Health reform: China offers a cautionary tale

Health reform: China offers a cautionary tale

Wang Li is a 48-year old farmer from Dalian, China. After a two-day trip to the major provincial hospital, he’s heading home to his village to die. Wang has lung cancer, and even with insurance, his surgery will cost him 20,000RMB—$3,000, which is twice his annual salary. The surgery would be curative, but it doesn’t matter. “I cannot burden my family,” he said.

I am a Chinese-born, American physician who just returned from a two-month research trip spanning twelve cities and nine provinces in China, where many of the healthcare reforms in contention in the U.S. have already been tried. As Americans contemplate the decisions ahead, consider China’s cautionary tale.

Today’s China is one of great disparity. The wealthy minority receives top-notch care, while the poor majority suffers from little access to care and no way to pay for it. Stories abound of patients like Wang Li who sign out of hospitals when they run out of savings, knowing they will die without treatment.

It wasn’t always this way. In the mid-twentieth century, China had universal healthcare with a robust primary care system. Millions of “barefoot doctors” provided basic medical services in villages, and attention to prevention ensured significant gains in life expectancy.

The reforms of the 1980s changed healthcare from being a social good to a commodity. Universal insurance was dismantled, and 900 million people lost coverage overnight. Healthcare was decentralized to provincial governments, who allowed the market to operate with few restrictions.

What’s emerged is a fragmented system fraught with inefficiencies and perverse incentives. In Beijing, if a doctor diagnoses someone with a common cold and sends the patient home, she gets paid, 4.5RMB, less than a dollar. But if she orders tests and administers IV antibiotics, she gets paid 400RMB, 100 times more.

There are additional ethical concerns. Because local governments have ultimate responsibility for service provision, poor provinces can afford to pay their doctors little more than manual workers. Doctors are expected to “top up” their salary through other means. Some earn up to 5 times their salary through kickbacks from pharmaceutical companies by prescribing new, expensive medications; others accept direct bribes from patients (“hong bao”) as promise for better care.

The commoditization of healthcare has caused direct harm to the patient-physician relationship. Patients question whether doctors are acting in their best interest. Threats against doctors occur daily, and doctors have become terrified of the people they serve.

Understandably, the attrition rate among doctors is multiplying. The lack of doctors is particularly acute in rural areas. With low pay and few opportunities there, doctors flock to cities, leaving many villages without any doctor. The high reimbursement for treatments has resulted in a huge pay differential in favor of specialists, and China has gone from a model primary care system to having virtually no general practitioners.

To its credit, the Chinese government has recognized the inadequacies of its healthcare reform, and is making amends including a nationalized health insurance system and a code of conduct for doctors. For the U.S. in considering similar reforms, China’s failures offer three important lessons:

First, health insurance does not equate access or coverage. In China, those with insurance still have to pay 60-70% out of pocket, leaving many without actual health coverage. Taking “personal responsibility” for our health may be important, but we should not price people out of life-saving treatments. 

Second, fee-for-service should be abolished in favor of fee-for-diagnosis, with a specific illness billed a fixed amount regardless of the tests and procedures performed. Not only does such “bundled payments” require accurate diagnoses, they reduce cost and the potential for inefficiency and corruption.

Third, healthcare regulations need to be national decisions. Given the variability among states and our mobile healthcare workforce, decentralized policies don’t make sense and will exacerbate inequalities. Market-based innovation can still be encouraged with pilot projects starting at the state level, but the U.S. needs national consensus on overriding principles.

This year, America has a once-in-a-generation chance to fix our broken healthcare system. As policy-makers discuss implementation of the Accountable Care Act, they should learn from China’s experience and decide whether they see medical care as a commodity or social provision, and what are the responsibilities of the government to ensure the health and well-being of its citizens.

Leana Wen is an emergency physician who blogs at The Doctor is Listening. She is the co-author of When Doctors Don’t Listen: How to Prevent Misdiagnosis and Unnecessary Tests.  She can also be reached on Twitter @drleanawen.

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  • Rita Chobanian Swisher

    Thank you so much for writing this. It is wonderful that we are able to read such a thought-provoking piece, but I hope our legislators are listening first and foremost.

    • Suzi Q 38

      Sadly the legislators don’t care.

      • EE Smith

        And Mao did?

        • Suzi Q 38

          Im not talking about MAO.

    • EE Smith

      What is it that you two want our legislators to “listen to”? What is it you want them to “do”? Have you never read a single history book?

      Do you not even understand that this mid-twentieth century Chinese “utopia” in. re. free medical care (and unicorns, and rainbows) for all did not actually EXIST but is a figment of the Chinese Communist Party’s collective imagination cum propaganda??

