Healthcare Upheld!

It’s good news that the Supreme Court split 5-4 with Roberts (and not Kennedy?!?) as the deciding vote, to uphold the affordable care act. It’s interesting that this was controversial, and certainly Roberts led the court to a very safe middle ground making the issue about taxation and saying the commerce clause could not apply. If anything, I wonder if this weakens the previous commerce powers of Congress as defined by Wickard v. Filburn, I’d love to hear what a lawyer thinks.

What does this mean?

Well in the short term not a whole lot, this healthcare bill requires a very slow roll-out of provisions. This was never a revolutionary law, which is why it was so surprising that people treated what was essentially a free-market giveaway as if it were some act of revolutionary socialism. But it will mean that states will have to go ahead and start implementing exchanges, it means that lots of other cost-control provisions are going ahead, coverage for pre-existing conditions will remain (victory!), and most importantly, we can start a great cultural shift from using emergency rooms or just plain avoidance to deal with necessary health maintenance and primary care needs.

Now, I know many that think single payer is the only way that healthcare can be provided might have been hoping this hodgepodge mix of free-market and social reforms would fail in favor of a truly government-administered system. I would say to them, don’t worry! It’s possible to have highly efficacious universal healthcare based on insurance for all and subsidization for those who can not afford it. Most systems not inherited from the Soviets came to universal healthcare from different angles, and only really the UK, Canada, and New Zealand represent totally government-administered healthcare systems in such countries. In between would be Sweden, Japan, France, or Australia with government-administered payment or mixtures of public and private hospitals with government sponsored insurance options. Even Russia now has a mixture of public and private healthcare spending. Then there are the systems which look a bit more like what the ACA will be. For instance Germany, which has had universal health care since Otto von Bismarck, has health coverage through employer-subsidized sickness funds, a mixture of public and private hospitals and clinics. Finally, the Netherlands system probably is most like the system proposed by the ACA. They describe it as “private insurance with social conscience”, and the Netherlands enjoys metrics of patient satisfaction, short wait times, and access to procedures far superior to that of other systems including ours (which performs quite poorly on almost all metrics including access). On the extreme free-market side of universal health care is Singapore, which relies on universal governmental catastrophic insurance coverage, but an individual mandate on citizens to contribute to personal health savings funds which cover primary care and most expenditures until you go over a yearly limit. The only thing all of these systems have in common is that they spend half of what we spend yearly per capita on healthcare.

So, to those who oppose it because you either don’t want healthcare or because you don’t think it was enough, don’t despair! For those who think it’s the worst thing ever to pay for other’s health insurance, don’t worry! You already are! You have been since Reagan passed EMTALA. That won’t change, the cost might actually get cheaper (or at least stop increasing at such a violent pace). For those who think that anything but single-payer is awful, don’t complain! What’s most important is that we have universal coverage that encourages primary care usage, getting patients out of the ER and subsidization for the poorest among us. The international experience shows that truly single-payer systems are the minority, and most systems are a mixture of public and private hospitals, insurance and personal expenditure. Further, one of the best systems in the world, the Netherlands system closely resembles what the ACA will accomplish and has resulted in excellent outcomes and patient satisfaction in that country. In fact, most single-payer systems perform worse in terms of access, wait times, and satisfaction than the mixed systems, with the possible exception of Sweden (probably because they put so much money into it).

This is a victory for healthcare and the country. Even if it’s not “perfect”, or even if you think people being treated for their medical problems is some kind of sin against capitalism, too bad. It will accomplish a great deal, there is international precedent that such systems work (and may work better than single-payer), and there is no escape from the fact that we have to pay for people’s healthcare. We can do it expensively, wastefully, and emergently in the ER, or we can do it like thoughtful, decent citizens who care about each other’s welfare and provide a baseline of access for all.

Bad news for the Affordable Care Act

The NYTimes reporting suggests a 5-4 split against ACA is likely:

Justice Kennedy, along with Justices Samuel A. Alito Jr. and Antonin Scalia and Chief Justice John G. Roberts Jr. all asked questions suggesting that they had a problem with the constitutionality of the mandate requiring most Americans to buy insurance. Justice Clarence Thomas, as usual, did not ask any questions, but he is widely expected to vote to overturn the mandate.

As does CNN’s Toobin’s analysis:

This is interesting. Part of the issue is how much of the law would fall if they turn against it? Would we still be able to prevent insurers from dumping patients and refusing to cover chronic conditions if the mandate falls? Will both provisions be struck down? All provisions?

