than in Rwanda. Someone walking into an American emergency room with a traumatic injury, diabetic shock, or pneumonia is going to be treated regardless of their cash on hand. And as much as supporters of universal health care like to trot out the model of someone who went bankrupt because of their medical bills, to paraphrase the Healthcare Economist, would you rather be bankrupt and alive, or dead and, well, dead?

Let us also not overlook this line from the NYT article: "[T]otal health expenditures in Rwanda come to about $307 million a year, and about 53 percent of that comes from foreign donors, the largest of which is the United States." So really, Rwanda is not providing its citizens with universal health insurance: the United States and the rest of the world is. The United States is likely the source of much of the medical technology, anti-HIV drugs, innovation and education (directly or indirectly) that finds its way into Rwandan hospitals. These research and development costs are a large percentage of the higher cost of medicine here in the US, and the fact that we pay them here makes them a virtual subsidy to the rest of the world.

And to answer the questions you posed to me, no, I do not have health insurance. I left a job that provided generous benefits, and I made the rational informed choice not to purchase health insurance. I assessed the costs of insurance, my medical history, my lifestyle, the degree of risk I am willing to take that I will not suffer a catastrophic trauma or illness, and forms of proactive preventive medicine. Since that time I have paid out of pocket for specialists, immunizations, and trips to pay-for-service clinics. I am aware of and prepared for the consequences of my decision, including a life where I may not be able to buy the clothes and take the trips I would like because I need to be on expensive medication for the rest of my existence. I do this because I know that no matter how hard the government may try, there is no way I can have my cake and eat it, too. The nature of the world is one of trade-offs, not solutions.

the silent type said...

I am attributing a moral superiority to Rwanda on the basis that it is at least attempting universal coverage for its citizens. Even moreso because it does not have the means to do so, as you point out, but we do. This is not a knock on foreign aid, because I believe it is important to donate when you can and we can, but if we have money to make sure Rwandans can get health insurance why can't we do it here? If we have money to break and then fix Iraq because we broke it, why can't we fix what's broken here? And there's plenty of stuff that's broken here. Plain and simple, I think their priorities are more in order on this point than ours.

You're right, there is a difference between quantity and quality and having insurance and having access to actual medical care. But we have the quality, right? Best health care money can buy, right? The stats on outcomes among industrialized nations don't quite bear that out if I remember correctly, but we'll let that slide. When do we work on the quantity? When do we decide that it's not acceptable for your options to be bankrupt and alive, or dead and, well dead?

Much like services for homeless individuals, the largest driver of health costs are the no more than 20% of the population with severe and chronic conditions. A decent amount of the time with preventative care, which folks are more likely to seek out when they have insurance, those conditions could have been either eliminated or managed in such a fashion that would not require the massive expenditure of resources needed now. There's also the overuse of elective procedures to consider, but that's a different story.

I'm glad that you are in a position to make the informed choice to opt out of the insurance system. I wish more people had the resources, lifestyles, and environmental factors to allow for that. Unfortunately, there aren't. The number of children in my neighborhood and the surrounding neighborhoods of the South Bronx and Harlem speak to that. I agree life is about trade-offs. There are somethings, however, that should be non-negotiable.