Isuf Kalo: Why President Obama wearied the “white coat” of Medicine?
| E Diel, 23.08.2009, 02:55 PM |

Prof. Dr .Isuf Kalo
Prof. Dr .Isuf Kalo
Why President Obama wearied the “white coat” of Medicine?


(Reflexions on a challenging health reform)

By   Prof. Dr .Isuf Kalo

Tirana – Albania
isufkalo@hotmail.com

Only few of people believed that what Mr. Obama said about Healthcare during the electoral campaign was not simply an electoral rhetoric or “business as usual”, but a real commitment about reform. Mr. Barak Obama showed that he was conscientious, convinced and determined for what he was declaring.
Immediately after his election as a president of U.S.A, he created a precedent when he declared that his first priority and the front-page of his presidency will be the   health of American people .The issue of health has been traditionally forgot, or purposely neglected from the previous American presidents, considering it as “futile” or may be because they were afraid to afford this so called “dangerous minefield”. The new President with a few words conveyed straightway two clear historical messages to the American people:
Firstly, that nothing was more important and more urgent to him that the health and the welfare of all citizens and of their families whatever could be each of them.
Secondly, that the American nation and American people in order to be strong and prosperous must enjoy a good health. None objective and progress will be realized in any field, sector or system of the country (including the economy), without firstly insuring a good health for the all population and without improving and reforming fundamentally the current American system of the Healthcare and Medicine.

The first surprise

These two messages for many Americans were somehow surprising. For the first time in their history they, were invited to drew out their  attention ,  from the challenges of cosmos, traveling in moon, “star wars” or confrontation  with “World Global Dangers “which have brought to the U.S.A many glory, fame  and prestige (but also a lot of  victims and heavy financial burden  ) and finally to concentrate to them self , to some think basic :as  their own health, the welfare of everyone, and on how to afford their  daily life problems
     In addition the American nation and everyone in the world was  surprised also with  the unusual determination  of New President to act immediately and to  daring  to inject for improvement of the American Health System an amount  of 634 billion dollars from the  state  budget (during  the 10 future years). These actions have provoked of course immediate comments and reactions: several of them positive ones: supportive, enthusiastic or euphoric and some of them negative: doubts, worry, jealousy, opposition. and disapproval. Several questions were raised. Has the new President weighted well what he meant in this field? Has he counted properly the implications and consequences of these actions? Is this reform a genuine innovation or is it a new kind of populism? What has inspired, what has motivated him to undertake this reform? Were there some sound evidences and facts or simply his emotions and his good intentions to reform the Health system?

The Heavy weight of the prejudices

The above doubts and dilemmas are connected with the fact that the Health issue has been, usually and historically everywhere in the world .disregarded by  the politicians Due to  the lack of knowledge or because of political and electoral costs related to every  reform in Health system  they often have neglected it or concisely avoided it (sometimes with diplomacy and sometimes harshly).They are some subjective perceptions and opinions of politicians regarding the health system  which  are not rarely painted with dark colors of the prejudices. The following are some of them:

-“The Medicine is not transparent .It’s a “foggy field,” with many surprises and enigmas. It is not worth, not rewording area. The successes on it are achieved with too many difficulties, very slowly and they are forgotten soon. On the contrary the failures and mistakes are always noisy and are remembered for ever”
“The financial greediness of medicine is insatiable. Medicine is always asking for money but never does not bring back anything. The investments on it are disappeared as the water in desert.” “The health system is very difficult to be managed properly. It is quite complex and pretentious. It is impenetrable inside his professional world and impossible to be controlled from outside.”
In addition to these “black” prejudices they are some deceptive experiences. The previous attempts   to reform profoundly the American health system did not have encouraging results. Such similar reform was proposed by Hilary Clinton during Bill Clinton’s presidency. Unfortunately it was blocked due to the strong opponents in 1994, even before its implementation. The critics and opponents of President Obama are mobilizing   today for the same fate: the failure of his reform. They would like to “stop “OBAMA CARE “and made this a political “Waterloo” to him Therefore, his supporters and well-wishers anxiously asking: Why did he choose by himself such a challenging issue full of dangers? It looks as the Devil played a game to him….!

The “Devil” within the Health and Medicine!?

