Sistemas de Saúde: a escolha entre o privado e o público

março 20, 2017.

Em sua edição do último sábado (18/03/2017) o jornal The New York Times publicou um texto tão extraordinário quanto surpreendente com o título “A liberdade (de escolha) enganosa do Sistema Americano de Saúde” – The Fake Freedom of American Health Care. Escrito pela Sra. Anu Partanen tem a vantagem de discutir questões essenciais sobre a oferta de serviços de saúde sob o ponto de vista de um cliente, talvez se possa dizer de um paciente, ou de uma vítima dos sistemas de saúde. Embora tenha como foco o sistema de saúde dos Estados Unidos da América com base na atual proposição do governo republicano de Donald Trump de acabar com o Obamacare, o sistema implementado por seu antecessor, o texto é um libelo que se aplica a múltiplas realidades de muitos países ocidentais e de seus habitantes que desejam, em última análise, contar com serviços de saúde que os protejam principalmente quando estiverem doentes e sem forçosamente jogá-los na miséria.

Lançando mão de sua experiência pessoal em anos de residência na Finlândia, a autora compara os sistemas de saúde dos dois países: um essencialmente público que presta cuidados a todos os finlandeses, e outro radicalmente privado, onde é preciso pagar – e muito caro – para ser atendido. Questões que fazem parte do dia a dia de boa parte da população brasileira podem ser encontradas no texto (p.ex., as armadilhas colocadas em nosso caminho pelos Planos de Saúde, o acesso a serviços essenciais justamente quando a pessoa está fragilizada pela doença). Ao final ela apela aos republicanos para que considerem a hipótese de apoiar a construção de um sistema público de saúde nos Estados Unidos, o que se afigura como um desejo absolutamente inviável.

Mundo Século XXI resume a seguir alguns dos pontos mais significativos da matéria, em tradução livre a partir do original que, em inglês, é incluído ao final. Para acessá-lo o endereço é: https://www.nytimes.com/2017/03/18/opinion/the-fake-freedom-of-american-health-care.html?_r=0

**“A enganosa liberdade (de escolha) do Sistema Americano de Saúde” – Página de Opinião – The New York Times **

Na última semana o apartidário Departamento de Orçamento do Congresso estimou que o novo plano de saúde dos Republicanos aumentará o número de americanos sem seguro de saúde em 24 milhões de pessoas na próxima década, principalmente devido a mudanças nas regras (de acesso), nos subsídios e na cobertura do Medicaid, o que tornaria o sistema demasiado dispendioso para elas.

Os líderes republicanos parecem não se perturbar por isso porque, em suas cabeças, a decisão de não ter um plano de saúde porque é muito caro é um exercício de liberdade individual de escolha. Como declarou Jason Chaffetz, representante republicano por Utah, “os americanos fazem escolhas. Ao invés de comprar um novo iPhone que eles amam e gastar centenas de dólares nisso, quem sabe eles decidem investir na atenção à própria saúde?”

Segundo essa lógica, comprar cuidados de saúde é a mesma coisa que comprar qualquer coisa. Os Estados Unidos possuem as melhores escolas de medicina do mundo; os melhores médicos, institutos de pesquisa, hospitais e se você tiver dinheiro para custear os procedimentos de que necessita, sem dúvida terá o melhor à sua disposição. No entanto, este enfoque gera extremas desigualdades, pois este é o custo da liberdade (no caso, sem controle).  Essa modalidade tão peculiar de ver o conceito de “liberdade”, típida dos republicanos, obriga muitos americanos a gastar não apenas dinheiro, mas também tempo e energia, angustiados com a atordoante logística de cobertura e tratamento – planos confusos, preços de mensalidades exorbitantes, redes exclusivas de prestadores, exames e testes complementares misteriosos (e por vezes desnecessários), medicamentos com preços abusivos. E mais frequentemente do que raramente, as escolhas individuais são severamente restringidas por decisões tomadas por empregadores, seguradores, médicos, companhias farmacêuticas e outros atores privados. Tais grupos de interesse, e não o consumidor, decidem quais os planos estão disponíveis, o que esses planos cobrem, quais médicos os pacientes podem consultar e quanto tudo isso custará. E eu sequer mencionei os milhões de americanos que não ganham o suficiente para pagar por um seguro ou um tratamento que lhes salve a vida (de emergência). Se você não pode pagar, não comprar é uma dura escolha.

