Higher US expenditures on cancer patients do not result in improved mortality.

But you’d never know that reading AEI’s highly dubious contribution to the literature in this week’s Health Affairs (lay Reuters article here). Consistent with their free-market solves everything and can do no wrong (cover ears and yell “nananananananana”) attitude towards the broken US healthcare system, they have managed to contaminate the literature with a paper that suggests our higher expenditures on cancer are generating significant returns in patient survival. Except that it doesn’t show this, and to her great credit, Reuter’s Sharon Begley nails it:

Cancer patients in the United States who were diagnosed from 1995 to 1999 lived an average 11.1 years after that, compared with 9.3 years for those in 10 countries in Europe, researchers led by health economist Tomas Philipson of the University of Chicago reported in an analysis published Monday in the journal Health Affairs.

Those extra years came at a price. By 1999 (the last year the researchers analyzed), the United States was spending an average of $70,000 per cancer case (up 49 percent since 1983), compared with $44,000 in Europe (up 16 percent). Using standard figures for an extra year of life, the researchers concluded that the value of the U.S. survival gains outweighed the cost by an average $61,000 per case. The greater spending on cancer care in the United States, they conclude, is therefore “worth it.”

Experts shown an advance copy of the paper by Reuters argued that the tricky statistics of cancer outcomes tripped up the authors.

“This study is pure folly,” said biostatistician Dr. Don Berry of MD Anderson Cancer Center in Houston. “It’s completely misguided and it’s dangerous. Not only are the authors’ analyses flawed but their conclusions are also wrong.”

I am amazed, this is real science reporting here, because rather than just doing a press-release rehashing of the AEI-authors’ dubious assertions, she found some real cancer experts and shredded it.

The mistake they made, or possibly ignored, is lead-time bias. By using survival from diagnosis, rather than the patient’s actual mortality, they create the appearance of improved outcomes. But the reality is, earlier diagnosis is creating a false survival signal. The US isn’t actually extending lives in comparison to treatment in other countries, the overall mortality rates are the same.

Further the paper only showed the benefit in prostate cancer and breast cancer, and, if anything, worse survival for colon and uterine cancer given the amount of expenditure. The reason is pretty straightforward, and consistent with the lead-time bias issue. In the US, we probably over-screen for breast and prostate cancer, which means more people live with these diagnoses than do in other countries. It’s been a topic of debate among medical professions and discussed extensively by other medical bloggers like Orac because it’s quite possible, especially for breast and prostate cancers, that screening protocols are too inclusive. The result is there are more patients in the US that are given a cancer diagnosis, but they have disease that may never progress to being a life-threatening illness. Excessive screening may even result in unnecessary procedures and treatments when it comes to these two diseases, and we are still trying to work out what protocols will include the most patients with serious disease, while excluding as many false-positive patients as possible. This is acknowledged by Begley’s expert reviewers:

Even more problematic, said Berry, is a problem cancer experts have only recently recognized: overdiagnosis. Because cancer screening is much more widespread in the United States than in Europe, especially for breast and prostate cancer, “we find many more cancers than are found in Europe,” he said. “These are cancers that tend to be slowly growing and many would never kill anyone.”

Screening therefore turns thousands of healthy people into cancer patients, even though their tumor would never threaten their health or life. Counting these cases, of which there are more in the United States than Europe, artificially inflates survival time, experts said.

“As long as your calculation is based on survival gains, it is fundamentally misleading,” said Dr. H. Gilbert Welch, a healthcare expert at the Dartmouth Institute for Health Policy & Clinical Practice.

In the new analysis, the survival gains in the United States compared with Europe were greatest for prostate cancer, at more than triple the gains for breast cancer, the cancer with the second-greatest U.S. survival edge. “These are the two cancers where screening has raised the most serious issues about lead-time bias and overdiagnosis,” said Welch.

For melanoma and colorectal and uterine cancer, survival gains over the period analyzed were greater in Europe than the United States.

If anything the opposite is true based on the correct analysis which is based on mortality statistics, not survival.

Other calculations cast doubt on the superiority of U.S. cancer care. For instance, breast cancer mortality fell 36 percent in the United Kingdom from 1990 to 2006, calculates MD Anderson’s Berry, and fell 30 percent among whites in the United States. (The U.S. figure would be even lower, he said, if it included African-Americans, who generally have less access to health care.)

