The courts may have stopped the Feds from enforcing a ban but it seems the US Consulates either haven’t gotten the word that there is no ban or they have been instructed to put one into effect. India is not on the banned list and has never been a source of anything but people who have made great contributions to the US. Nevertheless, young Muslim physicians I recently met have gotten a clear message: “Muslims need not apply”. Stories are circulating in the medical community about visa applications that were formerly routinely approved are now being denied. As a result, Indian Muslim doctors who were planning to come to the US to complete advanced training or go into practice are already considering going to Canada or Europe. One young physician I met was very interested in coming to the US for a Masters in Public Health. He is going to wait to see if the fever of Muslim hate passes, but he is also now looking hard at alternatives. We should not underestimate the damage that is being done by the Trump led attack on the Muslim religion around the world.

AND ON THE FAILURE TO REPEAL/REPLACE

Word quickly reached even the most remote part of India where we are at the moment. Seen from afar the substance of the repeal effort was about the redistributive intents and effects of health reform. Ryan and Trump seemed perfectly willing to take resources from old people and poor people and give them to rich people. The Freedom Caucus wanted to shift benefits to lower middle income people through lower priced insurance. (They have their facts wrong and their solution won’t work but that is what they are trying to do.) The few moderate Republicans realized that a lot of their constituents were getting subsidies under the existing law and they wanted to preserve them. The Democrats got to sit back and make no choices. Different elements of the public figured accurately that the bill would take resources from them and all these pieces added up to huge majority opposed to the bill.

As I noted in an earlier blog, the Republicans needed the “savings” from killing Obamacare to fund part of their tax cuts for the rich plan. The money isn’t there now and Ryan/Trump are wounded. Out rich friends shouldn’t start spending their new money yet.

The US, South Africa and India have at least one thing in common. In all three the States or Provinces have great influence on health care and public health. Granting or leaving significant State power was a key element in the political compromises that enabled each of these countries to be created in their current form.

States in the US assumed primary responsibility for health from the start. Federal involvement, especially in financing health centers and partnering in Medicaid financing is relatively new and the Supreme Court reinforced the power of the States to say “No” when it slapped down the mandatory Medicaid expansion in the Affordable Care Act.

In South Africa and India primary responsibility for health care and public health were assigned to the existing states or provinces or tribal strongholds. The South African national government provides general per capita grants that are used in part to fund province level care and also provides restricted grants for specific programs such as HIV testing and care. The Indian national government also provides earmarked funds for specific national priorities but the individual States carry a greater total burden for financing health care.

As a result, national population health outcome measures are almost useless as indicators of health system performance or guides for national policy action. It is health outcomes at the State level that really tell the stories. In each of these countries the rates vary dramatically from State to State (Province to Province).(Note to readers: When I am not on the road I will create a chart showing the range of population outcomes in each country as a starting point for more detailed examination of reasons for differences.)

In all three countries there are important State/Province level differences in total population and geography, current income and wealth distribution, education, gender inequality, political leadership, ethnic diversity and religion. The quantity and quality of trained personnel varies greatly by State/Province as does the infrastructure for public health and healthcare. However, listing the differences is only a starting point  from which I will need to pursue answers when time and access to more material allows. However, it is going to become clear pretty fast that explanations for the differences are likely to found upstream in social and economic factors. The question will become why social and economic inequity persists among the States in these countries.

Health care is redistributive. Those of us who are healthier and wealthier always subsidize the care—in some way—of those who are sicker and poorer. (Students in my courses hear me say this dozens of times every semester.) What happens when the gap between those who have wealth and access to care is vast? Will those with the resources share with those who lack them? South Africa is the test case. Wealth in South Africa is less equitably distributed among the population than in almost any other country. The Gini Coefficient is about .69 (the higher the number the less equitable the distribution of wealth).

