Last year I wrote a post about Taiwan’s National Health Insurance program, having found a thoughtful article about the costs and benefits of Taiwan’s system. Now it seems that Taiwan’s system is getting even more attention, this time from a new PBS TV series: “Sick Around the World.” (All episodes of Frontline are available for free online viewing via the website!) Jonathan Cohn reviews the show and talks about health care in Taiwan:

The most interesting case study is probably Taiwan. A few years ago, when Taiwan decided to revamp its health care system, it studied other countries to determine which system might work best. Its conclusion? A single-payer system–one in which the government insures everybody directly–made the most sense.

Virtually alone among health care commentators in the U.S.–a category that includes me–Paul Krugman has been touting Taiwan for a while. The film makes it easy to see why. Today, the people of Taiwan have guaranteed access to health care–and, according to the film, it’s very good health care. There are no chronic waiting lists, like you find in Britain, and the care is very advanced. Among other things, Taiwan is among the world leaders in establishing electronic medical records–an innovation that should significantly improve care by keeping doctors and nurses better informed about patient histories and, no less important, avoiding potentially dangerous drug interactions.

Reid and Palfreman note, rightly, that the Taiwanese system isn’t as foreign as it seems: We actually have a similar program here in the U.S.–for the elderly. It’s called Medicare.

Now, over the past six months I’ve gotten to know Taiwan’s health care system better than I would have liked (don’t worry – everyone’s OK), and I have a pretty good sense of the good and the bad. The good is that one can go see any specialist just by showing up at the hospital and registering for an appointment. Its dirt cheap and you can see as many doctors and specialists as you like until you find something that works. The doctors are willing to do endless amounts of tests, and they dispense medicine generously (OK, that’s actually one of the bad things – but sometimes plenty of cheap meds is a plus). I’d say that the hospitals and doctors are all well trained and highly professional – even out here in the countryside.

On the other hand doctors here seem to see way too many patients in a day – far too many to give each one the time and care they need. Also, doctors rarely seem to talk to each other across specialties, and there is no framework for hospitals to share patient records unless you get the file out yourself and bring it to the other hospital. Doctors are used to assuming authority and don’t like being questioned and discourage second opinions. But when I think about these problems I don’t think they are unique to Taiwan. I think they are general problems with modern medicine – and don’t reflect on the benefits which come from having a single-payer system.

I have a relative who is a doctor in the US. He had a Taiwanese patient with leukemia. He told her to go home to Taiwan because he felt she would get better treatment there than in the US. She did, and she got better. I don’t know the facts of the case, but I’m sure the costs in Taiwan were quite manageable. I’ve paid no more than a couple of hundred dollars here for procedures which in the US would have cost thousands.

I’ve heard a lot of people from Canada, England, and Taiwan complain about their health care systems, and criticize those who paint too rosy a picture. Sure, but I think they grossly underestimate just how much worse the US is. Even if we are generous and assume that the systems are roughly comparable, Americans pay nearly twice as much as these other countries for care which is certainly no better, and possibly much worse. Few of the people who have said such things to me have actually watched Sicko. If you haven’t, I recommend that you do.

UPDATE: There was also this report on NPR:

To satisfy the patients in Taiwan, there’s no gatekeeper who controls access to specialists and no waiting lines.

If you woke up in Taiwan with shoulder pain, for example, Chang says that you would be able to see an orthopedic specialist the same morning, no recommendation from a general practitioner required.

“Our people don’t like the idea of gatekeepers. They want to decide by themselves,” Chang says.

Don’t Forget Your Smart Card

By consolidating so much — one government plan that covers everybody — Taiwan achieves remarkable efficiency.

Everybody here has to have a smart card to go to the doctor. The doctor puts it in a reader and the patient’s history and medications all show up on the screen. The bill goes directly to the government insurance office and is paid automatically.

So Taiwan has the lowest administrative costs in world: less than 2 percent.

The article says that the program, established in 1995, closely resembled “the government-run U.S. Medicare program for the elderly and the single-payer health insurance programs operated by the Canadian provinces” and that “many of the problems encountered by Taiwan’s NHI have long been familiar to these programs as well.” As many of you may know, many democrats are now suggesting that the Medicare model now be extended to all Americans, so the Taiwan experience is definitely worth a closer look.