Oito anos atrás mudei-me para a Finlândia, país que investiu em um sistema universal de saúde, financiado por impostos e manejado pelo Estado. Lá nunca me preocupei em saber de onde provinha minha assistência médica ou se eu poderia pagá-la. Eu pagava meus impostos – mais ou menos o mesmo que pago em impostos e taxas federais, estaduais e municipais morando na cidade de New York – e se precisasse consultar um médico contava com múltiplas opções. Se eu escolhesse uma clínica pública, isso me custaria um pequeno co-pagamento, usualmente em torno de 20 dólares, mas se estivesse grávida teria tudo gratuito. Poderia também optar por um clínico particular, contando para tal com subsídios públicos. Tudo funciona sem que se precise assinar algum contrato ou comprar um plano de saúde. Todos os finlandeses estão cobertos automaticamente por todos os cuidados médicos de que necessitem, independente do seu emprego ou de seu rendimento.

Trump chamou o sistema nacional de saúde canadense de “catastrófico”. De acordo com a ortodoxia republicana o governo sempre despreza a capacidade de escolha dos indivíduos e em seus serviços os tempos de espera são longos e a qualidade dos serviços é horrível. Mas, estão os republicanos certos a esse respeito? Praticamente cada uma das bem sucedidas democracias capitalistas ocidentais decidiu adotar alguma forma de atenção universal à saúde implementada pelo governo, considerando-a como a forma mais efetiva. Segundo a OCDE (Organização para Cooperação e Desenvolvimento Econômico) os Estados Unidos como um todo não superam os demais em qualidade da atenção à saúde. De fato, os EUA têm uma menor expectativa de vida, mais alta taxa de mortalidade infantil, menos médicos per capita que outros países desenvolvidos. Ocupa posições secundárias, p.ex., em sobrevivência por câncer de mama, câncer coloretal. Os americanos superam por larga margem os outros países da OCDE em termos de gastos com saúde, com resultados inferiores.

O problema com um enfoque de livre mercado é que a atenção à saúde é uma imensa, complexa e dispendiosa indústria, na qual os indivíduos raramente têm poder de mercado. Por seu lado, o ponto em que se baseia a cobertura universal em saúde é partilhar o risco para prover máximo benefício às pessoas quando precisarem de cuidados. Responsabilizar o governo por esse complexo sistema não significa impedir a escolha por parte do indivíduo; na verdade é o oposto: dar-lhes opções mais amplas. Organizar o setor saúde é uma tarefa assoberbante e ter uma entidade especializada para dirigir as negociações, regulamentar e por vezes prover serviços é muito mais eficiente do que forçar a cada um a assumi-la por si só.

O que acontece com o sistema de saúde americano hoje não faz com que me sinta mais livre e autônoma. Tendo que administrar os muitos aspectos envolvidos por mim mesma, lidando com a profusão de planos de saúde, preços e a dificuldade em conseguir consultas e marcar os exames acaso disponíveis com bons profissionais da minha rede credenciada, tem me deixado, assim como um grande número de outras pessoas, num estado de constante estresse. E isso que ainda não fiquei seriamente doente ou tive qualquer acidente grave. Gostaria de saber que o sistema automaticamente tomará cuidado de mim e de minha família, sem que eu tenha de enfrentar uma batalha para conseguir atendimento em meus momentos de maior necessidade e debilidade. Isto sim é liberdade, inclusive de saber que ninguém, por adoecer, irá à falência.