      Lord, I weep for this country.

      • Suzi Q 38

        After reading this story, it is not something that I would want for the US, obviously.
        The legislators don’t care, as long as they get their good medical care.

      • Ann

        It never ceases to amaze me that people can become so vitriolic in their comments to the ideas of others.That’s what has happened in DC. Didn’t the fear of Chinese history cause some of you to miss the point? Isn’t bouncing around ideas what graduate education is all about?. We are all on the same team in our great country. I am an RN who grew up in the UK practiced in the NHS, had a mother who died prematurely possibly because of poor treatment and yet I saw others receiving the best of care. All for ‘free’! Socialized medicine will not take away your constitutional rights, the world will not end and become communist just because others less fortunate than ourselves are given a little help. We win some, we lose some. We need to share in the USA – learn to do without such fancy facilities, stop demanding everything NOW and treat from our hearts. I once worked for an oncology group and at interview I was told that I had to remember that this was private pay America, not the NHS and remember to treat people appropriately. Excuse me? As a professional I treat everyone the same. I left that job very quickly when I saw that the treatment was not up to my NHS standards! If people weren’t scared of losing everything ie bankruptcy following major illness/treatment then stress/comorbidity would reduce, we would prescribe fewer anti depressants and other drugs ad infinitum and maybe would have the spare capacity for other things! And don’t get me on the subject of over prescribing. One can’t have a sore throat in the USA any more without people screaming strep throat/tests/ENT consult. What happened to gargling with salt, acetaminophen, increased fluids and watch and wait for (usually) the virus to go away? A little pain is what all us citizens could do with.

        • Guest

          Saying that under Mao there was excellent universal healthcare (never mind the tens of millions killed) but it all went downhill after that is the EXACT SAME as saying that under Hitler there was excellent universal healthcare (never mind the millions killed) but it all went downhill after that…

          It is REPUGNANT to hold up a tyrant’s dictatorial and murderous regime as a model for modern-day America to follow, and it’s NO SURPRISE that people here are disgusted by it.

          • Tom Garvey

            So, to take what you’re saying to its natural conclusion, since Hitler built a modern superhighway (the autobahn), all modern superhighways are fascist.

          • W.B.

            No, it would be the same as saying Hitler managed to “solve” the “problem” of the mentally ill in society (by KILLING them), and we should should look to his model for our own system!

          • ninguem

            W.B., the term “useful idiots” comes to mind. Popularly attributed to Lenin and Stalin, though actually of uncertain provenance except generally used by sympathizers of such murderous regimes.,

            The Chinese also claimed at the time of the Nixon visit, that they were doing major surgery under acupuncture. Or maybe more to the point, they let “useful idiots” in the Western media believe that they did the major surgery under acupuncture.

            The surgeries were done under regional anesthesia with major sedation……and acupuncture.

            The autobahn, which was designed in the Weimar days, built in the Nazi era. Maybe a better comparison is the Nazi era experiments. Why let good data go unused just because of the unethical way it was obtained?

            Well because, when one really looks at the data, the same mentality that allowed Nazi-era human vivisection allowed the researchers to ignore ordinary rues of scientific rigor.

            The work was useless.

            Same with the Mao-era “barefoot doctors”.

  • Chris

    In the mid-twentieth century, China had universal healthcare with a robust primary care system. Millions of “barefoot doctors“ provided basic medical services in villages, and attention to prevention ensured significant gains in life expectancy.”

    In the mid-twentieth century, the Communist Chinese government also killed tens of millions of Chinese.

    Some Chinese scholars estimated that 80 millions died of non-natural
    causes under Mao’s rule; 50 millions were killed or oppressed to death
    during Mao’s “Great Leap Forward”/”Cultural Revolution” from 1958-1962 alone.

    Revisionist history is an ugly thing. You will not win support by trying to sell educated Americans on a romantic vision of Communism and mass-murder.

    • ninguem

      What Chris said. Sheesh.

      In those mid-twentieth-century good old days, Mao killed more people than Hitler. Orders of magnitude more.

      Godwin’s Law be d@mned, I cannot believe any romanticizing of Chinese primary care in those days.

      The the mid-20th century that farmer with cancer would have been shot. Some primary care.

      He might have ended up as someone’s lunch for that matter.

    • James

      “A government big enough to give you everything you want, is a government big enough to take away everything that you have.”

      Thomas Jefferson

  • Mandy

    “[H]ealthcare regulations need to be national decisions”

    Central Planning, Chairman Mao style. What could possibly go wrong?