What I didn’t realize, although I should have when I think back on it, is that most of Taiwan’s health facilities are privately owned. (To be precise, “86 percent of hospitals (1999) and 65 percent of all hospital beds (2000)” are private, and half of the physicians have their own private clinics.) One problem with Taiwan’s medical system (as with just about everything else in Taiwan) is that it is “unevenly distributed geographically,” with very few doctors serving the Aborigine areas in the mountains. But the overall range of services and considerable amount of freedom of choice for the patients is quite impressive:

Benefits. The NHI’s benefits are comprehensive. They include inpatient care, ambulatory care, laboratory tests, diagnostic imaging, prescription and certain over-the-counter (OTC) drugs, dental care (except orthodontics and prosthodontics), traditional Chinese medicine, day care for the mentally ill, limited home health care, and certain preventive medicine (pediatric immunizations, adult health exams including pap smears, prenatal care, and well-child checkups). Expensive treatment for HIV/AIDS and organ transplants are also covered. This benefit package is much broader than that of the U.S. Medicare program.

Access and freedom of choice. More than 90 percent of Taiwan’s health care providers contract with the BNHI.22 Unlike U.S. managed care models, the NHI offers the insured complete freedom of choice among providers and therapies. There is no rationing of care, and there are no queues for care, as in the British and Canadian systems. The de facto absence of a referral system, so far, and the completely free choice of providers has meant that patients can go doctor shopping, and they often do.23 Furthermore, they can seek care at tertiary care institutions, regardless of the nature or severity of their illness.

Advocates of alternative medicine will be happy to know that “freedom of choice” among therapies includes traditional Chinese medicine, and there are numerous clinics and hospitals offering both traditional and western medicine.

Anyone who has seen Sicko will be particularly impressed with the following:

In 2002 Taiwan’s Supreme Court ruled that no one in Taiwan could be denied care because of lack of ability to pay. For those temporarily unable to pay premiums (for example, those who lose their jobs), the BNHI has a fund from which such people may take out interest-free loans to pay the premiums.

The system is not, however, without its problems. One is that doctors are rewarded for bringing in revenue, and this can sometimes lead to unnecessary procedures. The other is that hospitals can make up for lost revenue (due to price caps on their fees) by overcharging for drugs.

According to a December 2002 study report by the DoH, close to half of the doctors in Taiwan prescribe four to five drugs per visit for upper respiratory infections, and 10 percent prescribe more than eight drugs; in only fourteen of 103,024 outpatient visits did the doctor not prescribe any drugs. The CEO of a large private hospital told me that 44 percent of his hospital’s income is derived from the prescription and sale of drugs to patients.

Taiwan also has something else the US has been talking about, an electronic system for sharing medical records between care givers.

A revolutionary information technology (IT) innovation to improve the quality of the NHI’s system is the introduction in 2002 of the IC-Card, to replace the traditional paper card for accessing care. This credit card–size database contains important clinical as well as personal information on its holder. It will function as a communication tool between the NHI and providers and, once fully implemented, will also make it possible to electronically transfer medical records among providers (with the patient’s consent). This sharing of clinical information may help reduce the waste of duplicative services and curb that favorite pastime of Taiwanese patients: “doctor shopping.”

The article concludes with a discussion of some of the budgeting woes and problems of excess capacity. These are serious issues, but I just hope Taiwanese all see the movie Sicko before making any important policy decisions that might mistakenly seek to curb costs through US style reforms.

{health care, sicko}

Philip Boffey’s piece in the the NY Times is typical:

As the author of many health care editorials, I was eager to see Michael Moore’s “Sicko,” a polemical attack on undeniable flaws in the way this country provides health care. The film is unashamedly one-sided, superficial, overstated and occasionally suspect in its details. But on the big picture — the failure to ensure that everyone who needs medical care gets it — Mr. Moore is right.

First off, Boffey says the film is “unashamedly one-sided.” The implication seems to be that the film should be fair and balanced; but why should Michael Moore serve as yet another mouthpiece to an industry which has spent an excess of $2.2 billion on lobbying congress over the past decade – “$3.7 million of that amount just in the first quarter of 2007 alone”?

Secondly, the film is “superficial” and “overstated.” OK. Admitted. Here is a challenge: make a film about one of the most complex bureaucracies in the world which can go head-to-head against the top summer action films without simplifying just a little bit.

And doesn’t Boffey know how to use the internet? Moore’s website has a very detailed fact sheet on the claims made in the film.

