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martes, 3 de agosto de 2010

In Haiti, a Lesson for U.S. Health Care

Published: July 28, 2010 What may be needed, some have suggested, is for key nongovernmental organizations now offering health care in Haiti to work alongside the government’s Ministry of Health to rebuild destroyed facilities and to better train Haitian doctors and other providers. If the organizations could also cooperate financially by directing some of their budget into accounts run jointly with Haiti’s Ministry of Health, the government could reimburse providers like Dr. Théard for their work, thus removing competition between the foreign doctors and local private doctors. In time, as the Haitian government took control of health care delivery and education, the nongovernmental organizations would fade from the scene.
HAITI’S crisis — and its possible solution — provides a mirror for understanding our own difficulties delivering good health care in the United States. After all, it was a similar tension between private and public medical care that made it impossible for Congress, in passing reform legislation this year, to create a single-payer public health system. Many private health-care organizations — primarily for-profit insurance companies — strenuously resisted it, fearing that if the government suddenly provided high-quality, low-cost care for a significant part of the population, they would lose profits or go out of business. Worries about competition between public and private medicine, in other words, are universal.
It is clear that the American health care system functions at a much higher level than its Haitian counterpart does, but that’s mostly a matter of national wealth. Our healthier economy has allowed us to have a relatively viable private-sector health care system, though there remains tremendous disparity from one economic class to another in infant and maternal mortality and access to basic care. And now, because the growing cost of our health care system is unsustainable, we are faced with the need to consider an alternative.
The Haitian situation also suggests a solution — a way to provide health care for all in the United States without destroying our private medical sector. (This, by the way, was always President Obama’s goal, no matter how the right tried to defame his proposals.)
A public-private partnership like the one contemplated for Haiti could be created here. The government, through the Centers for Medicare and Medicaid Services, could team up with health care systems that provide high-quality care to people of all income levels — Kaiser-Permanente, in California, comes to mind, as does the Mayo Clinic network; the Geisinger Health System, in Pennsylvania; Partners HealthCare, in Boston; and Intermountain Healthcare, in Utah — to provide a public option. Private doctors could be paid for the work they did for the new public entity. People who did not want to join such a health plan could remain with their current private insurers.
Health care systems wishing to be part of the new partnership would have to demonstrate competence as well as fiscal responsibility. Those that did not provide good care at a reasonable price might fail, but in the long run the system could serve the broadest cross section of America, and it could do so without undermining private doctors — or at least not those who are motivated by care itself rather than by mere profit.
Although it is unrealistic to expect Congress to rewrite the health care law to allow for this proposal, there is room within the law for a state or regional pilot project to experiment with public-private medical partnerships.
Dr. Théard’s clinic in Port-au-Prince has not yet closed, but he tells me it is now fighting for its life, with little or no money for salaries, equipment or rent. “We are still open but without any help from any sector,” he said in an e-mail last week. “Equipment needs repair, buildings need repair and we are doing the best we can.”
Haiti’s need to fix its health care system is, if anything, more urgent than ours. But its best solution, a public-private partnership, is one that could easily work for America, too.
James Wilentz is a cardiologist at the Lenox Hill Heart and Vascular Institute.
http://www.nytimes.com/2010/07/29/opinion/29wilentz.html?pagewanted=2&_r=1&sq=Haiti&st=cse&scp=4