Health Care Reform Articles - February 1, 2020

Editor's Note -
 
Check out this video: https://www.youtube.com/watch?v=3oYmfeswDZs&feature=youtu.be

 -SPC

How Chaos at Chain Pharmacies Is Putting Patients at Risk

Pharmacists across the U.S. warn that the push to do more with less has made medication errors more likely. “I am a danger to the public,” one wrote to a regulator.

By Ellen Gabler - NYT - January 31,2019

For Alyssa Watrous, the medication mix-up meant a pounding headache, nausea and dizziness. In September, Ms. Watrous, a 17-year-old from Connecticut, was about to take another asthma pill when she realized CVS had mistakenly given her blood pressure medication intended for someone else.
Edward Walker, 38, landed in an emergency room, his eyes swollen and burning after he put drops in them for five days in November 2018 to treat a mild irritation. A Walgreens in Illinois had accidentally supplied him with ear drops — not eye drops.
For Mary Scheuerman, 85, the error was discovered only when she was dying in a Florida hospital in December 2018. A Publix pharmacy had dispensed a powerful chemotherapy drug instead of the antidepressant her doctor had prescribed. She died about two weeks later.
The people least surprised by such mistakes are pharmacists working in some of the nation’s biggest retail chains.

In letters to state regulatory boards and in interviews with The New York Times, many pharmacists at companies like CVS, Rite Aid and Walgreens described understaffed and chaotic workplaces where they said it had become difficult to perform their jobs safely, putting the public at risk of medication errors.
They struggle to fill prescriptions, give flu shots, tend the drive-through, answer phones, work the register, counsel patients and call doctors and insurance companies, they said — all the while racing to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less.
“I am a danger to the public working for CVS,” one pharmacist wrote in an anonymous letter to the Texas State Board of Pharmacy in April.
“The amount of busywork we must do while verifying prescriptions is absolutely dangerous,” another wrote to the Pennsylvania board in February. “Mistakes are going to be made and the patients are going to be the ones suffering.”
[Read how you can protect yourself against medication errors.]
State boards and associations in at least two dozen states have heard from distraught pharmacists, interviews and records show, while some doctors complain that pharmacies bombard them with requests for refills that patients have not asked for and should not receive. Such refills are closely tracked by pharmacy chains and can factor into employee bonuses.

Michael Jackson, chief executive of the Florida Pharmacy Association, said the number of complaints from members related to staffing cuts and worries about patient safety had become “overwhelming” in the past year.

The American Psychiatric Association is particularly concerned about CVS, America’s eighth-largest company, which it says routinely ignores doctors’ explicit instructions to dispense limited amounts of medication to mental health patients. The pharmacy’s practice of providing three-month supplies may inadvertently lead more patients to attempt suicide by overdosing, the association said.
“Clearly it is financially in their best interest to dispense as many pills as they can get paid for,” said Dr. Bruce Schwartz, a psychiatrist in New York and the group’s president.
A spokesman for CVS said it had created a system to address the issue, but Dr. Schwartz said complaints persisted.
Regulating the chains — five rank among the nation’s 100 largest companies — has proved difficult for state pharmacy boards, which oversee the industry but sometimes allow company representatives to hold seats. Florida’s nine-member board, for instance, includes a lawyer for CVS and a director of pharmacy affairs at Walgreens.
Aside from creating potential conflicts of interest, the industry presence can stifle complaints. “We are afraid to speak up and lose our jobs,” one pharmacist wrote anonymously last year in response to a survey by the Missouri Board of Pharmacy. “PLEASE HELP."

Officials from several state boards told The Times they had limited authority to dictate how companies ran their businesses. Efforts by legislatures in California and elsewhere have been unsuccessful in substantially changing how pharmacies operate.
A majority of state boards do not require pharmacies to report errors, let alone conduct thorough investigations when they occur. Most investigations focus on pharmacists, not the conditions in their workplaces.
In public meetings, boards in at least two states have instructed pharmacists to quit or speak up if they believe conditions are unsafe. But pharmacists said they feared retaliation, knowing they could easily be replaced.
The industry has been squeezed amid declining drug reimbursement rates and cost pressures from administrators of prescription drug plans. Consolidation, meanwhile, has left only a few major players. About 70 percent of prescriptions nationwide are dispensed by chain drugstores, supermarkets or retailers like Walmart, according to a 2019 Drug Channels Institute report.
CVS garners a quarter of the country’s total prescription revenue and dispenses more than a billion prescriptions a year. Walgreens captures almost 20 percent. Walmart, Kroger and Rite Aid fall next in line among brick-and-mortar stores.
In statements, the pharmacy chains said patient safety was of utmost concern, with staffing carefully set to ensure accurate dispensing. Investment in technology such as e-prescribing has increased safety and efficiency, the companies said. They denied that pharmacists were under extreme pressure or faced reprisals.
“When a pharmacist has a legitimate concern about working conditions, we make every effort to address that concern in good faith,” CVS said in a statement. Walgreens cited its confidential employee hotline and said it made “clear to all pharmacists that they should never work beyond what they believe is advisable.”

