THE BUS TO OZ

(Originally published at EisenhowersLastSmoke.org on 7/15/2013)

The summer after I turned 12, I went to camp somewhere in upstate New York. My mom took me to stay with my grandparents in Brooklyn , and then my grandfather (remember Ike) drove us to the city to meet up with the bus to camp. I had spent a lot of holidays and long weekends in Brooklyn, and had hardly been to any other part of New York, city or otherwise.

I remember the car ride to that bus clearly. I remember literally wishing it would go on forever. Not that riding around with my mom and grandparents was my tween ideal of a good time, but I was terrified of getting out of the car, and starting the new adventure I was about to have. Sleep away camp. For eight weeks. On my own – no sister with me, no school friends, no friends of friends. I wanted to go to camp, but I dreaded getting on that bus.

That 7th-grade feeling returned this past weekend, as I packed and repacked for my Eisenhower Fellowship to Australia, New Zealand, and Singapore. I’ll hit about 10 different places in at least three climates over about five weeks. I’ll meet dozens of new people, and I’ll probably spend a lot of time alone.

Don’t get me wrong, I want to go on the fellowship. In fact, I cannot believe how lucky I am that I was chosen to have this experience or that I have such a supportive family and employer to enable me to do it.  But traveling across the world, to a place I’ve never been, on my own, is frankly, as terrifying as it is exhilarating.  Actually, more terrifying.

The plane ride to L.A. is like the car ride to the bus. I’m packed. I’m going. It’s really here and this is really happening. And now, all I can do is put one foot in front of the other. Follow my itinerary. Get to my hotel. And start exploring Australia and its health care system in search of ideas and insights to bring back home.

One of the best things my mother taught me was that I could always come home. Whenever I left on any trip or adventure, of which there have been many, my mom has always assured me that I could come home if it was terrible. And I’ve always believed her, that if I needed to bail, there’d be no judgment, and maybe even plane fare or a ride. But of course, I’ve never taken her up on it.

So Oz, here I come. One foot in front of the other. A laptop, a camera, a notebook, (yes, like with paper inside), and way too many outfits.  But did I bring enough shoes?

EISENHOWER'S LAST SMOKE - THE NEW ZEALAND EDITION

(Originally published at EisenhowersLastSmoke.org on 7/11/2013)

Credit: Jennifer Hill http://www.jhilldesign.com/collections/new-zealand

Credit: Jennifer Hill http://www.jhilldesign.com/collections/new-zealand

“How can I convince you to come visit New Zealand when you’re in Australia?” asked Eisenhower Fellow and a member of the New Zealand parliament, David Clark (@DavidClarkNZ). I have to admit it didn’t take much. Having been to New Zealand once before, I remember the lush scenery, delicious seafood, and collective obsession about the national rugby team. I also remember someone telling me that New Zealand has more sheep than people. (It turns out that is true: http://datamarket.com/featured/man-vs-sheep-new-zealand-myth/)

The New Zealand health care system is a primarily public system, with about 1/3 of the population buying private insurance to have a broader choice of clinicians [or treatment sites] and shorter wait times. The population – just about four million people (with nine times as many sheep) – is two-thirds of European descent and 15% Maori, the indigenous people of New Zealand. Notably, the Maori people are reported to have greater challenges accessing health care, with almost a quarter of Maori adults reporting that cost prevented them from seeking primary care.

So it’s not a perfect system. However, in a Commonwealth Fund exploration of seven industrialized nations, New Zealand ranked #1 in patient-centered care, with Australia at #2 and the US, not surprisingly, bringing up the rear at #7. And, they have the lowest per capita expenditure in this set, spending about 1/3 the amount of the US per capita.

As health care leaders in the U.S. talk a lot about “patient-centered” care without always, you know, involving the patient, I am keen to find out what puts New Zealand in the top spot.

It’s also pretty cool to spend time with a member of parliament, particularly one who is committed to addressing issues of social mobility and reducing the wealth gap. Social and economic inequalities are fundamental contributors to the U.S. health system’s dysfunction, and New Zealand may have things to teach us here too.