Later Boffey questions the veracity of the stories told by Michael Moore and the people he interviews in the film:

Yet it is hard to know how true the stories are — Mr. Moore never gives enough details to help viewers determine — or how common the abuses may be.

Again Moore’s website has plenty of information about these people and their stories, complete with links to more in-depth newspaper stories.

The trip to Cuba is always a sore point with these “adult” critics.

After all these depressing tales, the second half of the film ushers us into a nirvana of humane and caring treatment supposedly provided to the citizens of Canada, France, Britain and even Cuba, a needlessly provocative choice that detracts from the main message.

Moore knows full well that without the Cuba trip his film wasn’t controversial enough, wasn’t immature enough, wasn’t reckless enough to attract any attention. The Cuba trip was political theatre, it was Moore’s “salt march,” and it worked.

These carefully guarded, “responsibly adult” reviews of Moore’s film miss the point. In order to write about the film you should read something about what is happening around the country outside movie theaters. I’m not talking about New Yorkers like my wife who end up drinking and dancing with health care activists after the film, I’m talking about your typical Texas redneck:

Sicko started; the stereotypical Texas guy sat down behind me and never stopped talking. He talked through the entire movie… and I listened. The first ten to twenty minutes of the film he spent badmouthing Moore to his wife and snorting in disgust whenever MM went into one of his trademark monologues. But as the movie wore on his protestations became quieter, less enthusiastic. Somewhere along the way, maybe at the half way point, right before my ears, Sicko changed this man’s mind. By the forty-five minute mark, he, along with the rest of the audience were breaking into spontaneous applause. He stopped pooh-poohing the movie and started shouting out “hell yeah!” at the screen. It was as if the whole world had been flipped upside down. This is Texas, where people support the president and voting democratic is something only done by the terrorists. Michael Moore should be public enemy number one.

By the time the movie was over, public enemy number one had become George Washington, Abraham Lincoln, and John F. Kennedy all rolled together. When the credits rolled the audience filed out and into the bathrooms. At the urinals, my redneck friend couldn’t stop talking about the film, and I kept listening. He struck up a conversation with a random black man in his 40s standing next to him, and soon everyone was peeing and talking about just how fucked everything is.

Moore’s films are always political theatre, and if you haven’t read Brecht before you write your “responsible” review, you haven’t done your homework. (And no, this doesn’t mean I have to like Fox News.)

(Texas link via BoingBoing)

UPDATE: Edited for clarity.

{NY Times, Michael Moore, Sicko, health care, activism, Brecht}

The Tainan City Government yesterday issued a medical report showing that residents living near a closed factory in southern Taiwan have extremely high levels of dioxin in their blood, in one case 30 times higher than the standards accepted by the United Nations.

… According to the report, one of the surveyed residents had 951 pg. of dioxin in his blood, which is 31 times higher than the U.N.-accepted standard of 32 pg., Su said. However, it was not the highest amount ever found in human body. President of Ukraine Victor Yushchenko was found to have higher amount when he found that he was poisoned, he said. [This is somewhat misleading since Yushchenko's levels were an order of magnitude greater: 6,000 times the acceptable standard. In fact, most people "have levels of between 15 and 45 units, accumulated over time because of industrial pollution that makes its way into the food chain." It is unfortunate that such poor reporting should mar an otherwise important article.]

… Confidential documents show that the Ministry of Economic Affairs warned TAIC in 1982 that mercury concentrations in fish caught in the reservoir exceeded safe levels for human consumption. Yet this was not brought to public attention, nor did it result in any attempt to prevent the further spread of pollution, or the consumption of fish harvested in contaminated areas.

When a colleague asked if I would take over ownership of his 8 month old golden retriever, Juno, I was worried that the same thing would happen to her. While I’ve always gotten a minimal amount of exercise on a regular basis, I’m not exactly what you’d call “the athletic type,” and I certainly don’t have 1/10th the energy of a young golden retriever!

Fortunately, rather than Juno staring at a computer screen blogging all day, it is I who find myself going on morning walks in the mountains behind my house – something Shashwati points out we didn’t do once all last year! They say pet owners live longer, healthier lives, and more frequent exercise may be one important reason. (This won’t help Taiwanese however, as they seem to walk their dogs by driving their scooters!)

In future posts I will write a bit about training Juno, as well as some of the unique challenges to raising a dog in Taiwan.

