This is another must read article by Atul Gawande regarding how idiotically and unnecessarily expensive our end of life care can be. In the article Gawande has anecdotes that will literally break your heart - you've been warned.
"The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the country’s long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.
Spending on a disease like cancer tends to follow a particular pattern. There are high initial costs as the cancer is treated, and then, if all goes well, these costs taper off. Medical spending for a breast-cancer survivor, for instance, averaged an estimated fifty-four thousand dollars in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy. For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end—to an average of sixty-three thousand dollars during the last six months of life with an incurable breast cancer. Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop."
"In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or 'I’m sorry' or 'I love you.'"
"These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition—advanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isn’t. So everyone struggles with this uncertainty—with how, and when, to accept that the battle is lost. As for last words, they hardly seem to exist anymore. Technology sustains our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are? Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly?"
"Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer. When Cox was transferred to hospice care, her doctors thought that she wouldn’t live much longer than a few weeks. With the supportive hospice therapy she received, she had already lived for a year."
"Two-thirds of the terminal-cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. But the third who did were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive-care unit. Two-thirds enrolled in hospice. These patients suffered less, were physically more capable, and were better able, for a longer period, to interact with others. Moreover, six months after the patients died their family members were much less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation, and to spare their family anguish."
This is a complicated story and Obama's health care plan initially tried to address this problem to some extent - before it was ripped out because of the "Death Panel" controversy:
"Given how prolonged some of these conversations have to be, many people argue that the key problem has been the financial incentives: we pay doctors to give chemotherapy and to do surgery, but not to take the time required to sort out when doing so is unwise. This certainly is a factor. (The new health-reform act was to have added Medicare coverage for these conversations, until it was deemed funding for 'death panels' and stripped out of the legislation.) But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.
But even still, the problem is deeper than this. As a society and as a culture, we just aren't comfortable dealing with death. I'm afraid that given our current political climate, I just don't see how we will get any better any time soon.
Showing posts with label Health Care. Show all posts
Showing posts with label Health Care. Show all posts
Wednesday, August 18, 2010
Tuesday, February 16, 2010
My Analysis of Sensible Conservative Alternatives
I've read a few high level summaries of some conservative proposals to health care reform, but Megan's is a pretty interesting proposal, briefly alluded to here.
First, she doesn't address Medicare which is an entirely different can of worms (old people have especially high health care costs especially end of life care, just as their ability to work and pay for such care degrades).
Her proposal is basically this:
"I think that the argument for catastrophic coverage is much stronger for a variety of reasons, which is why I'd like to see the government pick up the tab for expenses that total more than 15% or 20% of annual income. There's certainly also a case for providing basic care and treatment for certain chronic conditions to the poor, though even in that case, I'd like to see us at least try to handle the problem with a combination of catastrophic insurance, and better income supports. But if that failed--and it might--I'd absolutely support public provisions of those sorts of treatments to lower income Americans, along with no-brainers like prenatal and infant care."
So, in essence, she rejects the idea of health insurance at all for basic day to day health care that really should be paid for out of pocket, and believes it should only be used for catastrophic care that kicks in automatically as it reaches 15 to 20% of your income. In her view (and mine probably), that's probably about the level that, as health care costs rise above it, will push people into bankruptcy. Below that requires a pretty big sacrifice but a sacrifice that won't bankrupt a person. And this kind of health care plan would work well for many (most) people below 65 I'm willing to guess. And would go a long way in reducing cost and injecting efficiencies into the system because consumers of health care would be the ones actually paying directly for that health care.
By the way, this idea is a pretty strong revolutionary departure from our current system, and I have no doubts it would be a big improvement from our current messed up system.
I take some issue with the idea, though, in regards to how it treats those with chronic conditions. If a chronic condition consistently, year after year, puts you at the catastrophic levels, wouldn't 15-20% of your income significantly affect most middle income wage earners ability to do much of anything else useful with that money - say save for college, buy a house, save for other unforeseen expenses. I grant you that one costly health care event in a single year is painful but manageable, but if year after year, you have to take off 15-20% off of your salary for medical expenses - that's a pretty heavy burden.