Yes -said recently one of his cooperators in this reform- So it is -the “Devil” played a game to him. The Health system is not only a “life saving angel”. It has also something devilish inside. The “Devil” is all wrongdoing things which for decades have existed and has been accumulated within the American Health system asphyxiating it.
President Obama although not a doctor has the merit that he has diagnosed precisely that the American health system is ill, Very, very ill. And his illness is badly and obviously sinking the American economy.  Furthermore it is blocking the steps of the progress for all the country. That was why the new President disregarded the nice astronaut’s uniform or the glorious khaki uniform of the army and choice   to wear himself the simple “white coat “of the Medicine. It is the first American President who wears the “white coat”. He does this not to cure the patients but to cure the health system of his country. He felt this step as must necessary. , and as imperative
Therefore he started immediately the reform. “We cannot wait, we must not wait and we will not wait”- he affirmed clearly.

The bitter and true facts

Such clarity and the determination to act were dictated to him not solely by emotions but first of all by the facts. The data say that U.S.A spends actually 2.2 trillion dollars per annum, which corresponds to 8.000 dollars per person, or 18% of the GDP. This figure is 2-4 time higher than that of other developed countries and   it is undeniably more than in other countries of the world. Taking in consideration the actual rhythm of the increase of the expenses they are expected to be 4.3 trillion or 20% of GDP. How can afford the U.S.A all this increase of expenses?
An American family with normal incomings having the Health Insurance paid by the employer pays in addition 16700 dollars from their incomings per annum which correspond to 28% of the monthly budget... The American system is traditionally based on the health insurance, which in U.S.A is implemented somehow different from the Bismarck model. It is neither the “classic universal” model which is implemented in some European countries and Canada. The European model is based on solidarity, compulsory taxation and the pooling of them for medical expenses in one “pocket” and one “buyer” which is the state.
     On the contrary the insurance in U.S.A is diverse: public, private or paid directly by the employer and it is chosen according to the citizens’ preferences. Up to 45 million adult employees are ensured by “Medicare” which collects founds from the contributions of the employees, contributions of the employers and the state. While the persons with insufficient incomings and the unemployed workers, children and some invalids are covered by “Medicaid”, which is financed mainly by the state.
A specific program exists about children health care. Now recently is proposed a specific insurance program to make able the aged person to take care for themselves in their homes. Meanwhile the medical first aid service is offered to all the citizens nevertheless if they are insured or not. A considerable number of Americans are insured by themselves or by employer, paying the insurances in the private insurance agencies. They are thousands of them in USA.
‘Medicare” was founded in 1965 by the president Lyndon Johnson. It was designed to be self-financed through the employees’ contributions. However the financial analyze performed after 25 years, in 1990 resulted that “Medicare” has exceeded the expenses in the amount of 800%. The deficit is increasing every year and is expected to arrive in 37 trillion dollars in 2017. The primes for health insurance contributions are progressively increased. This situation has given negative effects to the employees who lose their job. A great number of them stop the health insurance because cannot afford the primes and the payments. Around 46 million Americans are actually without health insurance, while 14000 persons lose it every day as result of the unemployment. The impossibility to pay the medical care exhibit them towards dangers and complicated deceases which creates later a “financial Boomerang” because the society has to pay more now for them. According to American Medical Academy, the U.S.A is the only state among the developed and rich states which is not covering with insurance all its citizens.

