 Good afternoon. Welcome to Asian Review. I'm your host, Lily Ong. It's nice to be back in the studio. Happy New Year. Today we're going to talk about the healthcare system of America and compare it with the healthcare systems overseas. There's no better person to talk about this with than Ms. Dr. Christopher Flanders. He's the Executive Director of the Hawaii Medical Association. Welcome to the show, Dr. Flanders. Well, thank you for having me and happy New Year. Thank you. Thanks for being here. Dr. Flanders, out of the 35 OECD countries, 32 of them have introduced universal healthcare, but United States is not one of them. Before we get your thoughts on what you think of universal healthcare for America, could you give us some background to the current state of the American healthcare system? So as everybody knows, we've been having this discussion for several years that everybody felt that the American system is in trouble, is broken, and that we can't continue to spend the amounts of money that we're spending on healthcare. About 16 percent of the GDP of the United States goes to healthcare, and that far exceeds what any other country is spending. So we really, it's obvious that we really need to do something to bring down those costs and to get spending under control. When this has been going on, there have been several attempts at doing this, as people probably have heard in the discussions, that going back to the days of Harry Truman in the 1940s, there was an attempt. And again, in the 70s with Richard Nixon, and again in the 90s with Bill Clinton, and then, of course, when Barack Obama came in in 2008, this was his top priority to reform the healthcare system in some form or fashion. Were they all trying to bring it closer to the universal healthcare system? That certainly is part of the discussion, or was part of the discussion, and continues to be. There was a lot of attention paid mostly to the European countries, and in Canada as well, because that's part of the culture that we're familiar with, and most people in the United States are familiar with Europe, and a lot emigrated from there, of course. Canada is a single payer system, is that right? Yeah. Canada is, yeah, it's a single payer system, although each province, each province, which is their equivalent of the states, sets up their own system. But it's all regulated and administered by the federal government in Canada, and a lot of states are that way. You know, there's universal healthcare, which sometimes gets confusing, because there's single payer, and there's universal healthcare. Universal healthcare simply means that everybody has insurance, and that they've got coverage for illnesses. Single payer means that all comes from one source. You know, the other option is that... And when you say all comes from one source, it could be from the government or the individuals, right? Yeah, it could be from government, it could be from individuals, it could be from employers, but somehow then that has to be fixed at the price side, so there's not a lot of competition. The other option is just the mandate that all employers supply insurance similar to what we have here in Hawaii, or that all individuals purchase insurance like they've got in Massachusetts. Well, we do have a legal mandate right now that Americans are supposed to have health insurance, or they pay a penalty, but despite that, that's about 26 million that are uninsured, so is there no oversight in the mandate? Yeah, the oversight is supposed to come from the Internal Revenue Service, and they've been spinning their wheels trying to get that engaged. If you notice that on your tax forms, there's a spot in there that has the amount that's been paid on your health insurance, or whether or not you've participated in health insurance, so there is that mechanism, but the enforcement hasn't really been there yet. I'd say. So when I look at the Obamacare, I think that was the closest America ever came to having health care, and then when Trump came on board, he was trying to repeal Obamacare, but with Trump care, it would actually put 20 to 40 million more people out of insurance. What do you think about that? I know eventually it did not go through. What are your thoughts on that? So people having insurance and having access to health care is one of the priorities of physicians, and that we feel very strongly that everybody needs to have access to good quality health care, and if that's getting through insurance, we're all for that. The whole Trump thing about doing away with a mandate, I think it's more about political philosophy than it is about a working combination to have everybody get access. So we didn't really like that, and a lot of the reform propositions that were put forward in the United States Congress, the American Medical Association, of which I sit in their house of delegates, we oppose those just based on that, that we feel very strongly that everybody needs to have access to quality care. And when we look at the World Health Organization ranking, and even the ranking by the Commonwealth Fund, America was ranked last in the Commonwealth Fund ranking. They were looking at 11 developed countries, and even in the World Health Organization ranking where there's 195 countries being looked at, America was ranked number 37 overall. What are your thoughts on that? Yeah, and that is part of the concern, of course, right? Do you think much about those ranking today? Yeah, I think we have to pay attention to those. We're spending more money than anybody else. You would think we'd be at the top. And a lot of that is the access issues that we have pockets in the U.S. where we don't have good access to health care. And Hawaii is a good example. We've got, because of our island state nature, we've got a lot of people who live on Hawaii Island, myself included, that don't have convenient access to health care. Are you referring to geographical transportation issues? Yeah, geographic and just having an even distribution of physicians in the rural areas is one of the other concerns. So we need to work on a system that not only brings down costs, but increases access. Is the government providing any kind of incentive to get physicians to work in suburban or rural areas, just like they do with the teachers in America? Do they do