Errors, the companies said, were regrettable but rare; they declined to provide data about mistakes.
The National Association of Chain Drug Stores, a trade group, said that “pharmacies consider even one prescription error to be one too many” and “seek continuous improvement.” The organization said it was wrong to “assume cause-effect relationships” between errors and pharmacists’ workload.
The specifics and severity of errors are nearly impossible to tally. Aside from lax reporting requirements, many mistakes never become public because companies settle with victims or their families, often requiring a confidentiality agreement. A CVS form for staff members to report errors asks whether the patient is a “media threat,” according to a photo provided to The Times. CVS said in a statement it would not provide details on what it called its “escalation process.”

The last comprehensive study of medication errors was over a decade ago: The Institute of Medicine estimated in 2006 that such mistakes harmed at least 1.5 million Americans each year.
Jonathan Lewis said he waited on hold with CVS for 40 minutes last summer, after discovering his antidepressant prescription had been refilled with another drug.
Mr. Lewis, 47, suspected something was wrong when he felt short of breath and extremely dizzy. Looking closely at the medication — and turning to Google — he figured out it was estrogen, not an antidepressant, which patients should not abruptly quit.

“It was very apparent they were very understaffed,” Mr. Lewis said, recalling long lines inside the Las Vegas store and at the drive-through when he picked up the prescription.

Pharmacists have written to state regulatory boards about their safety concerns.

“We are forced to harass patients at check out to fill unnecessary meds, request unnecessary refills, and to enroll in automatic fill programs that result in dangerous duplications and meds to be filled that were intended for single time use.”

Missouri pharmacist

“My fellow pharmacists and pharmacy technicians are at our breaking point. Chain pharmacy practices are preventing us from taking care of our patients and putting them at risk of dangerous medication errors.”

New Jersey pharmacist

“The mistakes I have seen occur in this environment are both frightening and understandable when we are under the gun to perform the impossible. I’ve had a technician mix two strengths of a critical blood pressure medication.”

South Carolina pharmacist

“A fatigued and distracted pharmacist in a fast-paced, chaotic environment is much more likely to make an error. The harm from a medication error ranges from being a slight inconvenience to being fatal.”

Texas pharmacist

“Something needs to be done about this before lives are lost. Our patients depend on us for their safety and wellness. We have to live up to their expectations.”

North Carolina pharmacist

“We are being asked to do things that we know at a gut level are dangerous. If we won’t or can’t do them, our employers will find someone else who will, and they will likely try to pay them less for the same work.”

South Carolina pharmacist

“We are forced to harass patients at check out to fill unnecessary meds, request unnecessary refills, and to enroll in automatic fill programs that result in dangerous duplications and meds to be filled that were intended for single time use.”

Missouri pharmacist

“My fellow pharmacists and pharmacy technicians are at our breaking point. Chain pharmacy practices are preventing us from taking care of our patients and putting them at risk of dangerous medication errors.”

New Jersey pharmacist

Too Much, Too Fast

The day before Wesley Hickman quit his job as a pharmacist at CVS, he worked a 13-hour shift with no breaks for lunch or dinner, he said.
As the only pharmacist on duty that day at the Leland, N.C., store, Dr. Hickman filled 552 prescriptions — about one every minute and 25 seconds — while counseling patients, giving shots, making calls and staffing the drive-through, he said. Partway through his shift the next day, in December 2018, he called his manager.

“I said, ‘I am not going to work in a situation that is unsafe.’ I shut the door and left,” said Dr. Hickman, who now runs an independent pharmacy.
Dr. Hickman felt that the multitude of required tasks distracted from his most important jobs: filling prescriptions accurately and counseling patients. He had begged his district manager to schedule more pharmacists, but the request was denied, he said.

CVS said it could not comment on the “individual concerns” of a former employee.
With nearly 10,000 pharmacies across the country, CVS is the largest chain and among the most aggressive in imposing performance metrics, pharmacists said. Both CVS and Walgreens tie bonuses to achieving them, according to company documents.
Nearly everything is tracked and scrutinized: phone calls to patients, the time it takes to fill a prescription, the number of immunizations given, the number of customers signing up for 90-day supplies of medication, to name a few.
The fact that tasks are being tracked is not the problem, pharmacists say, as customers can benefit from services like reminders for flu shots and refills. The issue is that employees are heavily evaluated on hitting targets, they say, including in areas they cannot control.
In Missouri, dozens of pharmacists said in a recent survey by the state board that the focus on metrics was a threat to patient safety and their own job security.
“Metrics put unnecessary pressure on pharmacy staff to fill prescriptions as fast as possible, resulting in errors,” one pharmacist wrote.
Of the nearly 1,000 pharmacists who took the survey, 60 percent said they “agree” or “strongly agree” that they “feel pressured or intimidated to meet standards or metrics that may interfere with safe patient care.” About 60 percent of respondents worked for retail chains, as opposed to hospitals or independent pharmacies.
Surveys in Maryland and Tennessee revealed similar concerns.
The specific goals are not made public, and can vary by store, but internal CVS documents reviewed by The Times show what was expected in some locations last year.