Cancer mortality in the United States is higher than in 11 countries reporting to the Organization for Economic Co-operation and Development, and lower than the rate in 14. Mortality is lower in Switzerland, Sweden, Japan and Finland, among others, but higher in Hungary, Slovenia, France and Britain, in the latest years for which OECD has data.

The reduction in cancer mortality in the United States since 2000 also puts it toward the middle of OECD countries. It is less than in Israel, Japan, Switzerland and some others, for instance, but better than in Britain, Estonia and Poland.

To sum up, the authors successfully identified lead-time bias in two cancers which the US is known to screen more for than other nations with universal healthcare systems that have health expenditures of roughly 50% less than ours, per capita. They then falsely attributed this lead time bias to our excessive health expenditures, then generalized this biased finding to suggest our excessive expenditures overall provide benefit to our population. This is despite a large body of literature, using appropriate measures of health outcomes, that suggest many other countries do better than us in cancer and medically-preventible disease mortality in general.

It is amazing that this paper passed peer-review, and that such a substandard analysis by authors with clear ideological biases was not detected and rejected. And one could have predicted this considering the author’s affiliation with AEI and Manhattan Institutes, think tanks which routinely engage in denial of science like global warming. This is a comparable mistake to accepting a paper from the Discovery Institute, or Peter Duesberg without approaching it with a hefty dose of skepticism. Anti-science ideologues tend to write shoddy, unscientific papers, and some basic peer review should have prevented this analysis from contaminating the literature.

Shame on Health Affairs for publishing this garbage, but let’s a salute Reuter’s for doing an excellent job in appropriate post hoc review of this flawed paper.

Three reasons the Supreme Court should uphold ACA

With the Supreme Court hearing arguments for the next three days on the Affordable Care Act, many commentators, including Dahlia Lithwick appear to have so much contempt for the Roberts court that they believe the issue will likely be settled on politics rather than law.

The first proposition is that the health care law is constitutional. The second is that the court could strike it down anyway.

The law is a completely valid exercise of Congress’ Commerce Clause power, and all the conservative longing for the good old days of the pre-New Deal courts won’t put us back in those days as if by magic. Nor does it amount to much of an argument.

Despite the fact that reading the entrails of those opinions suggest that they’d contribute to an easy fifth, sixth, and seventh vote to uphold the individual mandate as a legitimate exercise of Congressional power, the real question isn’t whether those Justices will be bound by 70 years of precedent or their own prior writings on federal power. The only question is whether they will ignore it all to deprive the Obama of one of his signature accomplishments.

Professor Randy Barnett, the intellectual power behind the entire health care challenge, wrote recently that Justice Scalia could break from his previous opinions–freeing him to strike down the Affordable Care Act–“without breaking a sweat.” I suspect that’s right.

If that’s true, we should stop fussing about old precedents. These old milestones of jurisprudence aren’t what will give Scalia pause. What matters is whether the five conservative justices are so intent in striking down Obama’shealthcare law that they would risk a chilly and divisive 5-4 dip back into the waters of Bush v. Gore and Citizens United.

It disturbs me when legal commentators as experienced and knowledgeable as Lithwick have essentially given up on the notion that the court is non-partisan or above the political fray. Instead, they seem to think it’s just another political body, making decisions based on partisan point-scoring over legitimate constitutional analysis. With the tea party rallying to keep us uninsured under the false notion that the bill will increase costs (it will actually reduce the deficit according to the CBO) and impinge their freedoms. These are the false arguments that people like Nick Gillespie (or libertarian Fonzie) are using, quite successfully, to convince the American people to oppose their own interest. Gillespie argues in his three point essay that (1) it’s unconstitutionally intrusive legislation (2) it’s price tag is ballooning, and (3) it won’t make us healthier. The first claim is debatable since it’s ultimately up to the courts. However good arguments suggest congress does have the power to pass such regulation.

For one previous case like Wickard and Raich suggest extensive powers for congress to regulate commerce. Second, if one of every seven dollars is spent on healthcare, it represents a significant portion of the economy. Third, and most importantly, the uninsured inflict an economic penalty on taxpayers and the insured, so rather than claiming they have a right not to buy, I would argue we have a right to address the cost the uninsured inflict on society. The penalty for not carrying insurance I believe makes complete sense in this regard.

The second claim is blatantly false and his description of the costs as “ballooning” is unsupportable based on the CBO reports. This talking point is an outright lie being spread far and wide by right wingers. The CBO director had to issue a comment to correct this widespread deception.