I say this selfishly because I believe (I haven't run the numbers) that if we had to pay for diabetes care 100% ourselves, we would approach that level pretty quickly almost every year. And you cannot legitimately opt out of health care for chronic conditions without seriously sacrifices your long term health (although some would probably try).
One more point on the catastrophic portion of this plan if applied in a single payer free market environment, those with chronic illness may still be left out. Catastrophes are just more likely when you have chronic illness. So, as McArdle alludes to, this catastrophic insurance would probably have to be government funded or government regulated through an insurance exchange to be effective.
So, lets say we take McArdle's plan: an insurance exchange that offered nothing but catastrophic insurance. Say you throw me a bone and offer the idea of instituting a high risk insurance pool subsidized by government tax payers to make management of chronic disease more in-line cost-wise with current insurance plans. We still pay a lot of out of pocket for our diabetes, but its affordable - we are still able to afford a house, an education, etc. Its affordable because its subsidized.
Then how does this plan compare with the Senate's plan? Not much. You would have to have mandates on the catastrophic care if its provided by an exchange or you pay for it through taxes (another kind of mandate) if its funded by the government.
The high risk pool would be either funded by taxes or by higher premiums for everyone in the regulated exchange.
Basically, if you've given me a single, significant (but in my view necessary) concession to McArdle's plan, her plan is really, really close to the Senate's bill - a bill that McArdle ironically does not support.
First, she doesn't address Medicare which is an entirely different can of worms (old people have especially high health care costs especially end of life care, just as their ability to work and pay for such care degrades).
Her proposal is basically this:
"I think that the argument for catastrophic coverage is much stronger for a variety of reasons, which is why I'd like to see the government pick up the tab for expenses that total more than 15% or 20% of annual income. There's certainly also a case for providing basic care and treatment for certain chronic conditions to the poor, though even in that case, I'd like to see us at least try to handle the problem with a combination of catastrophic insurance, and better income supports. But if that failed--and it might--I'd absolutely support public provisions of those sorts of treatments to lower income Americans, along with no-brainers like prenatal and infant care."
So, in essence, she rejects the idea of health insurance at all for basic day to day health care that really should be paid for out of pocket, and believes it should only be used for catastrophic care that kicks in automatically as it reaches 15 to 20% of your income. In her view (and mine probably), that's probably about the level that, as health care costs rise above it, will push people into bankruptcy. Below that requires a pretty big sacrifice but a sacrifice that won't bankrupt a person. And this kind of health care plan would work well for many (most) people below 65 I'm willing to guess. And would go a long way in reducing cost and injecting efficiencies into the system because consumers of health care would be the ones actually paying directly for that health care.
By the way, this idea is a pretty strong revolutionary departure from our current system, and I have no doubts it would be a big improvement from our current messed up system.
I take some issue with the idea, though, in regards to how it treats those with chronic conditions. If a chronic condition consistently, year after year, puts you at the catastrophic levels, wouldn't 15-20% of your income significantly affect most middle income wage earners ability to do much of anything else useful with that money - say save for college, buy a house, save for other unforeseen expenses. I grant you that one costly health care event in a single year is painful but manageable, but if year after year, you have to take off 15-20% off of your salary for medical expenses - that's a pretty heavy burden.
I say this selfishly because I believe (I haven't run the numbers) that if we had to pay for diabetes care 100% ourselves, we would approach that level pretty quickly almost every year. And you cannot legitimately opt out of health care for chronic conditions without seriously sacrifices your long term health (although some would probably try).
One more point on the catastrophic portion of this plan if applied in a single payer free market environment, those with chronic illness may still be left out. Catastrophes are just more likely when you have chronic illness. So, as McArdle alludes to, this catastrophic insurance would probably have to be government funded or government regulated through an insurance exchange to be effective.