Staff members were supposed to persuade 65 percent of patients picking up prescriptions to sign up for automatic refills, 55 percent to switch to 90-day supplies from 30-day, and 75 percent to have the pharmacy contact their doctor with a “proactive refill request” if a prescription was expiring or had no refills, the documents show.

Pharmacy staff members are also expected to call dozens of patients each day, based on a computer-generated list. They are assessed on the number of patients they reach, and the number who agree to their requests.
Representatives from CVS and Walgreens said metrics were meant to provide better patient care, not penalize pharmacists. Some are related to reimbursements to pharmacies by insurance companies and the government. CVS said it had halved its number of metrics over the past 18 months.
But dozens of pharmacists described the emphasis on metrics as burdensome, and said they faced backlash for failing to meet the goals or suggesting they were unrealistic or unsafe.
“Any dissent perceived by corporate is met with a target placed on one’s back,” an unnamed pharmacist wrote to the South Carolina board last year.
In comments to state boards and interviews with The Times, pharmacists explained how staffing cuts had led to longer shifts, often with no break to use the restroom or eat.

“I certainly make more mistakes,” another South Carolina pharmacist wrote to the board. “I had two misfills in three years with the previous staffing and now I make 10-12 per year (that are caught).”
Much of the blame for understaffing has been directed at pressure from companies that manage drug plans for health insurers and Medicare.
Acting as middlemen between drug manufacturers, insurers and pharmacies, the companies — known as pharmacy benefit managers, or P.B.M.s — negotiate prices and channel to pharmacies the more than $300 billion spent on outpatient prescription drugs in the United States annually.
The benefit managers charge fees to pharmacies, and have been widely criticized for a lack of transparency and applying fees inconsistently. In a letter to the Department of Health and Human Services in September, a bipartisan group of senators noted an “extraordinary 45,000 percent increase” in fees paid by pharmacies from 2010 to 2017.
While benefit managers have caused economic upheaval in the industry, some pharmacy chains are players in that market too: CVS Health owns CVS Caremark, the largest benefit manager; Walgreens Boots Alliance has a partnership with Prime Therapeutics; Rite Aid owns a P.B.M., too.

The Pharmaceutical Care Management Association, the trade group representing benefit managers, contends that they make prescriptions more affordable, and pushes back against the notion that P.B.M.s are responsible for pressures on pharmacies, instead of a competitive market.

Pharmacists have written to state regulatory boards about their safety concerns.

“There is so much pressure to work so quickly that there are nights I go home just hoping I haven't made a mistake in all the craziness. I work 8-10 hour shifts without a single break. Some days I go an entire shift without finding any time to leave to use the restroom.”

Missouri pharmacist

“I am expected to make 50-100 phone calls in addition to answering phone calls, consultations, vaccinations and prescription verification. This has resulted in dispensing errors. A member of our staff misfilled a narcotic prescription for immediate release rather than extended release which resulted luckily in only patient fatigue, but it could have easily been deadly.”

South Carolina pharmacist

“Thank the Lord I have not had any life-threatening misfills, but I have had a number of ‘minor’ misfills mostly due to having to be responsible for so many duties at once and constantly being pulled away from verification to multitask.”

South Carolina pharmacist

“I'm confident that I’ve had dispensing errors which have left my pharmacy, but I was working too fast in order to meet our precious metrics to notice them. Let's hope nobody suffered or died because of it.”

Missouri pharmacist

“I am currently a pharmacist working at CVS. I am writing to you anonymously today as I fear for losing my job should my identity be known; however, I feel it is my duty to bring our current conditions to the board of pharmacy.”

North Carolina pharmacist

“I've refrained from drinking fluids due to the fact that I couldn't get to the restroom. I have ended up with kidney stones and infections on more than one occasion.”

South Carolina pharmacist

“There is so much pressure to work so quickly that there are nights I go home just hoping I haven't made a mistake in all the craziness. I work 8-10 hour shifts without a single break. Some days I go an entire shift without finding any time to leave to use the restroom.”

Missouri pharmacist

“I am expected to make 50-100 phone calls in addition to answering phone calls, consultations, vaccinations and prescription verification. This has resulted in dispensing errors. A member of our staff misfilled a narcotic prescription for immediate release rather than extended release which resulted luckily in only patient fatigue, but it could have easily been deadly.”

