Thursday, December 22, 2016

Uncertain Health in an Insecure World – 100

Does Putin-care?

Eponymous references can be complementary – The Marshall Plan (for U.S. General C. George Marshall) was a model of massive resource mobilization to reconstruct post-WWII Europe. But eponyms are often pejorative – the Ponzi scheme (for U.S. Italian immigrant Charles Ponzi) symbolizes a seemingly legit investment model operated by a swindler.

Recall, Nazism was never eponymized as Hitler-ism.

The Atlantic magazine dubbed Obamacare the “grand bargain” of modern U.S. domestic policy. This eponym was coined by the plan’s Republican opponents in order to attach incendiary linkages to socialized medicine. In the 2010 U.S. mid-term Tea Party election, it almost worked! Donald Trump’s campaign drumbeat to “repeal and replace” the policy resonated successfully with much of his electoral base. But the present President and his loyal supporters still view The Accountable Care Act as his greatest enduring legacy.

Like life, literature is replete with examples of ironic adoration and sarcastic perjoration, often imbuing characters with a skewed sense of their actual role in events.

In The Cancer Ward (published in English, 1968; published in Russian as Rakovy Korpus, 1991), 1970 Nobel Prize winning author Aleksandr Solzhenitsyn deftly weaves the dark course of a terminal disease with the decay of Soviet society under ruthless Stalinism.  Like the novel’s protagonist, Oleg Kostoglotov, Solzhenitsyn was exiled to a Kazakhstan gulag under Article 58 (above), and officially rehabilitated in 1957. Shortly after his release, like Oleg, Solzhenitsyn was diagnosed with terminal cancer. For decades after Stalin’s death in 1953, the prognosis for the Soviet Union remained as bleak as that of a malignant tumor.

An “evil man” at the zoo had thrown tobacco in the Macaque Rhesus monkey’s eyes, blinding it.

President Vladimir Putin met briefly with a frail Solzhenitsyn before the author’s 2008 death from heart failure.

In 1991, Vladimir Putin retired from the Komitét gosudárstvennoj bezopásnosti (KGB) as a lieutenant colonel. Not a model KGB operative, Putin was relegated to posting in East Germany until he was rescued by President Mikhail Gorbachev. Twenty years later, and coincident with the launch of Obamacare, Putin announced his own ambitious Russian public healthcare policy reforms that did not (until today) ever reference his name.

Obamacare and Putin-care were separately and nearly simultaneously launched!

Since the 1980’s, the quality of healthcare and availability of medical technology in The Russian Federation fell far below the standard of other western developed countries. Russian healthcare spending per capita lagged behind Europe at US$158 per year. In 1996, like other European countries and most of the former British Commonwealth, Russia passed a law providing Mandatory Medical Insurance – nationwide socialized medicine for socialists, at long last.

During Putin’s first two terms as President (2000-2008), the Russian economy boomed. Putin was named 2007 Time Magazine Person of the Year. But in 2007, the OECD also reported that Russia’s public healthcare transition to a more decentralized, contested and insurance-based system remained stalled (purple line below). 

In 2011, then Prime Minister Putin pledged a US$10 billion healthcare investment (above), partly by boosting the obligatory employer contribution to compulsory medical insurance from 3.1% to 5.1%. This tax infused the funds needed for a May 2012 Decree to double healthcare staff wages by 2018. In 2013, there were 9.3 hospital beds per 1,000 person population in Russia – twice the OECD average. By 2014, higher wages increased healthcare employee costs, prompting the closure of 15 Moscow hospitals. 

After a term limit hiatus, Putin was re-elected as Russian President in March 2012. Soon thereafter, he ordered tanks into Crimea. Crippling sanctions hit Russia’s economy hard as the 2014 Sochi Winter Olympic Games unfolded. Despite his dodgy global record in Ukraine and Syria (or because of it?), Putin has been ranked #1 on Forbes Magazine annual list of most influential people in The World since 2013. 

In 2015, Mark Britnell exposed the modern Russian healthcare system’s vulnerability in In Search of the Perfect Health System. In 2004, per capita healthcare spending was US$441, or 4.4% of GDP. By 2013, Russian healthcare expenditures had doubled to US$957 or 6.5% of GDP. Under Putin’s Decrees and reforms, private medical clinic chains like Doktor Ryadom (below) treat some patients at low cost under the official public insurance plan, while legally charging other patients higher fees to generate a profit.

Despite this higher public spending and the creation of a public-private mosaic model of healthcare financing, in November 2016 the OECD reported that Putin’s reforms have actually worsened the Russian healthcare system, with broadly deteriorating population health status. The system remains too complex. The country’s >300 private insurers remain inefficient as purchasing groups. Reimbursement rates fail to cover the costs of care. The informal payment system, like the barter system used in The Cancer Ward, still permits “line jumping” that improves healthcare access for the wealthy and the privileged.

Mr. Britnell reflected that the Russian constitutional right to healthcare is “blocked by opaque and bureaucratic systems of (public) planning and regulation”, at both the federal and state levels
Just what’s a poor sick Russian to do?

Since mystic faith-healer Grigori Rasputin (above) tended to the sicklier and more anxious of the last Romanovs, alternative medicine has had a prominent role in Russian healthcare. Today, alternative medical providers operate in the shadows, practicing homeopathy at best and alchemy at worst. In remote regions and rural villages outside of the healthcare system mainstream, they peddle listening devices, herbal creams and nutritional supplements that promise to restore good health and cure various “dependencies.” Home remedies abound, used by millions of Russians who do not trust flu shots, but who firmly believe in their grandmother’s home cures – raspberry tea, chicken soup, and steam infusions made from boiled potatoes.

In 2008, there were 621,000 doctors and 1.3 million nurses employed by the Russian public healthcare system. Russia has since become a popular European location for medical education. Students flock from non-communist countries around the world, largely because tuition is affordable and the curriculum often uses English language instruction. Russian medical degrees (M.B.B.S.) are recognized globally, and are highly rated by UNESCO and WHO.  In 2016, Lomonosov Moscow State (below) was listed among the world’s best medical universities by QS World University Ranking.

In March 2012, during the politically rancorous heyday of early Obamacare implementation, then Russian President Dmitry Medvedev and Barack Obama had a chummy chat into an open mike, during which Obama asserting greater post-reelection “flexibility” to deal with global issues like missile defense. By contrast, at the 2016 G20 Summit in China, Putin and Obama exchanged a Syrian foreign policy/U.S. election hacking death stare (below).

Pending a post-election Trump Administration reversal, Obamacare rolls on and U.S. sanctions continue to crush the Russian economy.

It can be fairly stated that all that The World’s two most powerful people share in common is incomplete healthcare policy reform. For different reasons, neither Putin nor Obama will see their bold healthcare reform plans fully implemented.

Both men have handily won multiple national presidential elections.

But in the process of governing, through global chess moves, both men have achieved mutually assured domestic legacy destruction!

We in the Square call "Checkmate"!… Now enter Trump to flip over the playing board.