So, lets say we take McArdle's plan: an insurance exchange that offered nothing but catastrophic insurance. Say you throw me a bone and offer the idea of instituting a high risk insurance pool subsidized by government tax payers to make management of chronic disease more in-line cost-wise with current insurance plans. We still pay a lot of out of pocket for our diabetes, but its affordable - we are still able to afford a house, an education, etc. Its affordable because its subsidized.
Then how does this plan compare with the Senate's plan? Not much. You would have to have mandates on the catastrophic care if its provided by an exchange or you pay for it through taxes (another kind of mandate) if its funded by the government.
The high risk pool would be either funded by taxes or by higher premiums for everyone in the regulated exchange.
Basically, if you've given me a single, significant (but in my view necessary) concession to McArdle's plan, her plan is really, really close to the Senate's bill - a bill that McArdle ironically does not support.
Monday, February 15, 2010
Pass.The.Darn.Health.Care.Bill
I've done my fair share of debating about the health care legislation now stalled in Congress. I have no idea what the chances of its passing is. But being the father of a daughter with type 1 diabetes - a preexisting condition that will follow her all her life - I know she will be uninsureable under our current system. She (and I) will have to find refuge under government subsidized employer based insurance. Which means I must find big employers and hope that employer based insurance remains in tact for years to come.
I'm not totally confident that this is my only option. I need to look into it. Type 1 diabetes has a pretty strong community and I'm guessing I will always find ways to make sure she has access to insulin no matter what happens.
But, this system we have is arbitrary, random, inefficient, and insane. The Senate bill goes a long ways to making it less insane and provides some serious steps forward to finding greater efficiencies.
There are fairly serious conservative proposals out there, but if you delve deeper into the more serious proposals that actually make attempts to provide coverage for everyone - they really are not a big departure from the Senate bill.
Detractors claim that the Senate bill is a government takeover. Really? That implies the government isn't already all over our health care system. It is. The bill just makes its involvement a little more obvious, and in doing so, has a greater chance in extending its subsidies more equitably.
Anyway, here's a little anecdote about how insane our current health care system works. In this story, a man has a preexisting condition created from childhood abuse and as a result is literally denied coverage from the single-payer system. He's lucky because he qualified for medicaid, but he has to make sure he stays qualified for medicaid - which means basically, no chance at building up assets for retirement, children's education, or other concerns.
I'm not totally confident that this is my only option. I need to look into it. Type 1 diabetes has a pretty strong community and I'm guessing I will always find ways to make sure she has access to insulin no matter what happens.
But, this system we have is arbitrary, random, inefficient, and insane. The Senate bill goes a long ways to making it less insane and provides some serious steps forward to finding greater efficiencies.
There are fairly serious conservative proposals out there, but if you delve deeper into the more serious proposals that actually make attempts to provide coverage for everyone - they really are not a big departure from the Senate bill.
Detractors claim that the Senate bill is a government takeover. Really? That implies the government isn't already all over our health care system. It is. The bill just makes its involvement a little more obvious, and in doing so, has a greater chance in extending its subsidies more equitably.
Anyway, here's a little anecdote about how insane our current health care system works. In this story, a man has a preexisting condition created from childhood abuse and as a result is literally denied coverage from the single-payer system. He's lucky because he qualified for medicaid, but he has to make sure he stays qualified for medicaid - which means basically, no chance at building up assets for retirement, children's education, or other concerns.
Faces of American Health Care, Part Three: Shane Hutte's Bittersweet Blessing from austin considine on Vimeo.
Saturday, August 8, 2009
I Really Don't Get the Hatred and Anger from the Republicans
On vacation last week, I turned on the TV in our hotel and there was Glenn Beck ranting about how Obama is leading us into socialism or some such. And now there's real fear, palpable, irrational fear that Obama's health care plan is going to lead us right into fascism.
I'm an avid reader of Andrew Sullivan's blog who is a pretty pragmatic moderate conservative who happened to support Barack Obama for president. He had some pretty interesting blog posts today detailing some of the craziness. Craziness I tell you, can someone, anyone explain it to me:
Ok, this one is Sarah Palin who is a certifiable nut.