I think a strategic error was made in not describing the penalty as a tax. Because no one doubts congress’ power to tax, and after all, it made sense to tax the uninsured considering as a group they cost the taxpayers $43 billion a year in unpaid medical bills.

The other interesting outcome may be political. Without Obamacare to rile up the base, what issue will Republicans have left come next fall? This was their touchstone, and if the Supreme Court pulls the rug out from under them, they’re going to have to come up with a new form of librul fascism to rail against for November.

In the end this may be an opportunity or a catastrophe for medical care depending on how we are led into the future. The failure of this law may result in a tax-supported single payer system. It may result in expansion of health exchanges to cover the uninsured. It may result in a new national flat tax, like Japan’s, that results in income-based subsidization of healthcare costs. All of these things are clearly constitutional based on the congressional ability to tax.

The worst outcome would be if we saw another 15 year delay in addressing the crisis of rising health care expenditures and coverage for the uninsured. Or, if it became delegated to the states to create individual universal systems as, sadly, most red states have no financial capacity to afford it. Already the southern and para-Mississippi states have higher obesity rates, poorer objective measures of health, worse infant mortality, and higher bankruptcy rates etc., this will likely worsen these disparities. California, New York, Massachusetts (will they lose their mandate?), Maryland and other states which are the major federal revenue generators could probably manage it if they could convince their population to support universal healthcare legislation with additional taxes, but a patchwork approach will create unnecessary complexity. What if a Pennsylvanian gets a surgery in Maryland? What if someone wants to chose an out-of-state hospital, which they very frequently do? What about emergency care for out-of-staters? Will this just further increase disparities between the states until the we see an ever worsening downward slope in quality of life as you approach the Mississippi river? Will states like Texas that can probably afford reform refuse to enact any out of cold-hearted laissez-faire libertarianism?

It’s sad, but oh well. America gets the government it elects.

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…
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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.

What is the cause of excess costs in US healthcare?

The question has come up again and again in our discussions on health care in the US and around the world, why does it cost so much more in the US when we get so much less?

The drug companies and their lobbyists are already out in force trying to make sure their pocketbooks aren’t hit by the inevitable reforms that are coming. In particular they insist drugs aren’t the problem in the US, it’s administrative costs! I would tend to disagree.

Based upon my experience working in the sytem, the main causes of excess costs I would hypothesize are the following (in order of importance):

  1. An excess of cost in administration far out of line with most countries around the world.
  2. Pharmaceutical costs – especially due to the effects of direct to consumer advertising (DTCA) encouraging use of more expensive, newer drugs (which is only allowed in the US), Medicare part D which forbids collective bargaining for lower drug prices, and a broken patent system that allows drug makers to patent and charge more for non-novel medications.
  3. The absence of a universal system that prevents risk-sharing, and causes the uninsured to avoid treatment until problems are more critical, and more expensive.
  4. Excessive reimbursement of physicians for procedural skills, rather than cost-saving physician roles such as primary care and family practice that emphasize early diagnosis and proper management of disease.
  5. Excesses of cost caused by “defensive medicine”. While torts themselves don’t cause a great deal of monetary damage, the culture they create is one of paranoia in physicians who make decisions with lawsuits in mind, rather than the interests of patients and society
  6. The excessive costs in ICU care, especially at the end of life, which may also be reduced by better EMRs with recording of living wills, and public information campaigns designed to inform people about the pain, invasiveness and futility of “doing everything” in the elderly.
  7. The absence of an electronic medical record that is universal which causes redundancy in testing as patients see new doctors who then order redundant tests because sharing of information is so inefficient.

But these may just be my biased views based on my own limited experience. Let’s see what the data show. The McKinsey Global Institute has generated a report on this, and has broken down the data according to the individual costs in our system, while comparing it to that of other countries.

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What is health care like in France?


Here it comes. How dare I suggest the US could learn anything from France? By most assessments France provides the best health care in the world, with excellent life expectancy, low rates of health-care amenable disease, and again, despite providing excellent universal care, they spend less per capita than the US. Using about 10.7% of GDP and about 2000USD less per capita than the US they are providing the best health care in the world. To top it off, France’s system isn’t even socialized. That’s right. It’s yet another system that is a mixture of public and private funding that, if anything, provides the greatest level of physician and patient autonomy in making health care decisions. It is not, I repeat, not a single payer system. Doctors are largely self-employed, there is no big government authority telling doctors and patients what to do, just a progressive tax structure and requirements to pay into the system that fully subsidizes a functional healthcare system.