that? Yeah, you think that would be part of the formula, right? But as long as I've been in medicine, it's been kind of a long time now, that's been part of the decision. Why don't we incentivize? Why don't we take Medicare dollars and Medicaid dollars and pay the rural physicians a higher rate than the urban physicians? But the truth is that it's usually the reverse, because the cost of doing business is higher in the cities than it is out in the countryside. So that incentive part of it isn't there. Now, it's common to have some state, primarily state-centered incentives. Like here in Hawaii, we've got a guaranteed student loan forgiveness program that if a physician graduates from medical school and goes and practices in an underserved area for a given period of time, say five years, then the state will forgive those loans. And those have shown some promise and some success. Was Hawaii the first state to do that? No, that's been fairly common. And actually, we had to work kind of hard to get that program put into place. Those programs have been around for quite a while. It used to be that there was the National Health Corps set up where, and you remember the show, Northern Exposure, where it was the young doctor who was put in this small town in rural Alaska. And that was part of that whole program to pay off the loans. And so it's those kind of things that we really need to implement, I think. And is the funding for those programs coming from the state side, Laura? It's kind of a mix here in Hawaii. There's a grant that we receive from the federal government that is a matching grant. So every dollar that the state puts into it, the U.S. government will match that. So it's kind of a partnership on that. Now, would you agree that not just not only do we need more doctors in rural areas, we need more doctors across the board? Do you think we need that? Yeah, I think we do. The studies here in Hawaii have shown that even Honolulu is short on positions in some specialties. And if you agree with that, may I ask, and correct me if I'm wronged, why would the American Medical Association advocate for a cap limit on the number of doctors? Oh, I don't know that they are advocating for it. Oh, medical students. I'm sorry, medical students. I think there's a cap limit on that. Now, you know, we've actually, the last few years, have been advocating for an increase. And not just in the number of students who are in medical school, but what's probably more important at this point is the number of postgraduate spots that are available. And those are the spots that train this, not just the specialties, but family practice, internal medicine are considered specialties, but their primary care specialties. But there aren't enough of those spots for every graduate from a U.S. medical school to be able to do that. And that's, you know, without that extra training, you really can't practice medicine. And as you mentioned, United States spent about 18%, 16 to 18% of the GDP on healthcare costs. Do you think the massive, I'm guessing it's massive, the massive insurance that comes from malpractice plays into that entire cost calculus? Because America is such a litigious society, how big of a chunk is that coming from malpractice insurance costs? Yeah, malpractice insurance does play, or not just the insurance part of it, but the response to the threat of litigation also plays a part. And most people have probably heard the term of defensive medicine, where tests that might not normally be ordered get ordered just so they can protect themselves in case they're sued. For example, somebody comes into the emergency room with a headache. They may get a CT scan, a CAT scan, or an MRI, just to rule out that there's not a bleed in the head that's causing the headache. So there's a lot of maybe unnecessary or preventable procedures that may not have happened? Well, yeah, it's all how you define necessary and unnecessary. And in the system that we have now, we spend a lot of time and effort arguing necessary versus unnecessary testing. What about giving the choice to the patients? Are they well informed enough to decide, you know, should I proceed with such a procedure or not? You know, it's an interesting thing that health care is probably one of the few areas where if you as a patient are going to make a substantial investment in money and something that you don't ask questions like that. So if you go out and you're going to buy a new car, you ask a lot of questions about that car of your salespeople and you want answers and you decide whether or not that particular car is worth the investment you're going to make in it. But if you go to a surgeon and the number one, the questions aren't ever really asked about, you know, experience and success rates and those kind of things. But because of the absence of deductibles or co-payment, they are less, I guess, prudent about spending. Yeah, I think that a lot of patients don't have skin in the game, if you will, that they do pay a little bit. But the co-pays that we pay in the United States are less than what a lot of countries pay in their co-pays in the countries with so-called socialized medicine systems. So they don't really have a big investment other than their personal health. They're financially not a big investment paid. So they don't feel like they're pushing to ask those questions. There's been talk about different ways that we can have some kind of patient investment in their own health care and, you know, either with positive reinforcement, with rewards for doing, you know, appropriate behaviors or stopping inappropriate behaviors, smoking and so forth, losing weight. Yeah. Well, thank you so much, Dr. Philandes. We're going to take a little break here. And when we come back, we're going to compare and contrast some of the health care system in the world with America's system. Thank you so much. Hello, everyone. I'm Desoto Brown, the co-host of Human Humane Architecture, which is seen on Think Tech Hawaii every other Tuesday at 4 p.m. And with the show's host, Martin Desbang, we discuss architecture here in the Hawaiian Islands and how it not only affects the way we live, but other aspects of our life, not only here in Hawaii, but internationally as well. So join us for Human Humane Architecture every other Tuesday at 4 p.m. on Think