    • Mandy

      Come to think of it, I wonder what the penalties were for doctors failing to meet their quotas in aid of Mao’s glorious five-year-plans? If y’all think Press Ganey is a harsh taskmaster…

  • buzzkillersmith

    Mao killed more people than Hitler. China is a abhorrent dictatorship. With all due respect, Dr. W., we Americans ain’t looking to China for tips on how to practice medicine or how to live life. Don’t you know this?

    • Mandy

      Didn’t China just fire the head of its Food and Drug Administration a few years back? And by “fire”, I mean “place in front of a firing squad and perforate with bullets until dead”?

      Wonder how that would work here, vis a vis federal bureaucrats who manage to embarrass the president — “pour encourager les autres”, nomesayin’?

  • ninguem

    Maybe you can meet him, the next time the “Bodies” exhibit rolls into town.

  • querywoman

    It’s hard to write more than this other stuff but there’s more: forced abortions, some newborns get excellent care while unwanted babies are almost “exposed” to death, using the organs from executed criminals for transplants, etc.!
    Didn’t Stalin also kill more than Hitler!

  • C.L.J. Murphy

    It looks like your romantic dream of a Communist-imposed centrally-planned great-leap-forward-style ‘barefoot doctor revolution’ led by an omnipotent mass-murdering tyrant is probably not going to fly in 21st century America.

    Thank God.

    • ninguem

      Not surprising I suppose, but she’s in academics.

      Good that you posted anonymously, lest you end up in a re-education camp. But you’ll get primary care.

    • EE Smith

      Ouch. Harsh, but not inaccurate.

  • donald aievoli

    Personal responsibility and lifestyle should be reflected in health care pricing. I am obese and use chewing tobacco and my insurance plan reflects those facts. I have no out of pocket maximum because of my lifestyle choices. From a liability perspective, I don’t like being priced in this manner but I don’t have the right to be subsidized by others who do make the right choices regarding their health.

    • Dorothygreen

      Thank you for this statement. This is one necessary way to help pay the bill. We need to extend it further and the only way to do that is to use the “tobacco model” of a tax, message, farm bill for health, not profits,stop the TV ads for all you can eat and sugary stuff to kids, implement massive education from birth to old age on nutrient dense food. If we change our eating cuture we can save our soil, water, health care money, not need more doctors, overlapping drugs for preventable diseases. The innovation is here, the clinical data is here and we piddle around with far less important issues.
      The point of the article is that China is going toward capitalization of health care that the US should be getting rid of, There is no place in health care for for profit insurance for basic care. Companies can sell the :perks, at profit but basic care must be universal.

      • donald aievoli

        Dorothy, I agree with you about education. But I disagree with government fiats, such as Bloomberg’s soda law. People should have the choice but there should be market based consequences for making poor choices. This is called putting your money where your mouth is. The freeloading has to stop.

    • Guest

      “I am obese and use chewing tobacco and my insurance plan reflects those facts.”

      Obama’s “Affordable Care Act” means that insurers will no longer be able to charge you more for “pre-existing conditions” – including obesity. In some states and DC, smoking too will be classed a “pre-existing condition” for which insurance companies will not be able to charge you extra.

      It will be your conscientious, fit, healthy, non-smoking neighbor picking up the tab for your self-inflicted increased risks. Do be sure to say “thank you” next time you see him.

      • donald aievoli

        Doesn’t make much sense with respect to combatting a growing obese population.

  • Tom Garvey

    The content of most of the comments seems analogous to the following:

    Mao was evil. Mao created a socialized medical system. Therefore, socialized medical systems are evil.

    Take a deep breath. Look up the meaning of ‘non sequitur.’ Then, try again, please.

    • Guest

      Don’t confuse the others with rational posts like these!

    • W.B.

      Do you really believe the author’s claim that mid-twentieth century China was a model of perfect social justice and equitable universal healthcare for all? When during that period, up to 50 million Chinese were STARVING TO DEATH and being EXECUTED BY THE STATE?

      You really think her hypothetical lung cancer patient would have had better treatment back then than his American equivalent?

      OH YES, and Hitler solved the problem of catering to the mentally ill!

    • ninguem

      Tom Garvey, why don’t you look up the term “useful idiot”.

      Mao was evil. Mao was the greatest mass murderer in history, worse even than Hitler. Mao created a socialized medical system that was of a kind with everything else Mao did. Evil and murderous.

      No one is saying ALL socialized medical systems are evil. Mao’s was, along with everything else he did. The only person saying ALL socialized medical system are evil… you.

      Maybe you need to look up the meaning of “projection”.

  • Daniel

    Thank you, Leana. A well-written piece. Don’t let the shrill trolls in the comments get to you.

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