Strange Paradoxes

The most disturbing paradox is that “the American citizens although pay more and more for the Medicine, they receive less and less health care. The Health system looks as a new brandy car from out but in fact inside has a destroyed motor which spends too much petrol and as result the car moves a little”. In spite of the impressive technologic progress, glory in the scientific researching work (the U.S.A has the greatest number of the scientists awarded with Nobel Prize), the high professional capabilities and the great amount of money expensed for it, the American Health System results surprisingly without the expected productivity, performance and quality. A great number of the available and allocated resources are misused and lost without having effect as result of the bad management and “ of the medical malpractice”( Astronomic Medical Malpractice).
The American Medical Institute reported this paradox of the discrepancy between possibilities and achievements with publication of the famous document “The Big chiasm” since in 1999.According to the report “Commonwealth Fund” in 2008 the U.S.A was listed the last compared with other developed 19 countries. Moreover in 2000, the U.S.A compared with 191 other countries of the world was listed in the 37th place by W.H.O and in the 41st place according to the list of countries with low infantile mortality.
According to Glyn, Ash and Adam in 2003 only 54.9% of the Americans received right qualitative and appropriate medical care. Up to 1/3 of the ill persons who hospitalized once were obliged to re-hospitalize unpredictably again as result of not right medical care that patients received in the hospitals. Up to 50% of them affirmed that after the discharged from the hospital were not checked more by any doctor. Only “Medicare” paid in 2004 for the spontaneous re-hospitalizations 17.4 milliard dollars more than what was predicted in the yearly budget.
Also the other insurance company “Medicaid” the 2/3rd of its budget spends in asylums where it serves only to 1 million persons while 10 million aged Americans have need for house healthcare service. Their number will increase in 15 millions in 2020 and in 26 millions in 2030.
Meanwhile the healthcare system suffers from dangers and shortcoming problems of the safety and the considerable mistakes which instead to cure harm the patients. In 2000, the American Hospital Society informed that every year die in hospital as result of the evitable mistakes around 100.000 patients. The hospitals according to this statistics result to have greater number of the deaths than the national roads with automobile accidents. The reasons behind this gloomy situation are not connected only with professional skills but also with the influence of some other factors, unfortunately part of the system as consumerism, corruption and private health insurance agencies.
The influence of consumerism and the thirsty for manipulative and corruptive easy profits by the professional doctors, pharmaceutics firms and the insurance agencies, despite the harmful effects to the patients, have made the money the real driver of the healthcare system. Instead of being simply a helpful tool to achieve the noble objectives of the Medicine, the money unfortunately is made the God of the Medicine itself. The margin of the clear profit by the hospitals, doctors, insurances, medical examinations and medicaments varies from 25%-30% to the total cost of the Healthcare and Medicine. These in fact raise an ethical question and dilemma.
On other hand we must recognize that the unstoppable increase of medical expenses is dictated by inevitable objective factors as are:
- The progressive aging of the population (the elderly people are super consumers of medical services and of drugs),
-and the bio-technology, the new equipments and medicaments for which the U.S.A are leader in the world.
 It is true that those new technologies are helping to solve some of longtime waiting unresolved health problems but being innovations they have a very high cost which unfortunately is increasing every year. So they  are  necessary and in  some cases they  are irreplaceable, or imperative  for saving life but the  question is : how to be afforded all these expenses in the future? That is why President Obama pointed to gave an end to the further degradation by saying ‘Now or never”

Huge problem -Huge reform

The reform proposed by President Obama aims three great objectives. Firstly, the solution of the problems which are inherited from the past, that is to say the no coverage with health insurance of 17% of the population which was abandoned until now.
Secondly, the correction of the existing anomalies in the actual healthcare system concerning the function, cost , efficiency ,quality and security of the healthcare and thirdly the projection of preventive activities in order to do not repeat and to minimize the potential danger healthcare problems in the future.

You cannot wear brandy clothes up while down to be barefoot.
Concerning the issue of the expenses coverage and insurance the American Healthcare seemed as a lady of the fashion who walks proudly, wore with fur and very luxury brandy clothes up to the head and body but with the feet left unprotected, simply barefoot. While 5% of the population uses 50% of the total expenses of the healthcare service of the U.S.A, a segment of 17% of population are completely left out of it.
The full coverage with effective health insurance, affordable and flexible for all the Americans who have lost it or are without it represents not only a moral obligation towards this handicap but it is also an economic necessity. The statistics say that in 2003 the cost of this “ boomerang “ the cure of this contingent of patients in the services of the first aid as result of their aggravated health was of 37 milliard dollars.
That is why a new state agency named as National Health Insurance Exchange will be found in order to offer to the persons, above, a financial support for the health insurance in one of the health insurance agencies (public or private) which will be chosen by them. This step needs a preliminary governmental financing approximately 50-65 milliards dollars per annum, President Obama has shown his readiness to inject it immediately without hesitation in the ill body of the American Healthcare System. This step echoes the project of reform drafted by Hilary Clinton in the middle of 90’, differencing only in the amount of money which in Hilary Clinton’s draft was greater and in the form of the insurance which was drafted as an obligatory one, while in President Obama’s reform the patient can choose the private insurance agencies as well. This difference is based on President Obama’s will to respect the traditional desire of the Americans to choose the insurance agencies by their own self.
 The vision of President Obama about Healthcare differs fundamentally from that of his electoral rival Mr. McCain, who the solution of the insurance problems wanted to treat according to the principles of ‘harsh capitalism”, as an individual problem of the citizens , where were not necessary the interference of state and any preliminary financial investment. “The Insurance let be firstly affordable and then to be extended gradually-said Mr. McCain. He believed that everything would be regulated spontaneously by the free “vibrant” market through some taxation moderator mechanisms.
On the contrary the reform of President Obama says: “Firstly to be insured those who have been out of the insure coverage (this will lows the average cost of the insurance) and this make it spontaneously affordable.”
 Up to 7 million American adults and 4 million children until now not insured are expected to be included in the insurance schemes within the next future year. The state will interfere through “re-insurance”, i.e. the state will take over it some super expenses that have to do the private insurance agencies concerning some specific sever health conditions. These healthy conditions are specific and need treatment with medicaments and health services very expensive. They would create financial catastrophes if the families and the patients would pay through their expenses.
This step will slow the quotas of contribution for the insurance in these agencies. In this way the insurance agencies and employers will face the new regulator mechanisms which will not permit the abuse of artificial increase of contributions’ quote and prices or discrimination and exclusion of the citizens from the coverage schemes as result of their diseases. The parents also will oblige to insure legally their children. The state will stimulate the wider use of generic medicaments which are much cheaper than those produced with patent and the pharmaceutical companies will sell them with half price for the aged people. The participation of a public state agency in the market of the insurances puts a new equilibrium of the competition, aiming to give an end to the monopoly arrogance of the private healthcare insurances toward citizens. The opponents call these measures as “socialists” and of “the big government”. On the contrary Obama supporters call them as “re-establishment of the right, ethic, quality and rationality” and the “governance of great responsibility”