South Carolina pharmacist

Falling Through the Cracks

Dr. Mark Lopatin, a rheumatologist in Pennsylvania, says he is inundated with refill requests for almost every prescription he writes. At times Dr. Lopatin prescribes drugs intended only for a brief treatment — a steroid to treat a flare-up of arthritis, for instance.
But within days or weeks, he said, the pharmacy sends a refill request even though the prescription did not call for one. Each time, his office looks at the patient’s chart to confirm the request is warranted. About half are not, he said.
Aside from creating unnecessary work, Dr. Lopatin believes, the flood of requests poses a safety issue. “When you are bombarded with refill after refill, it’s easy for things to fall through the cracks, despite your best efforts,” he said.
Pharmacists told The Times that many unwanted refill requests were generated by automated systems designed in part to increase sales. Others were the result of phone calls from pharmacists, who said they faced pressure to reach quotas.
In February, a CVS pharmacist wrote to the South Carolina board that cold calls to doctors should stop, explaining that a call was considered “successful” only if the doctor agreed to the refill.
“What this means is that we are overwhelming doctor’s office staff with constant calls, and patients are often kept on medication that is unneeded for extended periods of time,” the pharmacist wrote.

CVS says outreach to patients and doctors can help patients stay up-to-date on their medications, and lead to lower costs and better health.
Dr. Rachel Poliquin, a psychiatrist in North Carolina who says she constantly gets refill requests, estimates that about 90 percent of her patients say they never asked their pharmacy to contact her.
While Dr. Poliquin has a policy that patients must contact her directly for more medication, she worries about clinics where prescriptions may get rubber-stamped in a flurry of requests. Then patients — especially those who are elderly or mentally ill — may continue taking medication unnecessarily, she said.
The American Psychiatric Association has been trying to tackle a related problem after hearing from members that CVS was giving patients larger supplies of medication than doctors had directed.
While it is common for pharmacies to dispense 90 days’ worth of maintenance medications — to treat chronic conditions like high blood pressure or diabetes — doctors say it is inappropriate for other drugs.
For example, patients with bipolar disorder are often prescribed lithium, a potentially lethal drug if taken in excess. It is common for psychiatrists to start a patient on a low dose or to limit the number of pills dispensed at once, especially if the person is considered a suicide risk.
But increasingly, the psychiatric association has heard from members that smaller quantities specified on prescriptions are being ignored, particularly by CVS, according to Dr. Schwartz, the group’s president.

CVS has created a system where doctors can register and request that 90-day supplies not be dispensed to their patients. But doctors report that the registry has not solved the problem, Dr. Schwartz said. In a statement, CVS said it continued to “refine and enhance” the program.

Dr. Charles Denby, a psychiatrist in Rhode Island, became so concerned by the practice that he started stamping prescriptions, “AT MONTHLY INTERVALS ONLY.” Despite those explicit instructions, Dr. Denby said, he received faxes from CVS saying his patients had asked for — and been given — 90-day supplies.
Dr. Denby, who retired in December, said it was a “baldfaced lie” that the patients had asked for the medication, providing statements from patients saying as much.
“I am disgusted with this,” said Dr. Denby, who worries that patients may attempt suicide with excess medication. “There are going to be people dead only because they have enough medication to do the deed with.”

‘We Already Have Systems in Place’

Alton James never learned how the mistake came about that he says killed his 85-year-old mother, Mary Scheuerman, in 2018.

He knows he picked up her prescription at the pharmacy in a Publix supermarket in Lakeland, Fla. He knows he gave her a pill each morning. He knows that after six days, she turned pale, her blood pressure dropped and she was rushed to the hospital.

Mr. James remembers a doctor telling him his mother’s blood had a toxic level of methotrexate, a drug often used to treat cancer. But Mrs. Scheuerman didn’t have cancer. She was supposed to be taking an antidepressant. Mr. James said a pharmacy employee later confirmed that someone had mistakenly dispensed methotrexate.
Five days after entering the hospital, Mrs. Scheuerman died, with organ failure listed as the lead cause, according to medical records cited by Mr. James.
The Institute for Safe Medication Practices has warned about methotrexate, listing it as a “high-alert medication” that can be deadly when taken incorrectly. Mr. James reported the pharmacy’s error to the group, writing that he wanted to raise awareness about the drug and push Publix, one of the country’s largest supermarket chains, to “clean up” its pharmacy division, according to a copy of his report provided to The Times.
The company acknowledged the mistake and offered a settlement, Mr. James wrote, but would not discuss how to avoid future errors, saying, “We already have systems in place.”

