Monday, May 11, 2009

Here's To Your Health(care)

The photo was taken by Elisa Young from her yard and is referred to in the second comment below.

The quest for certainty blocks the search for meaning. Uncertainty is the very condition to impel man to unfold his powers.

---Erich Fromm

The lesson which life repeats and constantly enforces is "look under foot." You are always nearer the divine and the true sources of your power than you think. The lure of the distant and difficult is deceptive. The great opportunity is where you are. Do not despise your own place and hour. Every place is under the stars, every place is of the world.

---John Burroughs

A single atom of the sweetness of wisdom in a man's heart is better than a thousand pavilions in Paradise.

---Abu Yazid al-Bistami

I'm trying to learn about health care, attempts to reform, single payer and other alternatives. I'm not very good at figuring things like this out, and I've put it off hoping smarter people would get it right for me. Currently I'm catching up with an article by Shannon Brownlee from an AARP magazine last summer that's been laying around. Ms. Brownlee's article turns out to be online too, and I recommend it. Just read the first paragraph and I think you'll want to continue. Her book, Overtreated: Why Too Much Medicine Is Making Us Sicker And Poorer, apparently has caught on, at least with policymakers.

I hadn't planned to write anything about this now...but I guess I can't wait---even until I finish that article. Obama's getting after it today, and this president moves fast. After living under the last administration that did nothing fast, except go on vacation and get us into wars, this new one is a real culture shock. During his hilarious speech the other night at the White House Correspondents' Dinner, President Obama said his first 100 days went so well that he plans for his second 100 to be completed in 73 days.

From what I can gather, Obama's plan this afternoon will follow the same lines that Shannon Brownlee has been developing. We need to trim the current system and practices before moving into some more radical approach. He thinks savings of 2 trillion dollars is a realistic goal. If this is the direction the country will move in health care reform, we need to be paying attention right now.

This morning Paul Krugman has a column in the NY Times anticipating this precise development. To save us all time and preserve it, here it is~~~

The New York Times
May 11, 2009
Op-Ed Columnist
Harry, Louise and Barack
Is this the end for Harry and Louise?
Harry and Louise were the fictional couple who appeared in advertisements run by the insurance industry in 1993, fretting about what would happen if “government bureaucrats” started making health care decisions. The ads helped kill the Clinton health care plan, and have stood, ever since, as a symbol of the ability of powerful special interests to block health care reform.
But on Saturday, excited administration officials called me to say that this time the medical-industrial complex (their term, not mine) is offering to be helpful.
Six major industry players — including America’s Health Insurance Plans (AHIP), a descendant of the lobbying group that spawned Harry and Louise — have sent a letter to President Obama sketching out a plan to control health care costs. What’s more, the letter implicitly endorses much of what administration officials have been saying about health economics.
Are there reasons to be suspicious about this gift? You bet — and I’ll get to that in a bit. But first things first: on the face of it, this is tremendously good news.
The signatories of the letter say that they’re developing proposals to help the administration achieve its goal of shaving 1.5 percentage points off the growth rate of health care spending. That may not sound like much, but it’s actually huge: achieving that goal would save $2 trillion over the next decade.
How are costs to be contained? There are few details, but the industry has clearly been reading Peter Orszag, the budget director.
In his previous job, as the director of the Congressional Budget Office, Mr. Orszag argued that America spends far too much on some types of health care with little or no medical benefit, even as it spends too little on other types of care, like prevention and treatment of chronic conditions. Putting these together, he concluded that “substantial opportunities exist to reduce costs without harming health over all.”
Sure enough, the health industry letter talks of “reducing over-use and under-use of health care by aligning quality and efficiency incentives.” It also picks up a related favorite Orszag theme, calling for “adherence to evidence-based best practices and therapies.” All in all, it’s just what the doctor, er, budget director ordered.
Before we start celebrating, however, we have to ask the obvious question. Is this gift a Trojan horse? After all, several of the organizations that sent that letter have in the past been major villains when it comes to health care policy.
I’ve already mentioned AHIP. There’s also the Pharmaceutical Research and Manufacturers of America (PhRMA), the lobbying group that helped push through the Medicare Modernization Act of 2003 — a bill that both prevented Medicare from bargaining over drug prices and locked in huge overpayments to private insurers. Indeed, one of the new letter’s signatories is former Representative Billy Tauzin, who shepherded that bill through Congress then immediately left public office to become PhRMA’s lavishly paid president.
The point is that there’s every reason to be cynical about these players’ motives. Remember that what the rest of us call health care costs, they call income.
What’s presumably going on here is that key interest groups have realized that health care reform is going to happen no matter what they do, and that aligning themselves with the Party of No will just deny them a seat at the table. (Republicans, after all, still denounce research into which medical procedures are effective and which are not as a dastardly plot to deprive Americans of their freedom to choose.)
I would strongly urge the Obama administration to hang tough in the bargaining ahead. In particular, AHIP will surely try to use the good will created by its stance on cost control to kill an important part of health reform: giving Americans the choice of buying into a public insurance plan as an alternative to private insurers. The administration should not give in on this point.
But let me not be too negative. The fact that the medical-industrial complex is trying to shape health care reform rather than block it is a tremendously good omen. It looks as if America may finally get what every other advanced country already has: a system that guarantees essential health care to all its citizens.
And serious cost control would change everything, not just for health care, but for America’s fiscal future. As Mr. Orszag has emphasized, rising health care costs are the main reason long-run budget projections look so grim. Slow the rate at which those costs rise, and the future will look far brighter.
I still won’t count my health care chickens until they’re hatched. But this is some of the best policy news I’ve heard in a long time.
Copyright 2009 The New York Times Company