The third claim is a bit of a red herring. The health benefits of people being insured may eventually result in a healthier population but probably not by much and it’s besides the point. We’re not arguing the law will make us healthier. We’re arguing that the reform law will reduce healthcare expenditures, and protect people economically from the often devastating costs of illness.

But rather than just knocking down their arguments I think it’s important to remind people of the positive reasons we should support this bill. So I have my own list of 3 reasons this bill should be upheld and we should all support it.
Continue reading “Three reasons the Supreme Court should uphold ACA”

What is the cause of excess costs in US healthcare? Take three – signs of reform

We’ve already extensively discussed why it costs twice as much for the US to provide healthcare for it’s citizens all the while failing to cover health care for all. Most recently, we discussed the hidden tax of the uninsured and the perverse incentive structure of US healthcare which encourage costlier care, more utilization, and more procedures.

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To summarize, the US spends more on healthcare compared to other industrialized nations because

  1. We deliver it inefficiently
  2. Without universality problems present when critical and in the ER
  3. Fee-for-service incentives in the form of excessive reimbursement for procedures and hospitals ramp up costs by encouraging doctors to overuse expensive tests and perform more procedures
  4. Direct-to-consumer advertising (we are one of two countries that allow advertisement of prescription drugs) and medicare part D encourage overuse of pharmaceuticals while tying providers hands when it comes to bargaining for lower drug prices
  5. Defensive medicine
  6. Poor management of end-of-life decisions and excessive and futile overuse of resources at the end of life
  7. Absence of a universal electronic medical record (or record format) to prevent redundancy and waste.

Now, what about the new Affordable Care Act? Are there going to be measures to address these sources of excess cost while creating universal coverage? The WaPo has an article outlining reforms addressing many of these specific problems.

First off, fee-for-service is going to be discouraged with increased use of “bundling” of costs:
Continue reading “What is the cause of excess costs in US healthcare? Take three – signs of reform”

Supreme Court to Debate Affordable Care Act Next week – and plaintiff's case has imploded

With the impending, and unprecedented, 3 days of arguments over the Affordable Care Act occurring early next week, it’s interesting to see that the test case being used to challenge the law has now become a test case demonstrating the necessity of the law.

Mary Brown, the woman who asserts no one has the authority to make her buy health care is now bankrupt, at least in part due to medical bills. From theLA Times article:

Mary Brown, a 56-year-old Florida woman who owned a small auto repair shop but had no health insurance, became the lead plaintiff challenging President Obama’s healthcare law because she was passionate about the issue.

Brown “doesn’t have insurance. She doesn’t want to pay for it. And she doesn’t want the government to tell her she has to have it,” said Karen Harned, a lawyer for the National Federation of Independent Business. Brown is a plaintiff in the federation’s case, which the Supreme Court plans to hear later this month.

But court records reveal that Brown and her husband filed for bankruptcy last fall with $4,500 in unpaid medical bills. Those bills could change Brown from a symbol of proud independence into an example of exactly the problem the healthcare law was intended to address.

I think at this point the solicitor general just has to point at the plaintiff and say “See! See!”.

People without health insurance are still covered by the ethical obligations of EMTALA. They can still see doctors and get treatment and not pay their bills. Then who pays for it? All of the rest of us.

The “individual mandate” should be called a “personal responsibility” provision, because the fact is all these rugged individualists are parasites. They are refusing to pay into the system then benefiting when they, inevitably, need to use it.

And how about the argument that the commerce clause can’t for such an individual responsibility provision?

The couple owed $2,140 to Bay Medical Center in Panama City, $610 to Bay Medical Physicians, $835 to an eye doctor in Alabama and $900 to a specialist in Mississippi.

“This is a very common problem. We cover $30 million in charity and uncompensated care every year,” said Christa Hild, a spokeswoman for the hospital center. “If it’s a bad debt, we have to absorb it.”

So, this couple has generated bills in three different states that they now will not be able to pay and the rest of us have to eat the bill for them. It’s amazing how the plaintiff’s own actions have justified nearly every argument for the bill. When healthcare now represents something like 1 in 7 dollars spent in this country, how can we argue that the commerce clause does not allow congress to regulate it?