This one shows some crazy hatred and anger over something they seemed to not understand at all. To quote Sullivan:
"What's fascinating to me is not just the blind fury of the people - it is much more than anger, it is close to explosive - but the bizarre points they are making. One man insists that when the new proposals come into force, his son with cerebral palsy will be denied all care. He is close to murderously adamant about this. But under what interpretation of any of the bills would that be true? Another woman asks heatedly, "Exactly where's the money coming from? Is it coming out of my paycheck? I wanna know if it's coming out of my paycheck--yes or no!" Well, if she has health insurance from her employer, yes it already is coming out of her pay-check in larger and larger amounts. Is she aware of this? Are the Dems planning to tax her to pay for insuring the uninsured? Unless she's very wealthy, no. And these pretty basic misunderstandings are then converted into a simple slogan: "Liberty or Tyranny!""
Or the folks carrying swatsika signs at a Nancy Pelosi townhall.
What's sad is that what's likely to be passed is going to be verrry modest reform and will likely not include a public option and will likely make a few insurance companies even richer, but no matter what, Obama will still be a fascist.
This article was linked by Sullivan's blog makes the strong claim that we should just keep Canada out of our reform debate. They have their system with their challenges. Nobody is arguing we should import it here.
A strong rebuttal on a Noonan's article that Obama is trying to bankrupt America with a new entitlement.
Loved this quote:
"What we have now is what we had in 1993: a radicalized base of a party that simply refuses to accept the legitimacy of another party in government."
And the hypocrisy of the Republican party:
"Now recall the Republicans' last major initiative on healthcare - the prescription drug benefit. That cost $32 trillion over the long run, and there was not even a gesture toward actually financing it. Much of the right was silent - as they were over all the other fiscally reckless policies of the past eight years."
A powerful description over the terms of the debate which the Republican party is inexplicably having a heart attack over.
"The passions out there are somewhat mystifying to me. Here is what we are debating: should we demand that insurance companies provide policies to anyone regardless of pre-existing conditions? Should we help the working poor buy that insurance with subsidies? Are competitive exchanges for health insurance a good or bad thing? Would a public option or a co-op help bring down healthcare costs? Does it make sense for the government to study the effectiveness of various treatments as a guide for doctors? These are all worth debating - and if you break it down into these questions, a majority would back them. Obama's proposals were very, very well illuminated in the campaign; there's nothing here that we weren't told to expect; in fact, he seems over-eager to placate moderates and keep some Republicans within the healthcare reform tent."
Finally, The Republican party is in real danger of just getting dismissed altogether, especially by the young who want no part of a party that has a hint of racism (seriously, only a handful of Republicans voted for Sotomayer, and coincidently one of those Republican Senators, one of the few Hispanic Republicans left at the federal level resigned). And you can't tell me that all of this hatred and fear spewed at Obama has no racial component to it.
Really, the extremes of the party are sounding more and more conspiracy John Birch Society all the time... And moderates are getting pushed out every day.
Its not something I want to see. I love a good healthy debate. Although it may not seem like it, I realize these issues are complicated and I honestly don't know enough about most things to really be sure my views are correct. I love to hear a well thought out, intelligent and informed dissenting opinion. And at the end of the day, I think having respectful discussions about the issues will help us work together toward solutions.
The shouting, the fear, and anger from the more vocal folks in the Republican party is frightening. Of course, you only hear those who are screaming. I know that many moderate, honest thinkers exist in the party. I just hope that civility wins out in the end.
Finally, Sullivan has a series called "View From Your Sickbed", anecdotes to be sure, but indicative about how crazy or current health care system works, here are a few:
View From Your Sickbed
View from Your Sickbed
View from Your Sickbed
I'm an avid reader of Andrew Sullivan's blog who is a pretty pragmatic moderate conservative who happened to support Barack Obama for president. He had some pretty interesting blog posts today detailing some of the craziness. Craziness I tell you, can someone, anyone explain it to me:
Ok, this one is Sarah Palin who is a certifiable nut.