The “nice melody “of quality of care

The second objective of the reform is the modernization of the current American Healthcare System. The idea here is not only for technologic modernization but for the conceptual, functional and regulator modernization. If the first objective regarding the universal coverage returns the moral honor to the American society, the second objective aims to re-establish the scientific and professional prestige, function and the necessary productivity of American health system.
The above mentioned statistics affirm that the today American Healthcare System has “fevers”, it is somehow chaotic and uncontrolled in its addiction toward the profit and unaccountable in its way of offering the healthcare. Being unfair and unequal, it is also not even in the expected parameters. The reform aims to reconstruct the “motor/core” and the functional mechanisms of it. The key words of it are: “standards, quality, performance, efficiency, safety, a new digitalized information system, equality and rights for the patients and the citizens, carefulness and activity based on Evidence and scientific facts, comparison and identification of the best medical practice, spreading of this experience, new stimulant payment schemes of the quality for the hospitals, first aid care in home and of medical personnel based not more as until now on the quantity of volume work, procedures and examinations but firstly on the performance, quality and cost-efficiency of the personnel  of the institution. Empowerment and support to the scientific researches for new discoveries and solutions of the enigmas and health disorders which continue to create health suffering to the Americans”.
Moreover this reform has a double aim;
 Firstly “to close the holes “in the health system in order to avoid the leaks of existing resources. It aims to low and avoid the malpractices and abuses but it does not limit the procedures of the healthcare if they are necessary and valuable concerning the health gain for the patients.
and secondly to establish new modern mechanisms to increase the performance and productivity of the all system to offer to the citizens qualitative healthcare according to the standards of the best practice
 President Obama offers 50 milliards dollar to computerize totally within 5 years the healthcare system, which it seems that will have positive implications to make able the measures and the comparison of the results, performance and the quality in order to reduce some actually unsuccessful practices.
1.1 milliard dollars will be granted for the establishment and the function of a new especially institute, which is believed that is a key element for the quality and the performance. It will perform measures, comparisons and will furnish the healthcare system with facts and new reliable scientific evidence. Exploiting these evidences will be easy to formulate the new kind of clinical guidelines of the best qualitative and the most cost effective medical practice.
 In the reform are predicted new regulatory and legal measures, close cooperation with the Department of the Justice and with the interested parties in the war without compromise against abuses and corruption. The relationship between the state and healthcare, which until now have been confidentially “give money and do not ask”, now and up will be “give, but ask and check”.
It is accounted that if is implemented successfully this reform, it will save in 10 years, 12 trillion dollars and every American will save from his expenses 25.000 dollars in year. All these results sound as music and as unbelievable melody to have been pronounced and articulated by the President of the strongest country in the world. However they have been waited with too much hope and as an omen of good understanding not only from Albanian Medicine and especially from National Center of the Quality Safety and the Accreditation of Health Institution but as well from all the global movement of health quality and safety in the world