What is the cause of excess costs in US healthcare? Take two

We’ve discussed it before, why are costs so much higher in US healthcare compared to other countries? The Washington Post has a pointless article which seems to answer with the tautology costs are high because healthcare in America costs more. How much more? Well, we spend nearly twice as much per capita as the next nearest country while failing to provide universal coverage:

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In the WaPo article they make a big deal of the costs of individual procedures like MRI being over a thousand in the US compared to $280 in France, but this is a simplistic analysis, and I think it misses the point as most authors do when discussing this issue. The reason things costs more is because in order to subsidize the hidden costs of medical care, providers charge more for imaging and procedures. For instance, Atul Gawande, in his New Yorker piece “The Cost Conundrum” wonders why is it costs are higher to treat the same conditions in rural areas and in a major academic centers like UCLA than at a highly specialized private hospitals like the Mayo Clinic? I think the reason is it’s not nearly as expensive to administer and provide care for a select group of insured midwesterners at the Mayo than it is to provide care to the underserved in the poor areas of inner-cities and in poor rural locations.

When you are serving a poorer, under-insured population like you get in LA or Baltimore for that matter, the insured are charged more because EMTALA requires hospitals to treat all comers, regardless of insured status. Medical centers like UCLA or University of Maryland are the final common pathway for the sickest and poorest patients who, even if stabilized at smaller local hospitals, are immediately transferred to such centers. These patients are expensive to treat, often have more co-morbidities like HIV or drug use and mental illness, and there is no reimbursement guarantee for taking care of them even though it is our legal and ethical responsibility to do so.

Further, the cost of defensive medicine, which applies to this patient population as much as any other, ramps the costs of all hospital admissions and medical practice in general. It is also incredibly hard to quantify its contribution to the overall costs of care.

As a result, to pay for excessive care of the uninsured, all procedures, all tests, all imaging, and all hospitalizations cost more. Caring for inpatients and the uninsured is expensive, so the costs are transferred to the prices of outpatient elective care and procedures which are often administered in a fee-for-service model. Hospitals have an incentive to provide as much outpatient elective care as possible in order to offset these other costs and to generate revenue. The providers that perform procedures or expensive testing then become far more expensive to pay as they are the major revenue generators for the hospital (hence surgeon vs pediatrician pay). Especially because in order to generate more revenue they are paid based on how many procedures they perform. All the incentives are towards more utilization, more procedures, more revenue generation. This is the hidden tax of the uninsured.

In a way, we have universal healthcare already, but we pay for it in the most irresponsible and costly way possible. We wait for small problems to become emergent, treat them in the most expensive outpatient provider possible (the ER), and then when we can’t pay the bills for the uninsured, we transfer the balance by increasing the costs of the care of insured patients showing up for their cholecystectomies or back surgery. Tack on the costs of defensive medicine and the fear of being sued unless everything is done to cover your ass, and you have a recipe for extremely costly care.

Other factors figure into higher costs as well, including hugely higher costs of medicare administration since Bush privatized it, higher prescription drug costs since Bush passed medicare part D and prevented bargaining with drug companies, and our incredibly high ICU expenditures at the end of life. the McKinsey report on excess costs demonstrated most of these issues in 2008. This is not news. The US spends far more on medical administration, outpatient/ambulatory care (with hospital-based outpatient care increasing most rapidly in costs), drugs, doctors salaries, and end-of-life care than we should as a percentage of our GDP.

So what should we do about it? At every step we need dismantle the tendency towards increasing costs. Here are my suggestions:
Continue reading “What is the cause of excess costs in US healthcare? Take two”

Conservatives crow over push for privatization in British NHS, compare apples to oranges

Hot Air and the daily caller are excited to pronounce socialized medicine dead as the British NHS plans to contract with private hospitals and providers on top of socialized care. From The Caller:

Joseph A. Morris, a former Reagan White House lawyer who now serves on the board of the American Conservative Union, told TheDC that socialized medicine has turned out to be a threat to Britons’ health, and to their economy as well.

“Europe’s message to the world is no longer that the socialist dream of the cradle-to-grave welfare state is an easy achievement,” Morris said. “Rather, it is the shouted warning that it is a fool’s paradise. The bills are coming due and the only real alternatives — serious financial reform of government or national bankruptcy — are not pleasant.”

Morris added that the British government, “unlike the Obama administration, is hearing the warnings, identifying its greatest vulnerabilities, and trying to race ahead of the deluge.”