[caption id="attachment_3836" align="aligncenter" width="128"] is 1 2 Sistema de saúde norte-americano e a proposta dos republicanos[/caption]

The NYT - The Opinion Pages The Fake Freedom of American Health Care By ANU PARTANEN MARCH 18, 2017

Last week the nonpartisan Congressional Budget Office estimated that the new Republican health plan would increase the number of uninsured Americans by 24 million people within a decade, mostly because changes in regulations, subsidies and Medicaid coverage would make insurance too expensive for them.

Republican leaders seem unfazed by this, perhaps because, in their minds, deciding not to have health care because it’s too expensive is an exercise of individual free will. As Representative Jason Chaffetz, Republican of Utah, put it: “Americans have choices. And they’ve got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care.”

There is an appealing logic to such thinking. The idea is that buying health care is like buying anything else. The United States is home to some of the world’s best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care. This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere. Such is the cost of freedom. As House Speaker Paul Ryan put it in a tweet: “Freedom is the ability to buy what you want to fit what you need.” Vice President Mike Pence picked up that baton: “Obamacare will be replaced with something that actually works — bringing freedom and individual responsibility back to American health care.”

In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment — confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices. And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost. And I haven’t even mentioned the millions of Americans who don’t earn enough to pay for insurance or a lifesaving treatment. If you can’t afford it, not buying it is hardly a choice.

Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes — which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City — and if I needed to see a doctor, I had several options.

For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home. If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.

If I had wanted to, I also could have easily paid to see a private doctor on my own, again with the help of public subsidies. All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.

Republicans are fond of criticizing this sort of European-style health care. President Trump has called Canada’s national health care system “catastrophic.” On CNN recently, Senator Ted Cruz gave multiple examples of how patients in countries with universal, government-managed health care get less care than Americans.

In Europe, he said, elderly people facing life-threatening diseases are often placed in palliative care and essentially told it’s their time to go. According to the Republican orthodoxy, government always takes away not only people’s freedom to choose their doctor, but also their doctor’s ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.

But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. According to the latest report of the O.E.C.D. — an organization of mostly wealthy nations — the United States as a whole does not actually outshine other countries in the quality of care.

In fact, the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries. When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world — but that’s barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries. In breast cancer survival, for example, the United States comes in second, after Sweden. Third-best is Norway, then Finland. All three countries have universal, government-run health care systems.

For colorectal cancer, the five-year survival rate after diagnosis in the United States brings it to a not very impressive ninth place in the O.E.C.D. statistics. Ahead of the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care. And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd. Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.

Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that’s not necessarily the case either. A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That’s a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.It’s not just American patients who endure endless bureaucratic hassles. American doctors were also significantly more likely to report as major problems the amount of time they spent on dealing with administrative burdens related to insurance and claims, as well as on getting patients medications or treatment because of restrictions imposed by insurance companies, compared with doctors in most of the other 10 countries studied — including Sweden and Britain.

Overall, Americans spend far more of their hard-earned money on health care than citizens of any other country, by a very wide margin. This means that it is in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone.

What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven’t even been seriously sick or injured yet.

As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.

Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America’s corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. Would this mean they would have to pay more in taxes? Possibly.

Many countries require employers and employees to contribute to the health care system through payroll taxes, more than the United States does. But again, Americans are paying far more for health care than anyone else, and America’s businesses are stuck managing this mess. It’s true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done. In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It’s a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies — a policy that has led to lower drug prices in those countries. Americans today are paying vastly more in money, worry and hassle for the same, and sometimes worse, care than people in other wealthy capitalist democracies. Some Americans have coverage that serves them well, but judging by the current mood, the number of Americans who think the system needs to change is growing. No health care system is perfect. But in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.

Tags: [Obamacare, Plano de Saúde, Republicanos, Saúde públlica ou privada, Sistema de Saúde, Trump]