A window of hope towards the future

President Obama is not the first politician observing that the financial problems which face Medicine today are as result of indifference from the politics and the health professionals of the problems which could be prevented since from the beginning. The same thing has happened also with the citizens concerning their life style, who unfortunately due to the insufficient cultural education continue to choose often unhealthy or dangerous life styles
 The commercialism, consumerism and the subjectivism has caught as a hostage the Medicine into the “diagnostic and curative castles”; instead to create widely spaces for prevention and prophylactic activities for the first time the Americans notice with grief that the younger’s of today have worse health than the previous generation.
In the Obama reform the diseases prevention and health promotion constitute   one of the main three pillars. It pays attention to the welfare and life style, to healthy conditions of work and the feeding of the citizens and children. It pays also attention to diagnosis, prevention and effective management of chronic diseases.
It is the first time that for these activities is invested 1 milliard dollars. It is to be mentioned that some initiatives of health prevention has been planned also before in several specific or fragmented projects regarding one or a number of danger factors. However those have not been successfully in their implementation. The hope for success this time is connected not only with the affirmation of the leadership of U.S.A in their implementation but because it is the only savior way to do not collapse the American Healthcare System in the future. This is not valid only for U.S.A

America is America and Albania is Albania.

There are not reasons, possibilities and temptations that the reform of President Obama to be copied as such in Albanian Healthcare System. However some messages from it can take universal value and can be looked with great interest in our context. Somme of them I think are the following:

-    President Obama is undertaking a real holistic “reform” not a “piece meal” or partial one. His interference is coordinated in several plans and it gives the sense of addressing all health system.
-    It is not performed for “luxury “or for propaganda purpose  but as an imperative, as moral and economic intervention
-    Such health reform needs the decisive role of the leader, his clarity of vision, the will and his sense of responsibility. It’s seems that “to have and to know “is not enough. First of all it’s necessary  to  wish.
-    The former director of W.H.O Dr Brutland had made clear when she said that “the main responsibility of the health situation in a country lay on the government of the country”. The reform seems to re-establishes the active role of the state which in relation to health system has been so far rather week or vanished in USA.
 The government most led politically the health system but also have to establish rules, and to control in order to avoid the abuses by interested   partners operating in market, which may cause damages to the health of the population.
-    The reform also indicates the responsibilities of everyone who is actor and beneficiary in the field of Healthcare.
-    This reform started purposely in the beginning of the presidential mandate. This may minimizes the possible electoral implications related to the unsatisfied and interesting parts with it.
-    The space of the action is wide and lays 10 years, which indicate that a comprehensive reform is not a fast procedure. In order to be sustainable the reform needs it’s time to ferment and to mature. The health reform must not be designed and be implemented quickly as a “Quix fix”.
-    Some of initiatives like that of total computerization, standardization, the measure of the performance, the improvement of the quality and safety are not original. They are started already several years ago by the “medical market” as well. However their development so far has not been so successful. The incorporation of them in such national strategy and under state responsibility may create more chances to be implemented faster and successfully.

-    It is evident the necessity for transparence and the  good will  consensus with a wider spectrum of the society, open dialogue firstly with the citizens who will be effected directly from the reform and then with opposition , professionals, insurance companies, academics and all the interested parties about the reform. If it is true the claim of Dr. David Schneider, the personal doctor of President Obama (who is not satisfied with the reform) that the preference of President Obama was firstly to adapt the British universal model about the insurance, but later on gave up in order to achieve a compromise with insurance companies, it seem that he has learned a lot from the Clinton’s failure in this field. However one thing is sure. After the consensus with all the interested parties, this health reform will not be considered as solely Obama reform or as Democrats reform but the health reform of all U.S.A.
-    Although this reform concern health system, it is obvious that there are mixed many other components as the economic, sociologic, ethic, legislative and human rights components. This confirms that the Health system is not longer perceived as narrow domain solely of the “white coats”- of doctors, medical associations and universities chairs or state health departments which are dealing directly with it. On the contrary, this reform is designed wider and in multidimensional way where are interfering several other crucial factors which implicate the present and the future of a country.
-    President Obama wore the “white coat”! Let’s wish him:  Good Luck! Lets wish him also to keep it on as longer as possible during  all his presidency

P.S. This paper has been published first of all in “Zemra Shqiptare” (Albanian Heart) and after in two parts in the Albanian Newspaper SHEKULLI «  on 13 and 14 August 2009


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