Quinty said...

Since often enough we put our Capitalist Orthodoxy ahead of the public good in this country I would settle for any half decent plan which covers everybody. Senator Ben Nelson - A Democrat - actually came out and complained the other day about the loss of profit to insurance companies if a single payer system were established.

So does a national need for healthcare services exist only for the benefit of insurance companies, providing them with a national need to exploit and profit from? I don't believe there is another country in the world in which this form of illogic could exist. But then we are the only "advanced" country in the world which still doesn’t have universal coverage for all.

Opponents of single payer are always pointing out its faults. But their complaints are spurious. True, there are a variety of problems among other countries with national healthcare programs. But ask the people in any one of those countries if they would ever trade their system for ours? What's more, if we are the "best," as we constantly boast, we could follow Taiwan's example and study the systems in other countries, avoiding their errors. Copying procedures which work. Taiwan avoided the pitfalls critics of universal healthcare complain about.

There some good private/public partnerships in other countries. I'll be happy if we finally just adopt a half decent universal system, covering all. But those who are constantly concerned with the tax payer's dollar (Republicans) don't appear to worry about healthcare dollars needlessly going to a middleman, the insurance companies. So they should want to liminate the for profit insurance companies from the process. But this is the United States of America, and such commons sense is brushed off as “Socialism. No more need be said, end of story.” Profit above the public good, and that means lowering taxes. In that light it all makes sense.

AARP sells auto insurance, life insurance, and health insurance. They are an insurance company as well as an advocacy group. As Krugman said about the insurance companies in general, I think we should be "cynical" about them too.

T. R. Reid is a journalist who has studied healthcare systems in other countries. He had an excellent documentary on Frontline regarding this some time ago.

jazzolog said...

I get it that Barack Obama wants concensus and to hear and engage all sides, but I found Monday's "announcement" a bit anti-climactic and plenty disappointing. Am I dreaming or did his campaign promise to deliver sweeping changes in healthcare? This is it? A PR photo-op with the health care industry? James Ridgeway put it this way yesterday~~~

"It all adds up to a brilliant move, when you think about it. It makes the private health care companies look cooperative and proactive, rather than like the greedy obstructionists they really are. It gets these companies on the inside track with the administration, and creates common cause with the unions. In particular, it establishes a solid place at the table for the health insurance industry, the blood-sucking middlemen who ought to be kicked out of the health care system altogether."

He cites the Washington Post's similar concerns in his column. The past couple days friends have been emailing their own views on healthcare issues. With their permission I'm sharing two.

The first is from Elisa Young who lives in Racine, Ohio, on land her family has farmed for 7 generations. As result of social and environmental challenges by the 4 power plants that share the riverside (with plans for a 5th), Elisa formed Meigs (County) Citizen Action Now. Those "powerhouses," as they're referred to locally, provide much of the electricity for the Northeast, including New York City. She's a determined fixture at the numerous EPA hearings that usually lead to OKs for more coal-powered "development."

"I have not had health insurance for over a year now since I lost my job (in healthcare). I went in for a physical several months ago that I had to have done for school. Had woken up with a really bad headache that morning. My blood pressure was okay, and it wasn't like a migraine, just a pounding ache. When I'd gone outside to walk the dog, I opened up the door and saw the air. I never lived in a place before where the air was visible - sometimes in streaks, sometimes an orange haze, sometimes orange-blue plumes. This looked like something out of Lord of the Rings to me, and it was what I had slept by an open window under, breathing in my sleep. The emissions from all four power plants were blowing over the farm - the 2 in WV blowing directly across my house, and the 2 from Cheshire behind the big barn. Went back inside got my camera and took pictures.