The Constitution of South Africa includes an explicit right to health care for all as a core responsibility of the government. In 2011 the government set the country on a 14 year path to National Health Insurance. The plan has been most completely described in an official White Paper issued in 2016. The goal is to provide equitable access to quality care for everyone by pooling all the money now spent for health care into a National Health Insurance Fund controlled at the National level. All citizens will be required to enroll in the program. Care will be largely free at the point of service. The White Paper calls for the National Fund to purchase clinical services through contracts with reorganized primary care and hospital networks. Public primary clinics that are now run entirely by nurses are expected to expand their scope of services to meet new national standards by hiring or contracting with physicians now in the private sector. The clinics  will be paid capitation fees for the individuals who select them. Hospitals, both public and private, will be paid on a uniform DRG based system. The effect will be an increase in resources for public clinics and hospitals and a significant decrease in prices to private doctors and hospitals who will be expected to make up these losses by serving many more people. The current private insurance companies will have no or minimal roles in future according to the White Paper. Costs will be managed and quality improved through implementation of a sophisticated electronic medical record system. The White Paper includes calls for greater attention to upstream determinants of health and prevention, but the focus is on curative medical care because, as one senior official said: South Africa has an extraordinarily high burden of disease.The tone of the White Paper is aspirational. It calls for a huge transformation but provides no details on how to get from here to there.

Some economists and public health experts think South Africa spends about enough money and has enough health professionals to care for the population if resources can be reallocated.  South Africa spends  8.8 % of its GDP on health, which is about the average for OECD countries. However, 84% of the population relies on a public sector delivery system that consumes about 4.1% of GDP. 16% of the population relies on an entirely separate private insurance and delivery system that consumes 4.4% a bit more than the public sector.

This inequity plays out in stark terms and is the core of the current debate about national health reform in South Africa.  Virtually every conversation, policy paper, newspaper or taxi-cab interview starts with some version of this inequity. For example the Minister of Health recently noted that 80% of medical specialists are in private practice, serving only 16% of the population. He said that one private hospital in Johannesburg has 30 affiliated gynecologists while the entire province of Limpopo in the Northern part of the country has seven South African gynecologists for its 40 public hospitals. (Cape Times, Feb 21, 2017) He said the private gynecologists earn more than five times what the public sector specialists earn but that under National Health Reform, their excessive fees would be reduced and they would take care of more poor people.

How reallocation is supposed to happen is completely unsettled. There are small government sponsored work groups developing specific proposals but none of the issues of governance, finance, operations or professional autonomy have been settled. New policy development is already stalling out in anticipation of a national election that will bring new leadership to the country in 2019.

Every government official and professional level person I met in my recent trip to South Africa has private insurance and uses the private system exclusively. Some shuddered at the thought of their doctors’ offices and hospitals being crowded with new patients. These senior people had considerable sympathy for the plight of those who rely on the public system but in the same breadth indicated that they didn’t want to give up what they now had.

Virtually all public employees and their dependents have some form of private medical insurance. Public employees will have to implement national health insurance policies but  concern for themselves and their families may be more powerful than political appeals for “solidarity” in health reform. They are already moving very slowly on health reform.

Not one of the craftspeople, workers, and small business owners I met has private insurance. Almost all said they “don’t get sick” or use the public system. They said it was “ok”. Spending the whole day waiting on lines was just part of going to clinic or hospital. Residents of a shanty town in Soweto told me they would go to a clinic nearby or to the big hospital—but they have to walk the several miles to get there because they can not afford a taxi. Only one uninsured person told me he had a private doctor whom he paid out of pocket. There was virtually no awareness that the government had proposed something called national health insurance and therefore no expectation that their own access to care might change. For them, South Africa has universal health care. It just doesn’t work very well. My questions to experts about consumer expectations for health reform were met with blank stares.

There is deep and mutual distrust between the public and private sector leaders at the national and provincial levels. However collaboration among the actors is a core component of the proposed reforms. High level government officials argue the distrust can be managed and resolved through stringent contracts. Academics who have studied provincial and district operations on the ground dismiss the possibility of writing and enforcing sophisticated contracts. One of them said: “The people promoting contracting have no idea what actually goes on at the operating level. They have never been there.”

All of the people I interviewed were deeply skeptical that progress would be made toward national health insurance anytime soon. One very senior official who was a prime author of the White Paper suggested I stop thinking about health insurance. Rather, think about delivery system reform. Nevertheless, there was a very strong feeling of optimism that  health equity could be improved among most of my interviewees. They pointed to the successful implementation of HIV/AIDS testing and treatment throughout the country in the public sector. We did that, they all said, so maybe we can fix health equity as well. I hope they are correct.