AUSTRALIA: BUILDING CONSUMER CAPACITY FOR HEALTH CARE DECISION-MAKING

(Originally published at EisenhowersLastSmoke.com on 7/7/2013)

Credit: Jennifer Hill, creator of the series, Places I've Never Been.  http://www.jhilldesign.com/products/a-toast-to-australia

Credit: Jennifer Hill, creator of the series, Places I've Never Been. http://www.jhilldesign.com/products/a-toast-to-australia

My first question to Australian Eisenhower Fellow David Flanagan (@DavidFlanagan_) when we met on a chilly April morning in Philadelphia at the Eisenhower Fellowships opening session was uninspiring. “How cold does it get in the winter really?” Not that I was regretting my timing to visit Australia in its winter season or anything…”Let’s just say that this morning I went for a walk,” replied David, “and it was the coldest I’ve ever been in my life.” I was delighted to hear that a cool Philadelphia spring was worse than all the Australian winters of David’s life!

A few hours later, he stood up to introduce himself and explained that he believed the success of the iron-ore mining company which he had founded was based in part on the way in which they had engaged their community in the business. Not in a superficial public relations sort of way, but rather in an authentic and comprehensive manner that demonstrated a genuine respect and concern for the company’s neighbors. I leaned over to my husband who was sitting in on the introductions and said, “And that’s why I’m going to Australia!”

It seems that Australians have a culture and collective philosophy of civic engagement that transcends industry or issue. At least a subset of consumers in Australia actually believe they have a voice in issues that affect them, and that corporations and government agencies facilitate that voice. The Australian government is focused on “capacity building to enable individuals to exercise control in their environment and make appropriate health choices.”  Australian health policy focuses on social determinants of well-being as well as physical and mental health, placing individual decision-making in the broadest possible context of health. The International Association for Public Participation (IAP2) is active in Australia, with certificate programs and public participation practitioner training to support government and corporate public engagement initiatives. Less obvious and more day-to-day, I’m told that when you ride in Australian taxi, you sit in the front seat, signaling equality between driver and passenger. Does that hold in the doctor-patient relationship as well?

Structurally, Australia’s health system combines a national health insurance plan, Medicare, with a private market for individual insurance, which gives subscribers more choices and more services. The government uses a mix of carrots and sticks to make sure people who can afford private “cover”, as it’s called, buy it. For example, if you buy private health insurance by age 30 you pay a lower premium for the rest of your life; each year after 31 that you sign on adds 2% more to the price of your health insurance. Moreover, high-income individuals who do not purchase private cover pay a Medicare surcharge.

And the Australians get impressive results. They spend approximately 9% of their GDP on health care, and they think it’s high. Of course, everything’s relative. Australia spends HALF what the U.S. spends on health care as a percent of GDP. Imagine what America could do with 9 points of GDP to invest in say, education, infrastructure, or technology?

Australians’ life expectancy is higher than Americans’ by about 3 years. At first blush that doesn’t sound like a lot, until you think about in terms of your own life or the lives of your loved ones. And their infant mortality is lower, at just over 4 deaths per 1000 live births compared to our 6[1]. Again, not a huge number until you think of two American babies who don’t survive their first year despite the good fortune to be born in one of the wealthiest nations in the world.

Though the Australian system should generally be a point of pride, there is an asterisk next to the national health care record. Australia’s indigenous people, who comprise about 2% of the population, have a life expectancy approximately 15 to 20 years shorter than the national average, and disease burdens estimated at three times greater.  But Australians are facing the issue. There is a campaign, for example, called Close the Gap, devoted to closing the health and life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians within a generation.  The Australian Department of Human Services has developed a dedicated help line and outreach strategies for Aboriginal and Torres Strait Islander people.

It should also be noted that Australians are not universally happy with their system. A doctor I contacted when I was planning my trip reported “disgust” with the way her father-in-law had been treated during a recent hospitalization. And a public involvement expert I plan to meet, Max Hardy of Twyfords ( http://www.twyfords.com.au/about-us/our-people/max-hardy) has suggested that Australia may be behind in consumer engagement. And he understands how vital it is. “Think of any challenge in our health system.  Including consumers in a meaningful way is all about addressing those challenges more effectively.”[2]

However imperfect the system may be, there should be much to learn from the Australians. As we approach 2014, approximately 12 million Americans are about to encounter the American individual market via health insurance exchanges. It’s a good time to understand what makes their individual market work, with approximately 50% of Australians buying in. Additionally, Australia manages to provide a universal safety net to provide for all citizens at a significantly lower cost. Even with that, they have marked disparities between their Aboriginal population and others, and they seem committed to doing something about the inequality. Here too, there should be much to learn about how to be sure the benefits of a high-functioning health care system accrue to low-income and minority populations, too.  And with 48 meetings scheduled and counting in four cities over 15 days, I should have a lot to report. Stay tuned!