Well, yes and no. The British government is interested in passing a bill that would allow private providers to be contracted by NHS and ostensibly compete with NHS where NHS is lagging. It’s hard to tell from coverage exactly what provisions will ultimately be in this bill, although the overriding goal seems to be to introduce “competition” into the NHS. Although, it’s hard to imagine the NHS being more efficient with introduction of competition as the Brits spend roughly half as much per capita and a much smaller fraction of their total GDP on health care compared to the US.

But are our right wingers correct that this is the death of socialized medicine and should be a warning about Obama care?
Continue reading “Conservatives crow over push for privatization in British NHS, compare apples to oranges”

More Evidence that Universal Health Care Would be Less Expensive

We’ve written quite a bit about single payer health care systems as well as other models that are a mixture of public and private spending.

We’ve also analyzed some of the sources of excess cost of US healthcare to other countries. What is uniformly true about universal health care systems is that they all spend less on medical care per capita than the US. The next nearest country in spending to us, France, spends 50% of what we do per capita while providing top notch care, possibly the best in the world. And while the cause of our excess costs are multifactorial, one of the greatest sources of excess cost is likely due to increased use of emergency rooms over primary care providers. We already have universal healthcare, if someone shows up injured or ill, hospitals are obligated to treat them. But forcing people to come to the ER when their problems have become critical increases the costs of treatment dramatically. Now a new paper in Health Affairs demonstrates the cost of ER use over PCPs and their findings confirm that as much the costs of the uninsured to the health care system dropped by 50% once low-income uninsured patients received health coverage. This is good news as it suggests as health care reform is enacted we should see huge savings just from having a universal system.

See more below…
Continue reading “More Evidence that Universal Health Care Would be Less Expensive”

How Do you Want to Die?

Via Zite I found the article How Doctors Die by Ken Murray and was surprised to find it one of the best I’ve read on the issue of end-of-life care. The context is that of how Doctors typically forgo extreme measures in the face of terminal diagnoses, and often reject the type of care we routinely provide to our patients as “not for us”. While the article lacks hard data on the prevalence of these attitudes or behaviors, I have to say this viewpoint is consistent my experience of learning my colleague’s beliefs and how I now personally feel about ICU care . And I’m someone who is interested in trauma and critical care as a career…

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Significantly, Murray discusses what “doing everything” can mean. Sadly, most people equate caring for their family member with asking for maximum care when they are sick or dying, but doctors know, and poorly communicate, that maximal care is often painful, expensive, and too often futile.

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

This situation of futile care is sometimes referenced with some some gallows humor as the chee chee. Why are we unable to communicate to patients that often the treatments that we can provide aren’t something we’d chose for ourselves or for those we love?
Continue reading “How Do you Want to Die?”

Welcome Back to Denialism Blog

Despite rumors to the contrary, I am not dead. Instead I’ve been working hard as a new surgical intern and sadly not finding the time to write for the denialism blog. However, now more than ever, it seems that we need to talk about the problem of denialism.

Two major new issues for denialism have cropped up, and both are major new forms of political denialism. The first, I’ll broadly describe as Obama-denialism. Obama is a muslim, Obama was not born in the US, there is a giant conspiracy involving the Hawaii Secretary of State, the Democratic Party and muslims worldwide to take over the US government with a madrassa-trained presidential double agent etc. These are of course nonsense. FighttheSmears a website created by Obama supporters has most of the more ridiculous rumors debunked, including the absurd birth certificate/birther conspiracy theory. appropriately mocking LA Times blog entry. Whatever. As readers of denialism blog, it should have been clear from the get-go that this is just the usual conspiracist-drivel propagated by people who are upset at having a black president, and, just like the truthers, holocaust deniers, AIDS denialists, or any other group driven by racism, paranoia or just plain stupidity they won’t be satisfied by any evidence that contradicts their illogical conclusions. The format of the arguments is prima-facie absurd. The conspiracies are non-parsimonious, and lead immediately to more questions that just don’t make any sense. Despite this, bigots and crackpots like Fox News and Lou Dobbs “cover the controversy” to keep it stirred up. We must address it for what it is, closet racism and sour grapes over losing an election.