Tech Hawaii. Aloha and Richard Concepcion, the host of Hispanic Hawaii. You can watch my show every other Tuesday at 2 p.m. We will bring you entertainment, educational, and also we tell you what is happening right here within our community. Think Tech Hawaii. Aloha. Aloha, and welcome back to Asian Review. Today we have with us in the studio Dr. Christopher Philandes, who's the Executive Director of the Hawaii Medical Association. And he's here with us today to compare and contrast the American healthcare system with those overseas of similarly developed nations. So Dr. Philandes, this country is, to put it positively in a positive way, is equitably polarized. So when liberals look to, you know, look for examples to support their destiny for universal healthcare, they can look to Canada, which is a single-payer system. They look to France, which is a multi-payer system. They can look to the Scandinavian countries, and they can even look to Germany, which is a hybrid system. Could you share with us what are your thoughts on some of the, you know, European systems? There's a lot of attention paid for that. And I think that primarily that attention was geared at the European areas rather than some of the other areas. That's where kind of this whole socialized healthcare system started. Norway started there. They were the first country to try this, and they did that in, I believe it was 1912, sometime in there, about 100 years ago. A lot of the European countries, and I think almost all of them now have gone that route, they've done it different ways. In some nations, it's the federal government that administers and runs through payroll, tax, and those kind of mechanisms, the cost of paying for healthcare. In some countries, there's a mandate either to the employees or to the employers that they supply their own or their workers' healthcare. And how are they doing financial wise? I imagine that's a huge financial strain. I know Britain is a truly socialized, you know, has a truly socialized healthcare system, but they are sort of collapsing under the financial strength. Yeah, they are. You know, we're having trouble with trying to control the rising costs of healthcare, but every other country is having problems controlling their healthcare costs too. It's not something that's unique to the American system. The healthcare inflation is worldwide. And a lot of that is geared because of the increasing technology that we use in healthcare, the things like the sophisticated studies like the MRIs and the new PET scans that are kind of nuclear-based, those aren't cheap. And so those have all cost money. And unfortunately, when they do the ranking, they don't look too much into those innovations. They do take a take at it. And they compliment the U.S. on innovation and medical technology that really benefits citizens across the world. But there's other issues they look at like accessibility, qualitative care and outcomes and so on and so forth. Yeah, those kind of things are hard to quantitate. So I think that unless it leads directly to improvement in longevity or increased quality of life that's measurable, that it doesn't get a lot of attention. And but those are things that every country is trying to deal with, as to how we control the overall costs of healthcare. And like you mentioned, Britain is, my wife and I went to London last year and we met with a couple of families from Britain. And they all remark that Britain is billions of dollars in debt and paying for their healthcare system that it doesn't pay for itself, even with the taxes that are charged. And of course, nobody wants to pay more taxes. So they're trying to struggle with that. And Norway is highly socialized too. Do you think it's because they are supported by their massive oil reserves because they have money coming from other sources to support that kind of system? Yeah, it's absolutely oil in Norway. Yeah, the way they've got that set up is that, you know, this kind of off on a tangent, but the federal government owns the oil fields and they contract with the oil companies to pull out the oil, but the oil belongs to them. So all that money comes into the country and that's used to pay for healthcare and a lot of other things. It's really a very progressive and interesting nation. We know the French system was ranked number one among the OECD countries. Is there any good from the French system that you think we could take and implement it here? You know, there are a lot of the ideas about the access and the ease in getting into the healthcare system because as we all know, the healthcare system is difficult to navigate once you get in. When things happen, they tend to happen fast and they tend to progress very quickly and people end up just getting swept along with the flow of the healthcare system, whether it's in a clinic or in the hospital. France, I think maybe has a better grip on that. Their costs tend to be fairly low and I think that's because the prices get set a little bit tighter and that's where a lot of the countries have focused their attention now, is some central mechanism to fix prices. Japan, if we move over to Asia, for example, if I could interrupt you just when you said the intervention on the prices, are they trying to fix the prices on the insurance products or prices on the medical system itself? Yeah, it's kind of both. It's not so much on the premium side, although that probably comes along with it, but on the payment side, for example, I was going to get into Japan, it maintains very tight control over their fee schedule. So even though people might have different insurance companies that are paying the physicians in the hospitals, all physicians in all hospitals get paid the same for the same procedure. So there's no competition really. It's single payer even though there are multiple companies that are paying. And then what they can do, what the federal government in Japan can do, is that they can regulate the budget by adjusting that fee schedule up or down. If they've got a tighten up on the amount of money that's going out, they lower that fee schedule. So earlier we talked about some of the examples, you know, the liberals will look to, I like to measure examples that the conservatives frequently look to besides Japan and that's Singapore. Have you heard much about