China has vowed to vaccinate all of its estimated 14 billion poultry to contain the spread of bird flu.

Let’s start with the fact that America’s health care system spends more, for worse results, than that of any other advanced country. In 2002 the United States spent $5,267 per person on health care. Canada spent $2,931; Germany spent $2,817; Britain spent only $2,160. Yet the United States has lower life expectancy and higher infant mortality than any of these countries. But don’t people in other countries sometimes find it hard to get medical treatment? Yes, sometimes – but so do Americans. No, Virginia, many Americans can’t count on ready access to high-quality medical care…. Americans are far more likely than others to forgo treatment because they can’t afford it. Forty percent of the Americans surveyed failed to fill a prescription because of cost. A third were deterred by cost from seeing a doctor when sick or from getting recommended tests or follow-up.

Why does American medicine cost so much yet achieve so little?… The U.S. system is much more bureaucratic… because private insurers and other players work hard at trying not to pay for medical care. And our fragmented system is unable to bargain… for lower prices. Taiwan, which moved 10 years ago from a U.S.-style system to a Canadian-style single-payer system, offers an object lesson in the economic advantages of universal coverage. In 1995 less than 60 percent of Taiwan’s residents had health insurance; by 2001 the number was 97 percent. Yet… this huge expansion in coverage came virtually free: it led to little if any increase in overall health care spending beyond normal growth due to rising population and incomes….

If Taiwan is going to improve its system, it will likely be by moving even more towards a European model, not by copying the mistakes of the US. But which European model will Taiwan adopt? Will it be “the Beveridge system (also called compulsory social insurance) seen in countries such as the UK and in northern Europe” or will it be “the Bismarckian system (also called social insurance) widely used in Germany, other European countries and Japan”? In America we can only wish that we were having such debates!

(Via Alas, a Blog)

But there are some things we can do – like beef up our “first responders.” In the case of the flu, that means our health care system.

Wait a sec… @#%&!

More info: The avian flu blog, and the avian flu wiki.

Because of their traditional responsibilities for collecting fuel and water, in many developing countries women and girls would benefit the most from access to improved energy services. The time and physical effort expended by women and girls in gathering fuel and carrying water seriously limits their ability to engage in educational and income-generating activities. Literacy rates and school enrolment levels are dramatically different for men and women in many developing countries. Much of women’s time is taken up with difficult and time-consuming chores related to producing and processing food without mechanical or electrical equipment and to cooking without clean-burning fuels and energy-efficient appliances.

Many women and girls also suffer from health problems related to gathering and using traditional fuels. In addition to the time and physical burdens involved in gathering fuel, women suffer serious long-term physical damage from strenuous work without sufficient recuperation time. Women must worry about falls, threats of assault, and snake bites during fuel gathering. They are also exposed to a variety of health hazards from cooking over poorly ventilated indoor fires, including respiratory infections, cancers, and eye diseases. Smoke from poorly ventilated indoor fires accounts for close to 2 million premature deaths per year.

A web site dedicated to solar cooking estimates that:

Many families living on less than one dollar a day spend 1/3 of it for cooking fuel. This cost often means less food to eat. Solar cookers typically reduce fuel needs by 1/3 and pay for themselves in two months of fuel savings. The gentler temperatures of box and panel types of solar cookers also preserve more nutrients.

Even simply using a solar cooker to sterilize water can make a huge difference:

Waterborne and smoke-related diseases are the primary killers of children. When fuel is scarce and expensive, it is hard to heed public health messages about boiling water. Every solar-cooked meal is smoke-free [smoke from cooking fires is also the major killer of young women in developing countries and is linked to low-birth weight and infant mortality] and solar cookers easily pasteurize water and milk.

But, you ask, how does food cooked on a solar cooker taste? You will be happy to know that that guardian of taste, the New York Times has fully endorsed solar cooking:

Mary retrieved the mushrooms after 90 minutes. Beautiful, juice-packed portobellos, made slightly mellow by the sherry. Then the scallops were done, soon followed by the chicken. ”That looks like something out of Bosch,” Mary said of the scallops, which were swollen and silky. The chicken was piercing and hearty, the peach cake just what you’d want on a summer afternoon.

They even have recipes. More recipes for solar cooking can be found here.

[Disclosure: The Mary mentioned in the above NY Times quote is a family friend. She is affiliated with Solar Cookers International, the non-profit organization behind Solarcooking.org website.]