This one shows some crazy hatred and anger over something they seemed to not understand at all. To quote Sullivan:
"What's fascinating to me is not just the blind fury of the people - it is much more than anger, it is close to explosive - but the bizarre points they are making. One man insists that when the new proposals come into force, his son with cerebral palsy will be denied all care. He is close to murderously adamant about this. But under what interpretation of any of the bills would that be true? Another woman asks heatedly, "Exactly where's the money coming from? Is it coming out of my paycheck? I wanna know if it's coming out of my paycheck--yes or no!" Well, if she has health insurance from her employer, yes it already is coming out of her pay-check in larger and larger amounts. Is she aware of this? Are the Dems planning to tax her to pay for insuring the uninsured? Unless she's very wealthy, no. And these pretty basic misunderstandings are then converted into a simple slogan: "Liberty or Tyranny!""
Or the folks carrying swatsika signs at a Nancy Pelosi townhall.
What's sad is that what's likely to be passed is going to be verrry modest reform and will likely not include a public option and will likely make a few insurance companies even richer, but no matter what, Obama will still be a fascist.
This article was linked by Sullivan's blog makes the strong claim that we should just keep Canada out of our reform debate. They have their system with their challenges. Nobody is arguing we should import it here.
A strong rebuttal on a Noonan's article that Obama is trying to bankrupt America with a new entitlement.
Loved this quote:
"What we have now is what we had in 1993: a radicalized base of a party that simply refuses to accept the legitimacy of another party in government."
And the hypocrisy of the Republican party:
"Now recall the Republicans' last major initiative on healthcare - the prescription drug benefit. That cost $32 trillion over the long run, and there was not even a gesture toward actually financing it. Much of the right was silent - as they were over all the other fiscally reckless policies of the past eight years."
A powerful description over the terms of the debate which the Republican party is inexplicably having a heart attack over.
"The passions out there are somewhat mystifying to me. Here is what we are debating: should we demand that insurance companies provide policies to anyone regardless of pre-existing conditions? Should we help the working poor buy that insurance with subsidies? Are competitive exchanges for health insurance a good or bad thing? Would a public option or a co-op help bring down healthcare costs? Does it make sense for the government to study the effectiveness of various treatments as a guide for doctors? These are all worth debating - and if you break it down into these questions, a majority would back them. Obama's proposals were very, very well illuminated in the campaign; there's nothing here that we weren't told to expect; in fact, he seems over-eager to placate moderates and keep some Republicans within the healthcare reform tent."
Finally, The Republican party is in real danger of just getting dismissed altogether, especially by the young who want no part of a party that has a hint of racism (seriously, only a handful of Republicans voted for Sotomayer, and coincidently one of those Republican Senators, one of the few Hispanic Republicans left at the federal level resigned). And you can't tell me that all of this hatred and fear spewed at Obama has no racial component to it.
Really, the extremes of the party are sounding more and more conspiracy John Birch Society all the time... And moderates are getting pushed out every day.
Its not something I want to see. I love a good healthy debate. Although it may not seem like it, I realize these issues are complicated and I honestly don't know enough about most things to really be sure my views are correct. I love to hear a well thought out, intelligent and informed dissenting opinion. And at the end of the day, I think having respectful discussions about the issues will help us work together toward solutions.
The shouting, the fear, and anger from the more vocal folks in the Republican party is frightening. Of course, you only hear those who are screaming. I know that many moderate, honest thinkers exist in the party. I just hope that civility wins out in the end.
Finally, Sullivan has a series called "View From Your Sickbed", anecdotes to be sure, but indicative about how crazy or current health care system works, here are a few:
View From Your Sickbed
View from Your Sickbed
View from Your Sickbed
Tuesday, August 4, 2009
The Health Care Debate
Health care obviously is the new hot topic for those of us who are passionate about our politics, and for good reason. Obama was trying desperately to get something through Congress and he's now looking to get something passed this year. In this space, I don't want to try to answer the question, "What's the hurry", I've heard this addressed elsewhere, but really there is no hurry.