Last September, Mr. James told The Times that Publix wanted him to sign a settlement agreement that would prevent him from speaking further about his mother’s death. Mr. James has since declined to comment, saying that the matter was “amicably resolved.”
A spokeswoman for Publix said privacy laws prevented the company from commenting on specific patients.
It can be difficult for patients and their families to decide whether to accept a settlement.
Last summer, CVS offered to compensate Kelsey and Donavan Sullivan after a pediatrician discovered the reflux medication they had been giving their 4-month-old for two months was actually a steroid. To be safely weaned, the baby had to keep taking it for two weeks after the error was discovered.
“It was like he was coming out of a fog,” Mrs. Sullivan recalled.

The couple, from Minnesota, are still considering a settlement but haven’t agreed to anything because they don’t know what long-term consequences their son might face.
The kinds of errors and how they occur vary considerably.
The paper stapled to a CVS bag containing medication for Ms. Watrous, the Connecticut teenager with asthma, listed her correct name and medication, but the bottle inside had someone else’s name.
Directions on the prescription for Mr. Walker, the Illinois man who got ear drops instead of eye drops from Walgreens, were clear: “Instill 1 drop in both eyes every 6 hours.” He later saw the box: “For use in ears only.”

In September, Stefanie Davis, 31, got the right medicine, Adderall, but the wrong dose. She pulled over on the interstate after feeling short of breath and dizzy with blurred vision. The pills, dispensed by a Walgreens in Sun City Center, Fla., were each 30 milligrams instead of her usual 20. She is fighting with Walgreens to cover a $900 bill for her visit to an emergency room.

Fixes That Fall Short

State boards and legislatures have wrestled with how to regulate the industry. Some states have adopted laws, for instance introducing mandatory lunch breaks or limiting the number of technicians a pharmacist can supervise.
But the laws aren’t always followed, can be difficult to enforce or can fail to address broader problems.
The National Association of Chain Drug Stores says some state boards are blocking meaningful change. The group, for instance, wants to free up pharmacists from some tasks by allowing technicians, who have less training, to do more.
It also supports efforts to change the insurance reimbursement model for pharmacies. Health care services provided by pharmacists to patients, such as prescribing birth control, are not consistently covered by insurers or allowed in all states. But it has been difficult to find consensus to change federal and state regulations.
While those debates continue, some state boards are trying to hold companies more accountable.

Often when an error is reported to a board, action is taken against the pharmacist, an obvious target. It is less common for a company to be scrutinized.

The South Carolina board discussed in November how to more thoroughly investigate conditions after a mistake. It also published a statement discouraging quotas and encouraging “employers to value patient safety over operational efficiency and financial targets.”
California passed a law saying no pharmacist could be required to work alone, but it has been largely ignored since taking effect last year, according to leaders of a pharmacists’ union. The state board is trying to clarify the law’s requirements.
In Illinois, a new law requires breaks for pharmacists and potential penalties for companies that do not provide a safe working environment. The law was in response to a 2016 Chicago Tribune investigation revealing that pharmacies failed to warn patients about dangerous drug combinations.
Some states are trying to make changes behind closed doors. After seeing results of its survey last year, the Missouri board invited companies to private meetings early this year to answer questions about errors, staffing and patient safety.
CVS and Walgreens said they would attend.
Research was contributed by Susan C. Beachy, Jack Begg, Alain Delaquérière and Sheelagh McNeill.

Ellen Gabler is an investigative reporter for The New York Times. @egabler 
https://www.nytimes.com/2020/01/31/health/pharmacists-medication-errors.html?action=click&module=Top%20Stories&pgtype=Homepage 

 Editor's Note -.
The above clipping is really about the dangers of for-profit medicine. When profit drives mission, bad things are more likely to happen!
-SPC

9 things Americans need to learn from the rest of the world’s health care systems

Universal health care is hard, but it should be possible — and eight more things I discovered from visiting other countries.

By Dylan Scott - VOX  Jan 29, 2020  

 

Everywhere I went last fall, I would often hear the same twang of pity when I told someone I’d come to their country from America to learn how their health care works.

There were three moments I will always remember, one from each of my trips to Taiwan, Australia, and the Netherlands. In Taiwan, I met a man named Wong Shin-Fa, of the Taroko people, an indigenous tribe living in the mountains on the island’s east coast.

I was walking along a township road, clearly out of place, and he was planting orchids with his mother. He stopped me and asked what I was doing there. I said I was a journalist from the US, reporting on health care. He smiled a bit and then went straight into a story, about his friend who was living in Los Angeles and broke his arm but came back to Taiwan to get it fixed because it’d be cheaper than getting it fixed in the US.

In Australia, my colleague Byrd Pinkerton and I got caught in a rainstorm while walking through a park to one of our appointments. We took shelter in a small building with a cafe and tourist information desk, and one of the employees, Mike, introduced himself. I ended up telling him why we were there; he considered it a moment and then said: Well, we’ve got some problems, but nothing as bad as yours. (Check out Everybody Covered on The Impact podcast series on Wednesday and Friday, with episodes covering Taiwan and Australia. Our project was made possible by a grant from The Commonwealth Fund.)