"After my physical was over and she was putting away my chart, I told my doctor, you know I woke up with a really bad headache this morning and this is what the air looked like. Can you tell me what the health effects of breathing is? She looked at me and said she was really tired of hearing it, every time you come in here you ask me something about those power plants, I think you should find another doctor, and she told me several names of where to start.

"I was in shock.

"When I left her office, the American Cancer Society office was across the hall, so I walked in there and started looking at the informational brochures to see what they might have. The guy behind the desk asked if he could help me, so I told him the same thing I'd told my doctor, and he handed me a copy of the 2007 cancer report for Ohio.

"The numbers were interesting It turned out we had the highest lung cancer death rate in the state for men and women combined. One of my neighbors had a lung transplant and died (he did smoke), another neighbor died of lung cancer (never smoked). Have lost multiple neighbors to cancer. The ACS numbers showed our county also had one of the lowest rates for new or early diagnosis. In my opinion, I think we end up with higher death rates because of what we are being subjected to combined with lack of health care. We have high unemployment and uninsured here, there is no hospital in the county, and if you do get diagnosed early enough to make a difference, people don't have the money for good health care, so we end up with more death statistics.

"I had a mass removed a couple of years ago at the James and they told me I should start and stay on Tamoxifen for 5 years to reduce the likelihood of what they'd diagnosed as pre-cancerous from becoming cancerous. They said if I stayed on it for 5 years it would reduce the chances to 47% that it would turn into cancer, which it usually does. How do you afford that with no health care?

"Not a judgement, just an observation, but isn't it funny we've evolved into a system where some people are dying from too much health care and others can't even get it?

"I know at some point gravity will drag the pendulum back to resembling something that looks more like the middle, but isn't it something, for now, this dichotomy?"

The second is from Richard Strax, a practicing physician and president of the Texas Radiological Society. You'll see Dr. Strax has a number of concerns on healthcare delivery in our country.

"Your latest missive really hit home for me. In a small way here in Texas I've been deeply immersed in the effort to improve healthcare and reduce overutilization for the past several months and have developed my own ideas from my perspective. The two articles you included by Brownlee and Krugman hit most of the issues at hand but not all.

"With respect to the two articles themselves, Paul Krugman indicates that shaving 1.5% off the growth in healthcare spending is huge. Shannon Brownlee suggests that reducing healthcare costs by 3% through rationing of fifteen common procedures did not amount to much. They may both be right since they are talking about slightly different issues, but this is an example of how numbers are thrown around in this arena and it takes alot of knowhow to avoid being misled.

"For my own part, I have testified twice in front of the Public Health Committee of the Texas legislature. I have been advocating for a bill to prevent doctors who own their own scanners from over-ordering the expensive tests for their own profit.

"Fighting me all the way has been the local medical society. This has been particularly disheartening since they have written ethical guidelines prohibiting doctors from getting paid based on the volume of patients they send to a scanner they own. They have made it clear that they consider unrestricted physician ownership more important than ethical boundaries designed to protect patients. I have had an op-ed piece about this published in the Houston Chronicle. That piece, published April 15, unfortunately is already off their website, but you can get the gist of it from this NY Times article. ....

"There are several things, I think, that could make a better system, specifically for Americans, than we have now.

"We need to train alot more doctors for primary care. While physician extenders such as nurse practitioners and PA's can do a decent job with primary care, I think that we can have fully trained physicians, with four times the training of extenders, for about the same money if we train more of them and subsidize the schooling in exchange for an agreement not to subspecialize.

"We need to get the private insurance companies out of our system. Their job is to restrict access to healthcare and for that they get a large amount of money that should go toward caring for patients. A single payer system would remove the cost burden of insurance companies.

"I do not favor physicians on a salary. Ask anyone who has experienced the VA. A salary rewards those who do the least. Instead, physicians should be paid based on quality and results. Those who take good care of patients based on objective measures should be better paid as an incentive for all to achieve the top rank.

"We need electronic medical records and electronic order entry and, added to that, a system that directs and restricts care according to evidence based practice. If patients want care that is not proven, they would pay out of pocket except as part of a bona fide research protocol.

"We need to bring the pharmaceutical companies into the fold. These companies chose to make medicine, not widgets, and they need to accept their role as part of a responsible health care team. Consider that they spend more on advertising than research ( and their claims that regulation of profits will kill new drugs falls flat.

"We need to take better responsibilty for our own health. That means getting check ups and vaccinations when we need them and making better lifestyle choices. That means wresting control of the 'food pyramid' from agrabusiness.

"I grew up the son of a physician who made house calls and on Saturdays, he took me along. That has never left me.