The second major issue, even more distressing to me now that I’m fully immersed in our health-care system, is that of universal health care denialism. Most upsetting to me was pronouncements like that of Sarah Palin that health care reform will lead to “death panels”. This is where the political opponents of progressive governance have crossed the line from the usual political ignorance and lies to truly despicable tactics designed to sink health care reform at any cost. The reality of the language originally in the bill was that it was designed to encourage physicians to have end-of-life discussions with their patients by paying them for such consultations. This is an area in which our health system currently fails miserably to the detriment of our patients. We truly need to have all patients interacting with our health system to have frank discussions about their wishes at the end of their lives, to have living wills, and make their desires for their level of intervention clear before they end up in the ICU, on a ventilator, and having invasive treatments performed ad nauseum that they may or may not approve of if they were able to communicate their wishes. But no, the political opponents of health care reform have instigated a scorched-earth policy, and even something as noncontroversial as asking people what they want their physicians to do when they’re sick has been thrown under the bus by the denialists. Other lies? Universal health care reform will turn us into communist Russia! A belief inconsistent with the fact that every other country in the industrialized world has survived the conversion to universal systems without requiring Stalinist dictatorships to enforce the dastardly public option. These arguments transcend mere denialism and can only be described as ideological insanity.

There is a legitimate debate to be had over health care, but we clearly are not having it. One legitimate question is how do we pay for it? I’m confident that reform will pay for itself and it is more expensive not to have universal access. As we discussed in our health care series, every other country in the world has accomplished this feat, provide equivalent or measurably better care in terms of access, health of populations, and life expectancy. Despite their universal coverage they all spend less than half as much per capita than the US on health coverage. Having people access the system in our ERs, lacking preventative care, and failing to provide the universal inexpensive interventions costs more than just providing care to people. After all, we already pay for the uninsured, hospitals and doctors are ethically obligated to provide care for everyone who walks in the door, insured or not. The costs of covering the uninsured are already built into our excess costs. Worse, having a administrative system designed to deny care is costly and unnecessary. The “privatization” or “subcontracting’ of medicare administration under Bush increased the cost of healthcare administration by 30% in three years despite the number of patients covered increasing by only about 4%. Paying for things in a planned, thoughtful and systematic way is cheaper than allowing problems to stew and boil over. I’ve already had way too many patients showing up in the ER with disastrous and expensive health problems requiring a huge expenditure of resources that if they had been addressed early would have cost next to nothing. And yes, they always tell me they didn’t get it addressed before it was critical because they lacked insurance. This is stupid and not the kind of care I want to be providing. Another legitimate question is will universality damage our technological and research prowess? Again I believe the answer is no. The US has excellent technology and research because we pay for it through government agencies like the NIH. The technology won’t go away because that has more to do with the culture of our healthcare system than the fact that we have oodles of money to pay for it (because we don’t really). It’s also not a fact that our technology necessarily makes our care better. CT scans, and MRIs are not as important to provision of health care as having ready access to services and adequate access to primary care physicians and preventative care. Another good question, is a public option necessary? Again I believe not. While I believe countries that provide a public option like Australia are ones on which we may model our system, other countries such as the Netherlands or Germany have developed excellent healthcare systems through insurers by tightly regulating them and not letting them screw their citizens. Here’s a great question, would anyone under these systems choose the US one? As evinced by the commentary from our health system, the critics of universal healthcare are speaking from ignorance when they claim citizens of other countries are suffering in their systems. The data we presented, and reinforced by commentary from all over the world, was that these systems have problems, but no one in their right mind would trade them for the US system.

Let’s get back to having a public debate that is not overwhelmed by the ideological fanatics and deniers and instead focus on the very real and critical problems that this president was elected to address. The denialists and their scorched earth tactics have done a great deal of harm to our debate on reform. Now more than ever, we need to talk about the difference between denialism and debate.

The Obama Plan – Part I

We’re starting to hear about how Obama intends to implement healthcare in this country.

President Barack Obama says he’s open to requiring all Americans to buy health insurance, as long as the plan provides a “hardship waiver” to exempt poor people from having to pay.

Obama opposed such an individual mandate during his campaign, but Congress increasingly is moving to embrace the idea.

In providing the first real details on how he wants to reshape the nation’s health care system, the president urged Congress on Wednesday toward a sweeping overhaul that would allow Americans to buy into a government insurance plan.

Obama outlined his goals in a letter to Sens. Edward Kennedy, D-Mass., and Max Baucus, D-Mont., chairmen of the two committees writing health care bills. It followed a meeting he held Tuesday with members of their committees, and amounted to a road map to keep Congress aligned with his goals.

The letter published at whitehouse.gov, lays out some basic ideas, but it seems as though Obama is willing to have congress work out the specifics.

Let’s go through his recommendations and talk about the implications.
Continue reading “The Obama Plan – Part I”