In the Netherlands, the researchers I met with at Radboud University had asked me to give a presentation on American health care, a quid pro quo for their presentation on the country’s after-hours care program. So I obliged. There were two moments when the audience audibly gasped: one when I explained how many people in the US are uninsured and another when I mentioned how much Americans have to spend out of pocket to meet their deductible.

Throughout my travels, I was ever mindful of my own country’s shortcomings in health care — and was constantly evaluating how what I was learning might inform our next steps in reforming it. People have often asked which system was my favorite and which one would work best in the US. Alas, that is not so simple a question to answer. But there were certainly plenty of lessons we can take to heart as our country engages in its own discussion of the future of health care.

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1) Every developed country in the world is committed to universal health care — except the United States

The first necessary condition for universal health care is a collective commitment to achieving it. Every one of the countries we covered — Taiwan, Australia, the Netherlands, and the United Kingdom — has made such a commitment. In fact, every other country in the developed world has decided that health care is something everybody should have access to and that the government should play a significant role in guaranteeing it.

Except for the United States. Our two political parties are still deeply polarized on this question: 85 percent of Democratic voters think it’s the government’s responsibility to ensure everybody has health coverage, but only 27 percent of Republicans agree. (Overall, including independents, 57 percent of Americans say the government has this obligation.)

In other countries, there might be disagreement about how to achieve universal health care, but both ends of the political spectrum start from the same premise: Everybody should be covered. Even in the Netherlands, which overhauled its health insurance in 2006 under a center-right government, there was no question about universal coverage.

I came across this quote from Princeton economist Uwe Reinhardt while I was starting to report this project, and it stuck with me throughout. From his most recent book Priced Out, which was published after he died in 2017:

Canada and virtually all European and Asian developed nations have reached, decades ago, a political consensus to treat health care as a social good.

By contrast, we in the United States have never reached a politically dominant consensus on the issue.

When I told people in Taiwan or the Netherlands that millions of Americans were uninsured and people could be charged thousands of dollars for medical care, it was unfathomable to them. Their countries had agreed that such things should never be allowed to happen.

The only question for them is how to prevent it.

2) Every system for universal health care comes with trade-offs that should be taken seriously

I saw all kinds of health systems in action: true single-payer in Taiwan, a mix of public and private insurance in Australia, private coverage for everybody in the Netherlands. Each of them surpassed the United States in two critical ways: Everybody had insurance, and costs to patients were much lower.

But each system also had its downsides.

In Taiwan, there still isn’t enough health care supply. The country does a good job of keeping wait times for surgeries down, but doctors say they’re overwhelmed. Taiwan’s doctor-to-patient and nurse-to-patient ratios are terrible compared to Europe. Specialty care in the rural parts of the country is lacking. On the whole, the medical field seems to be ambivalent about the national health insurance. And while it’s been difficult to measure whether there’s been a “brain drain” resulting from this dissatisfaction or how bad it’s been, it’s a real concern.

It could be that Taiwan is underfunding its health care system; it’s spending a smaller share of GDP than even the socialized systems in Europe. But raising taxes to more adequately fund the system or bumping up cost sharing to encourage more discretion in health care use is almost as big of a political challenge there as it would be here. Nobody wants to pay more for health care next year than they did the year before.

Australia has layered a private health care system on top of its universal public insurance program, and that gives both doctors and patients more choice about medical care. But once you have different tiers in your health care system, disparities are going to emerge. Wait times in Australia’s public hospitals are twice as long as those in private hospitals.

And because the Australian government is spending billions of dollars supporting a struggling private insurance industry for middle-class and wealthier patients, it has fewer resources to devote to disadvantaged populations, like indigenous Australians or patients living in rural areas who have less access to medical care. Public patients in public facilities face longer wait times.

Christina Animashaun/Vox

The Netherlands, meanwhile, has handed over the responsibility for providing coverage to private health insurers, and that has come with costs too. The Dutch have had to impose strict regulations on health insurance, including harsh penalties for people who fail to sign up for insurance on their own.

Patients have to pay out a 385-euro deductible every year — that’s serious money for lower-income families. Doctors in the Netherlands are more likely than those in more socialized systems to say their patients struggle to afford medical care. They are also more likely to say the administrative work they have to do is a drain on their time. Health care spending in the Netherlands has also been rising at a faster clip since the move to the mandatory private insurance system.

So the question becomes what kind of trade-off is more palatable. That’s a decision for each country to make: Taiwan wanted equity; Australia is trying to balance access and choice; the Netherlands bet on managed competition.

3) Universal health coverage requires a lot of government spending and regulations

There is no way to avoid it: If you want universal coverage, the government is going to play a huge role. In Taiwan and Australia, that means the government runs a universal insurance program that covers everybody for most medical services.

