What Can China’s Healthcare Dystopia Teach the U.S. About Our Future?

What does a healthcare dystopia look like?

In my recent TED talk, I introduce you to a world where people die waiting for healthcare, where corporate interests reign, and where doctors get paid to do more rather than to the right thing.

I’m a Chinese-born, American-trained physician. A couple of years ago, I was given an opportunity to conduct a research project on China’s healthcare system. I traveled to 15 cities from Beijing to Inner Mongolia, visited over 50 hospitals, and had unprecedented access to doctors, medical students, nurses, administrators, and government officials. Given how China’s developed into a major world power, I expected to find a fair, functional system.

However, instead of this utopia, I found a dystopic world. People spoke about the 1980s, when universal healthcare was dismantled, and 900 million people lost coverage overnight. Everyone had a story of friends and family who died in front of hospitals because they couldn’t pay.

Doctors were unhappy too. Imagine you’re a doctor, and you trained all your life to listen and heal; suddenly, overnight, you’re a businessman and you have to work your patient to get every cent.

On the other hand, if you’re a well-off patient and you hear that poor people get denied services, what do you want for yourself? You want everything to be done. Because you have the money, nobody will tell you about the risk of radiation of a CT scan. Same for expensive but untested medications, or potentially dangerous procedures. People got what they wanted, but at what cost?

No doubt, China has been very successful. The government has lifted millions out of poverty. But there is a fundamental problem, a blind spot that’s been missed in the rush towards economic reform.

This blind spot is our belief that being a consumer enables choice, and that choice is power. I’m all for empowering people to have choices. But turning patients into consumers means that healthcare is a commodity, not a right. It becomes possible to deny life-saving treatment, and to sell unnecessary, even harmful, interventions. The doctor-patient relationship becomes a transaction between salesman and client.

That blind spot, and the consequences, are not unique to China. Here in the U.S., costs of healthcare are escalating out of control. While millions remain uninsured, 30% of all tests and treatments are done are unnecessary. It’s far more profitable to peddle drugs than prevent illnesses. According to the New England Journal of Medicine, 94% of doctors have some affiliation with drug and medical device companies.

By no means am I romanticizing the pre-1980s Communist state. My family left on political asylum, and I am very grateful for the opportunities afforded to me by my adopted country. But capitalism doesn’t have to equate consumerism, and the beauty of a democracy is that we as citizens can decide what type of society we want to live in.

To prevent further problems in our country, and to stop the rest of the world from following us down this path, we have to make a difficult decision. We must decide if it’s important to us to preserve our core tenets of liberty, democracy, equity, and justice. If not, we know what the dystopic future will look like. If so, the time is now to decide that there are some things that are not for sale, and that we must realign incentives to help people be their best selves.

Rebranding “Patients” as “Healthcare Consumers”: Tread with Extreme Caution

On Monday, I had the privilege of serving as the keynote speaker for an excellent conference in Boston. Empowering Healthcare Consumers: a Community Conversation brought together an impressive array of people to discuss how to improve healthcare through empowerment. In attendance were over 150 community leaders, clinicians, hospital administrators, insurers, advocacy group leaders, and patients.

Patients—or I mean healthcare consumers? The conference organizers specifically requested that I use the terminology of “healthcare consumer” rather than “patient” in my presentation. Several of the speakers before me made the point eloquently as to why: “patient” has the connotation of passivity, and people need to be active to take charge of their health. We need to be savvy consumers and do our own research into the cost and quality of healthcare, much the same way we would if we were shopping for a new car.

The new language made me uneasy. Don’t get me wrong; I am all for people being empowered in their healthcare (I write a blog and published a book on this), and for transparency and availability of information to make informed choices. However, I also believe that healthcare is a human right. A patient deserves healthcare as a right. But does a consumer?

Those of us in favor of universal access to care argue that healthcare is not a commodity like cars and TVs. Using the language of people being consumers could undermine this fundamental tenet. If you are shopping for healthcare in the same way you shop for your car or TV, this implies that you buy what you can. (Can’t afford a new Lexus? Buy a used Toyota. Maybe wait a year.) This doesn’t—and shouldn’t—work for healthcare. (Need heart surgery? Choosing the “discount” surgeon, or waiting a year, don’t sound like good choices.) Those who can’t afford healthcare are priced out of it, and healthcare is no longer a public good, like public education and clean water.

I also worry about effects of rebranding on the physician-patient relationship. What happens when the doctor becomes the hired consultant of the savvy shopper patient? Perhaps the doctor will be more responsive to consumer demands—but perhaps this doctor will also feel more obligated to give the consumer exactly what he wants, including unnecessary tests and harmful procedures. And will these physicians still retain their sense of social responsibility, when healthcare is reduced from societal obligation to personal choice?

An extreme version of patient-as-consumer can be found in China, where people routinely pay their doctors under the table as promise to receive better care, and patients—even those dying of stroke and heart attack—are turned away from hospitals if they cannot pay upfront for their treatments. The physician-patient relationship has broken down so much that doctors have been murdered by angry patient families.

In such a system where it’s every man for himself, it’s hard to convince people that healthcare is something we all have to safeguard. We already live in a society where many believe that more is better—at least when it comes to ourselves. When making healthcare decisions, few take into account the cost to society. Yet, healthcare is not a limitless commodity. There are efforts underway to think of the escalating cost of healthcare as we do global warming; these efforts will not work if we adopt the language of consumerism.

So what is to be done? Here’s a suggestion. Instead of throwing out the word “patient”, change what it means. Encourage people to become the educated, empowered patient, even, dare I say, the pushy patient. This is the patient who will make individualized choices about her health as an active and equal partner with her doctor. This is the patient who will ensure the best possible care for herself and, in so doing, catalyze reform of our healthcare system to one that values informed decision-making and reaffirms health as a basic right.

What the U.S. Can Learn from China’s Health Care Reform

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, 4.5 RMB, 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.