Start with the Wikipedia entry, if you can stand to read it try the WHO document on the structure of the French system, or various articles which all seem to agree the French system rocks. The few criticisms stem from it’s relative cost compared to the other European systems and perhaps overutilization by citizens. But no one asserts that it provides poor care, that it rations care, that it limits doctor or patient autonomy, or has poor resources.

As with most health care systems, the more you read about it the more you see how the system reflects the values of the country. But these should be universal values.
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What is healthcare like in Germany?


What better argument for universal health care can you make than that of Germany? By far one of the most successful systems, it has had some form of universal health care for almost 130 years, and is currently one of the most successful health care systems in the world. It is again, a mixture of public and private funding, with employers providing most of the funding for health care by paying into one of several hundred “sickness funds” that provide health care funding to their employees. Germany is widely regarded as having excellent access, short wait times, care with the best technology and pharmaceuticals available, and this again while spending 10.7% of GDP (US 16%) with per capita spending of ~3.3k USD (approximately half of that in the US).

The German health care wikipedia entry is a good starting point, and it’s always fun to try to translate German web pages and try to make sense of Google translations. But I’ve found several good articles describing the system including several articles in the MSM like this NYT piece which refers to Americans as having an “… immature, asocial mentality [that] is rare in the rest of the world,” one for travelers, and one for those looking for German jobs. The consensus seems to be that Germany rocks when it comes to health care.

Let’s talk about how it performs and how it works.

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What is healthcare like in the Netherlands?


The Dutch really have it together on health care, they have a system that has been proposed as a model for the US to emulate. In stark contrast to many other European systems, it’s actually based entirely on private insurers, rather than a single-payer or entirely national system. Yet the Dutch system is universal, has far superior rates of satisfaction with quality of care and access, and still costs a fraction of what we pay for health care per capita in the US. How is this possible?

You can read the Wikipedia entry on the Dutch system or read about it on their Ministry of Health’s English webpage or watch the short film on their reforms below.

So, how does the Dutch system work?

Continue reading “What is healthcare like in the Netherlands?”

What’s health care like in Australia?


To start off some balanced discussions of what universal health care looks like around the world, I thought I would begin with Australia, a system that we could learn a great deal from.

In the US system, we do not have universal healthcare, we have mostly employer-subsidized healthcare, private insurance and medicare covering people’s health expense. We also lack a universal electronic medical record, our main recourse for responding to poor care is lawsuits, and we have a high disparity in services available to those with money and those who do not. We still manage to spend more on health care per capita than any country in the world, while being ranked 37th in the world by the WHO, 72nd in the world for healthiness of its citizens, and 19th among industrialized countries (last) by the Commonwealth fund. We have a very poor infant mortality rate, which is only partially explained by our willingness to treat more premature infants than other countries, and is mostly a result of poor health care infrastructure in several of the poorer, Southern states.

Australia’s system is not too fundamentally different from the mixture of employer and public based funding found here in the US. An outline of the health system is available from the Australian government and the Wikipedia entry is here. It’s spends about 8.8% of GDP on health care, compared to the US at 15.3% based on 2007 OECD data (or 9% and 16% respectively according to the Commonwealth fund data). Of that, about two-thirds is public, one third private expenditure. Let’s take a closer look…

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Are Patients in Universal Healthcare Countries Less Satisfied?

ResearchBlogging.orgA dishonest campaign has started against healthcare reform in this country and the first shot has come from Conservatives for Patients Rights (CPR), a group purporting to show that patients in universal health systems suffer from government interference in health care. To bolster their argument, they have a pile of anecdotes from people around the world who have suffered at the hands of evil government-run systems. The problem, of course, is that anecdotes are not data, it is impossible to determine the veracity or reasonableness of these claims, and there is no way, ethically or practically, to respond to claims against doctors in these systems.

And should we be surprised? Every other country in the industrialized world has universal healthcare. Some are government run, single payer systems, others are mixtures of private and public funding to guarantee universal coverage. I would be shocked if you couldn’t find a few people to provide testimonials about how they’re angry at their coverage. After all, Michael Moore made an entire movie about such testimonials against our system.

So what do we do? How do we find out the truth when the ideologues and financially interested parties have started a campaign to muddy the water with anecdotal attacks?

We look at the data of course. And surprise, surprise it doesn’t support CPR’s assertions that our system couldn’t stand some improvement.

During the next couple of weeks, I think we should talk about what healthcare looks like here in the US and around the world. Rather than a few horror stories, let’s take an in-depth look at what’s happening in universal systems, and whether or not we should consider a change.

Let’s start with an examination of some data from the literature on different experiences people have with these healthcare systems.
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