But even in the Netherlands, which relies on private health insurers, the government oversees everything. It sets rules about what benefits have to be covered, what prices can be charged, and what cost sharing is required. It collects contributions from employers to pay the cost of covering everybody and spreads it among the insurers based on the health status of their customers.

Christina Animashaun/Vox

All told, about 75 percent of the funding for health insurance in the Netherlands is still running through the national government, even if the actual insurance benefits are being administered by private companies.

The US stands alone in how much of its health spending comes from private sources — and still doesn’t have universal coverage.

4) Other countries put much stricter controls on health care costs than the US

Under all of these insurance schemes, the governments use much more force to keep health care prices down compared to the US.

In Taiwan, that means global budgets — an annual amount set aside every year for various sectors of the health industry (hospitals, drugs, traditional Chinese medicine, etc.).

In Australia, most doctors do what’s called bulk billing for their Medicare program: The government sets a price, and doctors generally accept it. They can choose to charge more, but it’s relatively rare. They’ve also set up a respected system for evaluating the value of drugs and what their national health insurance plan will pay for them, incorporating input from medical experts, patients, and the drug industry.

In the Netherlands, even with private insurers, the government sets limits on how much health spending can accrue in a given year and has the authority to impose budget cuts if spending exceeds that limit. Prices are also set for particular services, like after-hours primary care. Insurers do have some limited flexibility in which providers they contract with, but the government sets their health care budget for them.

We have experimented with that kind of system in the US, as Tara Golshan covered in this series in her story on Maryland. She documented how the state has tried to use a model like this, global budgets, to improve care for patients by encouraging hospitals to focus on the health of their patients instead of whether they have enough people in their beds.

But Maryland remains an exception. And as the research shows, the US spends dramatically more for many common medical services compared to other developed countries:

Christina Animashaun/Vox

5) Other countries are still figuring out how to deliver long-term care

Something we didn’t cover as much in our stories but that came up again and again in my reporting is the challenge for long-term care for older people and those with disabilities. For most developed economies, their aging populations will present a serious challenge of both cost and care delivery. The chart below shows what countries were already paying (notice the US lags significantly both overall and in public investment) and then projects what they will be paying in 2050:

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What was most interesting is that the countries’ different approaches to long-term care didn’t necessarily track with how they handle the rest of medical care. Taiwan, for example, even with its single-payer program, doesn’t include long-term care as a benefit. Yi Li Jie, a spinal atrophy patient I met, has to pay out of pocket for her caregivers; she also has to pay a substantial share of her transportation costs to get to medical appointments. Taiwan is beginning to debate how to add long-term care to its national health insurance plan, but it’s going to be expensive.

On the other end of the spectrum, the Netherlands has a universal public program to cover long-term care, even though it has private medical insurance. The country’s primary care is geared toward accommodating the needs of patients who are older or have disabilities; doctors make more home visits, and even the after-hours primary care program is set up to be able to reach older people and those with disabilities in their homes.

Of course, the needs for these populations extend beyond the basic provision of medical care. Australia recently transitioned to a new disability insurance program, which covers nonmedical supports for those folks, and beneficiaries have described it as “too complex and difficult to navigate,” as the Guardian reported.

No matter the health system, the most complex patients are going to have the most challenging needs to meet. Nobody has figured out a silver bullet for fixing that yet.

6) Private insurance can play a role in universal health care, but it comes with downsides

I think it’s telling that Uwe Reinhardt, invited to participate in Taiwan’s debate in the late 1980s about how to achieve universal health coverage, had a pretty simple answer to the question of which system was best for that country: single-payer. It would be the most equitable and the most efficient. But he didn’t believe it would work in the US, because of the influence wielded by private industry.

But other countries, like Australia and the Netherlands, have found a significant role for private insurance even as they strive toward the same goal. Frankly, however, private insurance seems to be more of a political compromise (and, by extension, to reflect some differences in societal values) than a preferred policy solution.

Australia had had private insurance for decades before its universal public insurance plan was introduced in the 1980s; both of its major political parties have come to accept the existence of that program. The conservatives scrapped the first public program in the ’70s, but they’ve given up trying to roll back the current one. Private insurance in Australia has given the better-off more options in their health care; that comes at the expense of some equity, but it is a compromise the country has been willing to make as it tries to balance access and choice.

It’s a different story with similar themes in the Netherlands: Its old two-tiered system was facing an existential crisis in the mid-2000s. Because a center-right government was in charge, they wanted to pursue a market-driven, managed-competition model to try to fix it. Universal coverage was still a shared goal for all the political parties, but they pursued private insurance to do it because it aligned more with the ideology of the ruling government.

Now critics say that was a mistake, that it has made health care more expensive in the Netherlands. But it was the pragmatic path available to the country at that moment.