[1] https://www.cia.gov/library/publications/the-world-factbook/fields/2091.html

[2] “Busting some myths about consumer and community engagement in health decision-making,” Melissa Sweet, Croakey, Nov. 16, 2012

BANISHING INSULARITY, PATRIOTICALLY

(Originally published at EisenhowersLastSmoke.com on 7/4/2013)

On this Fourth of July holiday, while Americans celebrate our nation’s independence and an excuse to eat juicy hamburgers with minimal guilt, I am packing for a trip that will take me pretty much as far from the U.S. as possible.  In just a week, I’ll be setting off on my five-week journey to Australia, New Zealand, and Singapore to study their health care systems and what role consumer empowerment has in the effectiveness of these systems.

Image 7-28-17 at 2.25 PM.jpg

Why go anywhere else? Don’t we have the “best health care in the world?” While I hear this notion quite a bit, most often from elected officials in political debates, data abounds to the contrary. The U.S. ranks #37 on the World Health Organization’s World Health Report, two slots above Cuba and 32 slots below Malta, a set of islands south of Sicily, and a member of the European Union.

Need more to go on? Well, the U.S. spends 18% of our GDP on health care , which is almost double the average spent in Organisation for Economic Co-operation and Development (OECD) countries and a third more than the next most spendy country, the Netherlands. Yet, in the U.S. we have 45 million people without health insurance. We rank 33rd in the world for life expectancy. And we rank 34th in the world in infant mortality: we have almost 7 deaths per 1000 live births per year[1] . (We’re just behind Cuba on this one.)  If you’re not a data wonk, then I invite you to think about your own experiences at the doctor’s office, hospital, or on the phone with an insurance company. Tell me your experience feels “best in class”. (Seriously, tell me: I’d love to know where that is). According to Gallup, 67% of Americans rate their health care coverage as excellent or very good[2]. That's not too bad, but we could do better. If that were a test score, it'd be a C- at best.

The chest-thumping patriotism espoused by politicians – “We’re the best in the world” – strikes me as a funny expression of love for country. If we’re truly invested in our country and our kids, a more nuanced approached might involve recognizing our weaknesses and taking examples anywhere we can. So,  I am going to see what’s happening in a few of these countries that are beating us on these lists. And patriotism aside, I’m wicked competitive. I take our wholly mediocre health performance personally.

Image 7-28-17 at 2.23 PM.jpg

I’m certainly not the first one to get this idea. In search of a health care system that works better than ours in the U.S., author T.R. Reid set out on a similar journey, which he chronicled in The Healing of America.  He quickly realizes “better than ours” does not sufficiently narrow down his choice of destinations! Reid actually dedicates his book to President Dwight D. Eisenhower, citing Eisenhower's willingness to use the best ideas, wherever they may have come from, as his own inspiration. Eisenhower reportedly demanded bigger thinking and better ideas for the U.S. interstate highway system based on what he had seen of the German autobahn. No matter that Germany had been an American enemy or that he observed the superior German highway system while at war. Their way worked better, and we ought not settle for less.

Many of us curse the number of cars that fit on these superhighways as we travel to our July 4th destinations. But the fact is, we have a better highway system because someone had the vision and pragmatism to look abroad for ideas and then to do the most patriotic thing possible: insist on the best for America.

To that end, I’ll go back to packing for a trip looking for ways to engage Americans in their health care. Over the next week I’ll post more about where I’m going and why, and in the meantime, you can get a preview here.

I’m also looking forward to grabbing a burger. Happy 4th, everyone!

[1] "CIA – The World Factbook: Infant Mortality Rate"Archived from the original on December 18, 2012 (Older data). Retrieved May 15, 2013.

[2] http://www.gallup.com/poll/159455/americans-satisfaction-health-coverage-slips-slightly.aspx