the healthcare system? No, I don't know that much about the healthcare system. I know that they've got a socialized program, more or less, in the universal system, but I'm not that familiar as to how that's set up. Yeah, well, I'm from there, so if you don't mind, I'll share with you. Yeah, no, absolutely. I'd love to hear it. So the conservatives sort of held that as the, as the gold standard. In fact, Fox News was advocating for America to copy Singapore, you know, healthcare miracle. So in Singapore, it's based on three ads. That's the MediSave, MediShield and the MediFun. So the MediSave is a mandatory health savings account. Every Singaporean workers have to contribute 7 to 9.5% of their wages into that account. And this is, this pays primarily for routine care. And it pushes the customers to look at routine care as a product, just like when you buy your shoes, when you buy your bag, you would think before you pay, versus you were giving a good example about how people in America, they don't ask those questions. They would just go with the procedures that's being recommended by the doctor. But in Singapore, because it's coming out of their own pocket, essentially, they would inquire, is this necessary? Why am I doing this? And then we have the MediShield so that when they hit the deductible, they can move on to the MediShield and that will cover, you know, the additional cost. So everybody has MediSave and MediShield is optional. We're automatically enrolled, but it's optional. You can opt out of it. And that's also a safety net, which is the MediFun. And that is funded by an investment income of a $3 billion endowment. So we don't touch the principle. And for 2018, we were just using the investment income from 2017 to pay for those who absolutely cannot pay. So it's sort of a payout of last resort. I know that America has sort of been looking at the Singapore system as well. Do you think such a system, based on just, you know, how I briefly described, do you think such a system will work in the United States as a mandatory health savings account? You know, yeah, I'm intrigued by that idea because prior to the Affordable Care Act, there were states that were developing the medical savings account systems. And I had one for several years. And it actually worked pretty well because it's a high deductible insurance company, meaning that you would have to pay the first amount of, you know, $3,000 or something of your health care. But you could also contribute a matching amount, so $3,000 into a savings account that you could use to pay that. Now, you know, that kind of puts skin in the game for patients. Because when they go in, you say, now all of a sudden, they've got to pull out the credit card that the bank gave them that has all the money that they've been able to save up. And they know how much that money is. And they want to know how much money is going to come out if they decide that they do want to go through with, you know, having this mole excise from my neck or whatever it might be. And so you start getting this give and take. And, you know, I think that's a good thing. I think that that more patient engagement, we get the better off that the system will be. I think you hit the nail on the head when you say gets the patient skin in the game. And Singapore system is truly the only universal health care system that gets the patients to pay for the chunk of the health care cost. The government actually pays just a quarter of the patient cost in the country. Yeah. So instead of having the insurance pay for most of the cost, which is evident in Western Europe and United States, their patients are one that pays the larger chunk of the cost. So they are forced to take responsibility for their own health. I want to talk a little bit about the pharmaceutical cost because I know that skyrocketed in United States too. Why does Medicaid prohibit? I mean, there's a lot that prohibits them from negotiating down the prices of the pharmaceutical products. Why is that? You know, I don't know what the history of that is because to me and to a lot of people, that just doesn't make any sense. We negotiate on the price of everything else. You know, why is there such a carve out? I don't really understand. And there's been a lot of attention paid to the cost of pharmaceuticals as a whole as to the last five, six years or so, especially the price of pharmaceuticals is just skyrocketed and even on drugs that have been around for years and years. And, you know, we asked the pharmaceutical companies, you know, what's going on here? Why is this happening? And, you know, I don't know that we've really been able to get a coherent answer as to what that costs. But that, I mean, if you have to point a finger at things, you know, that's probably one of the things that we need to take a look at. Do you think the doctors should bear some of that responsibility too? Because I know that pharmaceutical companies will sometimes woo doctors with incentives. They send them to resorts, expensive dinners, gifts like that. Is there any ethical oversight as far as, you know, where does the line stop? You know, that doesn't really happen. I mean, that may be used to happen, but now, for the most part, if you're going to go, it used to be that they did training for physicians and we'd be able to get our continuing medical education at programs that were paid for by pharmaceutical companies. And that's kind of disappeared. The, you know, the vacations and those things haven't been around in my time in medicine. So I'm not sure, you know, where, you know, that doesn't happen anymore. But, you know, pharmaceutical companies still can be an important source of information on new drug developments because there are questions that we need to ask about effectiveness and efficiency of drug regimens that only somebody associated with the pharmacology industry would know, particularly. So, you know, I think there's still a role in there. You know, there's never a kickback. There is never a, you know, we don't get paid for prescribing certain drug or whatever. And as I hear that periodically, and that's just not the case. I'm very glad to hear that. Well, Dr. Flanders, thank you so much for being with us today. I wish we have more time, but we'll come to the end of the show. Thank you for having me.