7) Health care providers are probably never going to be happy with a big government role

I’ll never forget a chart Po-Chang Lee, director-general of Taiwan’s National Health Insurance Administration, showed me during our interview. He had approval ratings for the single-payer plan on big whiteboards, and he had just been showing us the enormous spike in approval among the public for the national insurance plan and its steadiness over the years.

But then he pulled out a chart showing how doctors felt about the program.

As recently as 2016, 39 percent of physicians said they were either dissatisfied or very dissatisfied with national health insurance. Another 31 percent said they were neutral. Just 30 percent said they were satisfied or very satisfied (a paltry 2.9 percent said the latter).

I encountered that ambivalence from the two doctors I met in a coffee shop in downtown Taipei. One of them said he was by nature a lefty politically, but he felt the country’s very low cost sharing — what patients have to pay out of pocket when they go to the doctor or hospital — had spoiled patients. His friend cried out at one point, “We’re not the Avengers!”

But such complaints are not unique to Taiwan or its single-payer system. The data suggests physicians the world over are often frustrated by their health systems. Even in countries like the Netherlands and Australia, which have more of a role for private insurance and therefore for doctors to have more choice in their practice and the opportunity to make more money, opinions are split.

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But at the same time, providers everywhere are generally happy about the actual practice of medicine.

Christina Animashaun/Vox

It’s a pipe dream to think you can build a health system with only happy doctors. But luckily, doctors seem to get into medicine not because they like their country’s health care policies but because of the experience they have treating patients.

8) Health care delivery reforms are necessary to attain “health care as a human right”

Coverage isn’t enough. You actually have to get health care to people.

All of these systems, even with their varying approaches to insuring people, have had to add other reforms to improve medical care itself. In Taiwan, that meant setting up a rural health program that employed doctors to work in clinics at mountain outposts and make visits to indigenous communities part of their daily routine.

“That’s the essence of universal health coverage,” Hong-Jen Chang, the former NHIA director who set up the program, told me. “The principle of health [as a] human right is that everybody, regardless of geography, religion, gender, age, should have the right to access.”

In the Netherlands, it was the doctors who saw a delivery problem and came up with a way to fix it. Years ago, every individual doctor was responsible for providing after-hours care to their patients if needed. Elise Nillesen, who followed in her father’s footsteps to become a general practitioner, remembers her family had to stay home most nights when she was a child and couldn’t really take vacations.

So the doctors proposed a new model: What if they formed cooperatives so they could share the load? They would pool their patients together and each doctor would take a few shifts a month, either providing care in an after-hours clinic or doing home visits. They get paid a flat hourly rate by the private insurance plans.

The result? Today, people in the Netherlands say they have very little trouble getting after-hours care. Just one in four Dutch patients say it’s hard to get treated outside of business hours; in other developed countries, it’s closer to 50 percent or even higher.

9) It’s hard to translate health care policy successes elsewhere to the US

Maybe the most sobering interview I had was before I ever left the United States, with Ellen Nolte at the London School of Hygiene and Tropical Medicine. She has evaluated health care systems on how well they prevent deaths that should be avoidable with accessible medical care.

I had asked her what I thought was a pretty basic question: How would you describe the US health system in relation to other countries? Her answer surprised me.

“One thing that always strikes me about the American system,” she said, “is effectively there are, like, 51 American systems.”

Health care in the US varies by geography, of course, depending on which state you live in. It also varies by age: The US does quite well with the over-65 population (which is covered by one public program, Medicare) but struggles with the under-65 patients (covered by a hodgepodge of private and public insurers) compared to other countries. Racial disparities run deep too: There is effectively one health system for white people and another for minorities, given the disparities in income.

“If you want to have access, if you have money, then the US probably is a good system,” Nolte said. “If you want a fairly equitable system, it’s probably not the best. It’s probably better to look at other places.”

Taiwan and Australia have about the same population as Texas, but Taiwan’s is contained to a tiny island off the coast of China and Australia is a continent. The Netherlands is one of the most densely populated countries in the world; the United States is one of the least.

Then you’ve got political differences; Uwe Reinhardt famously didn’t believe single-payer could work in the US, not because it’s not a good idea but because the government was too beholden to corporate interests. The recent failure of surprise billing legislation in the face of industry opposition is certainly a warning sign to any aspiring reformers.

So the dissatisfying answer to “so what can the US learn from these other countries’ successes?” is: It’s complicated. But my hope for this series is it would speak to the kinds of values and strategies, if less the specific policies, that are necessary to achieve universal health care.

Every health system is different. But all of them, except ours, have figured out a way to make being uninsured or going bankrupt over medical bills a thing of the past. The US can do better.

https://www.vox.com/health-care/2020/1/29/21075388/medicare-for-all-what-countries-have-universal-health-care