An interesting confluence of articles recently appeared in two of America’s national newspapers. On Thursday, 6 August, the Washington Post ran an op-ed by a gentleman named Wendell Potter, who in his no-doubt comfortable retirement has had occasion to regret his career working as a shill for Cigna, one of America’s largest health insurers. Mr. Potter acknowledges numerous misdeeds designed to convince the American public of the horrors that would befall them if they opted for a publically funded health care system like that in Canada. In the first decade of the 21st century, Potter and his team enlisted national advertising agencies to run a successful campaign excoriating the overwhelming incompetence of Canadian medicine. In the photograph accompanying the article, Mr. Potter looks either extremely remorseful or profoundly dejected, I cannot tell which. I suppose it’s equally plausible that he is either ruing a misspent life or perhaps he’s just received his monthly healthcare premium bill and realizes that, unlike most of the rest of the world, he’s giving up approximately 25% of his disposable income to pay for health care he may or may not need (but is certainly going to have to fight to get reimbursed when his claim is denied). In a list surely truncated due to space limits, Mr. Potter proceeded to detail some of the many calumnies he foisted both upon the general public and on politicians eager to pass the (literal) buck on healthcare reform. Among these falsehoods were the extensive wait times Canadians had to endure to get health care (save for some elective procedures, Canadians get care faster than Americans do); the exodus of physicians from Canada to the US (a real knee-slapper, as Canada boasts more physicians per 1,000 people than the US), and phony reports of hordes of diseased Canadians streaming across the northern US border to seek the superior health care offered in the US. The combination of misinformation and savvy marketing was a potent one, and the meme of substandard “socialized” Canadian healthcare has exhibited remarkable staying power over the years, despite being largely a wholesale fabrication of America’s Big Healthcare industry. Mr. Potter, according to his essay, confesses multiple sins to atone for in selling Big Healthcare to all of us. But by his own admission the denigration of Canadian healthcare is the most significant among these, particularly in a time when Canadians have easy access to free COVID-19 testing and are not at risk for losing health insurance due to COVID-related job losses.
Ask yourself again: As an individual citizen, do you really want to be spending close to a quarter of your disposable income on healthcare premiums, presuming you are lucky enough to have—and to keep—job-related healthcare insurance? As a psychologist, do you really want to have to continue fighting for parity for reimbursement for many mental disorders, 12 years after the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was made law? As a society, do we really want the healthcare industry to account for almost 20% of our gross domestic product, rather than other industries that produce tangible goods or non-illness related services? This being a national election year, we will soon be bombarded with tropes about the evils of socialized (or Canadian, have it your way) medicine, with the pejorative label du jour being “Medicare for all”. Let’s not fall for it this time. If there is one point of agreement across the political spectrum it is that American healthcare is badly broken. Let’s forget the labels and focus on a fix that makes, at minimum, healthcare more accessible and less expensive for all of us. Uncoupling insurance from jobs is a work in progress. It needs to be completed. Ensuring access is both a matter of urgency and morality. There is no time to waste.
Simultaneously, Reed Abelson of the New York Times noted that American health insurers are experiencing an ‘embarrassment of profits’ during the pandemic. As I noted in this space a few months ago, Big Healthcare’s coffers are overflowing with premium payments because patients, often to their detriment, are either voluntarily postponing or cannot access elective health care. As Abelson noted, CVS, the owner of Aetna, reported income of over $3B, up $1B from last year, on revenues of $65B. Similarly, Anthem’s income is up $1.2B over last year, and UnitedHealth income is up a whopping $3.3B. Although the Affordable Care Act (perversely enough, being challenged by the current administration in front of the US Supreme Court in the midst of a pandemic) mandates that at least some of these riches be returned in the form of rebates to individual citizens, experts caution that these will not be quickly forthcoming and won’t amount to very much for the individual. But fear not, Anthem reassures you that they are giving donations to food charities. Which many citizens will likely need when their job-related healthcare insurance runs out. It seems a bit paradoxical that while your auto insurance company likely gave you a substantial reimbursement check for driving less during the pandemic your healthcare insurer has yet to rebate you back a share of your much higher monthly healthcare premium.
In part because of the failure to control the pandemic in the US (where coronavirus incidence and mortality far outstrip numbers of other developed countries), the incidence of psychological morbidity is higher among US citizens than in other nations. Continuing pre-pandemic trends, one-third of Americans have reported issues with anxiety, depression, or other psychological problems. Canada and the UK tie for a considerably distant second place, with 26% of surveyed citizens in those countries reporting adverse mental health sequelae of the pandemic. Now it must be said that mental health access is a universal issue, and no country has truly solved the conundrum of providing mental health services to all its citizenry. Nevertheless, the fact that only 31% of Americans report being able to see a mental health professional when they need one contrasts sharply with reports from that old health-care laggard Canada, where almost half (47%) of citizens are able to get mental health care when needed (Canada runs second only to Australia, where 51% of citizens can immediately access necessary mental health care).
Some years ago, in the course of returning from a stay in Japan, I was marooned in Narita airport for several hours waiting for a connecting flight. I passed the time reading an article about how common, indeed almost endemic, food-borne pathogens were in America. From highly toxic strains of e. coli to salmonella, the author argued that such pathogens are essentially baked into the food supply chain in North America, where industrial scale production of meat, eggs and some vegetables is a reality. As a consequence, American consumers have been taught by culinary experts to treat many foodstuffs as if they are unquestionably toxic. Uncooked chicken, we are told, should be handled in the kitchen like low-grade radioactive waste, with any surface it contacts requiring immediate and thorough decontamination. Raw eggs are, while not entirely forbidden, a form of legalized gambling. You might be safe some of the time, but sooner or later your luck will run out. My stomach turned slightly queasy as I thought back to my recent diet in Tokyo. Raw fish in the form of sushi of course provided much of my protein. A raw egg broken over a scoop of sticky rice and topped with scallions and dried tuna provided a nutritious and surprisingly tasty breakfast. For dinner one night, we were treated to a chef’s special that had even my Japanese companions guessing. A plate of carefully arranged thin slices of meat, barely seared on the edges, was presented to us—but what was it? Halibut? White tuna? “Chicken sashimi”, said the chef. It was delicious. Would I eat essentially raw chicken in the US? Hardly likely. The healthcare priorities of the two nations are reversed. In the US, we focus on the treatment of pathology—pathology that in this instance arises from a contaminated food supply. In Japan, the preventive emphasis on the production of safe food alleviates much of the burden of treating foodborne illness.
This small lesson I hope illustrates not only the importance of a safe food supply chain but the importance of prioritizing prevention when (and if) we have the political will to re-engage in the healthcare reform debate. It is not going to be pretty, but it is essential if we are to fix a desperately broken system. As Wendell Potter’s mea culpa shows, it is our responsibility to separate propaganda from fact. As members of one of the most privileged professions (inasmuch as we are privileged to share the confidences of our patients) it is also our social responsibility to take the lead in doing so.
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