"Today's doctors are overpaid and underconcerned. I feel badly about that. Maybe it's because of guilt that I give so much of my time to unpaid positions with the medical societies on the Public Health committees, doing peer review with the State Medical Board sanctioning doctors who have complaints filed against them, and working on staff committees at my hospital to improve patient care. These positions have often put me at odds with my peers, and physician friends tell me I'm crazy to give up my free time, but I feel I have to give something back.

"My father gave lots of free care to his patients, and always stressed how important it was to 'give something back'. I guess that has never left me, either.

"I'm concerned that this round of 'healthcare reform' will make the wrong changes. Instead of cost savings I expect to see mainly cost shifting, in favor of corporate interests that give lots of cash to the politicians. Call me cynical, but I think that doctors and hospitals will be paid less, access to care will be curtailed for most of us although some improvements in the form of electronic medical records will happen, and insurance companies, drug companies and equipment makers will come out largely unscathed. I hope not, but I'm afraid that that's how our system works today.

"We had to put down our dog of 16 years over the weekend. My wife and I and our daughter stood there with him while the deed was done. It has been a very sad time for our family. He was ill for a long time, incurable, and couldn't eat for days at the end. The vet did all sorts of tests, and wanted to do more until we finally said 'Stop!'. The veterinary business is emblematic of American healthcare. We want too much for ourselves, then we want it for our pets. It doesn't matter if it does no good, and cost is no object. We just want more, and we feel we are entitled to it."

What to do? Naomi Klein gave some good advice on the Charlie Rose show Monday night~~~

"The love of Obama is so over the top and this thing that happens to us, particularly in times of crisis, where we almost regress and we want to believe our leaders are going to take care of us--I think that's unhealthy--I think it's time to put away the t-shirts and all the memorabilia. He is the president of the most powerful nation on Earth and the superfan culture of the campaign has to be replaced with an engaged citizen culture that puts respectful pressure from below."

Quinty said...

Elisa Young’s doctor should be banished to the Farallones. (Some seagull guano covered rocks where seals breed just off San Francisco.) And there are millions of Americans who have similar stories. Stories which don’t compose what we like to think of as the American Dream.

Their suffering, if I may redundantly add, is another reflection of our Reaganesque Capitalist Orthodoxy. Sooner or later reality has to overcome pie in the sky greed, though the latter seems most solid footed and promising. At least that’s what they tell us.

This is from the Obama people, arriving May 12.:

“Yesterday afternoon, President Obama announced the three bedrock principles that any comprehensive health care reform must achieve: (1) reduce costs, (2) guarantee choice, and (3) ensure all Americans have quality, affordable health care. And he set a hard goal for getting it done by the end of this year.”

As I understand it the Congress will actually write the legislation, in “harmony” with the White House. Leaving aside all the obvious obstacles (the insurance companies, etc.) Blue Dog Democrats appear to offer some of the largest. Any plan will need their votes. I think Ridgeway may have jumped the gun and presents a somewhat black and white point of view. It isn’t over until its over. And it has only just begun.

Washington is a place where everyone solemnly talks about the need for “reform,” but if such “reforms” touch their districts, no matter what party, they are often loath to actually pursue reforms. A lot of that has popped up recently and I, at least, find it shocking. It puts a magnifying glass on Washington.

Here’s how health coverage is done in some other countries, if you’re interested:

I kind of wish we could do it the way Taiwan did. They appear to have been practical and simply studied the best ways of going about providing universal care in other countries. Here we have the Capitalist Orthodoxy to first surmount (lingering Republican axioms) before even beginning to talk about any deep public involvement.

Since the private sector is profit oriented they are not about to offer free healthcare in order to insure all. That should be obvious. The Orthodoxy prevents us as a nation from seeing that.

Though I think many Republicans in Congress are taking a risk if they stand in the way. Most Americans have come around to the idea of some sort of universal coverage. That pressure might help in swinging some votes.

I certainly agree with your doctor friend, we should get the insurance companies out of the system. Patients and healthcare needs are not commodities they can exploit and which exist for their benefit. And sending public tax dollars into their coffers is wasted tax money. Ah, but the Orthodoxy, the orthodoxy. (To be recited as if repeating, “the horror, the horror.”) His (the doctor’s) comments were extremely interesting, and I wish him luck.

Obama offered hope at a time when Washington seemed to only offer one disaster after another. I remember that the bad news on the news became daily. In steps Obama: dignified, charismatic, intelligent. The exact opposite to the Bush administration. No wonder he’s adored. He’s a center left self-described pragmatist. We are not going to get everything we want from him. This is a story which has only just begun to be told.