Obama is not trying to completely overturn health care from something we have now to something much, much different. He's trying to improve the system incrementally, slowly, in hopes of moving it toward something better. This is the right approach. Health care makes up 20% of our economy, we spend something like $2 trillion dollars on health care costs every single year. And the cost is going up. Because costs are going up faster than inflation and because costs are so expense, we desperately need reform. Health care expenses, more than anything else, is the biggest threat to our nation's long term solvency. But because its so complicated, we need to move reform incrementally, and that's exactly what Obama and Congress is looking to do.
And we need to move reform incrementally because that is the only sane way to do it, and incrementally is the usual way its been done. This really thoughtful essay on health care reform spends some time on how other countries went about providing universal access to its citizens.
"Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy."
and
"This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.
Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have."
and his take on Massachusett's plan is enlightening:
"Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents. It didn’t organize a government takeover of the state’s hospitals or insurance companies, or force people into a new system of state-run clinics. It built on what existed. On July 1, 2007, the state began offering an online choice of four private insurance plans for people without health coverage. The cost is zero for the poor; for the rest, it is limited to no more than about eight per cent of income. The vast majority of families, who had insurance through work, didn’t notice a thing when the program was launched. But those who had no coverage had to enroll in a plan or incur a tax penalty."
And the vast majority of those folks who live there don't want to go back.
The problem is that those who oppose reform make arguments that just don't make sense. Calling Obamacare socialist or worse.
I was recently sent this youtube link with John Stossel's take on health care. And he constantly kept comparing health care with cars or food. And providing a false choice between what we have now and Soviet Union socialism. Providing Michael Moore as the one opposing voice. Cherry picking facts about specific short comings of the Canadian system. John Stossel is a libertarian ideologue. Nothing wrong with that, but we need to have a sensible discussion on this issue. Stossel made some interesting points, but he also failed to address many of the specific problems with our system, problems he even brings up on this show.
And Stossel offers one of the most sensible voices of opposition to health care reform. Most are just nonsense, plain and simple.
I hope that we can all agree that everyone should have access to health care. The US system has, more or less provided a model for it over the years, and its largely a patchwork. Medicare for the elderly , medicaid for the poor (systems most similar to Canada's), veteran's have their system (a system modeled after the UK's). Most everyone else is covered through an employer provided insurance. And a big employer acts in many ways like a government would. Big companies have enough employers to be covered by a single insurance company (I have a choice of two) and negotiate a single rate for all of its employees regardless of a person's health. And they won't be kicked out if they get expensive. I haven't tested this yet and I'm not sure about it, but generally speaking I think employer based insurance will cover even pre-existing conditions?
I say I'm not sure because I have a diabetic daughter. If I lose my job (and my insurance) should I pay for COBRA (which is very expensive and would quickly eat away my savings) to avoid having an insurance gap? I think so, but I need to find out for sure.
But there are millions of Americans who are forced into the individual markets because they are either self-employed or work for an employer who doesn't provide insurance. Many others lose their insurance when they lose their jobs. Employer based plans are no-where near optimal and we need to either augment it with something else.
In my opinion, any health insurance plan must have the following attributes:
1) Cannot kick someone off the plan as soon as they get too expensive.
2) Cannot kick someone off the plan because of pre-existing conditions.
3) Uniform premiums to everyone regardless of health.
4) Everyone most be required to have insurance.
5) The poor must be given assistance so that no one is unable to afford coverage.
This is the basic model of the Massachussett's plan. And its a good one.
The fact is that currently insurance companies have an economic incentive to kick people off their plans if they get expensive. They'll make the applications confusing and complicated, and they'll allow you to pay the premiums, but if you get diagnosed with an expensive to treat illness, your application will be scrutinized to find a reason to kick you out.
The simple fact is the young and healthy have to subsidize care for those who are old and sick. If you have a system where the healthy choose not to pay for it, it becomes prohibitively expensive for those who need it. Since everyone is going to get old sometime, it makes some sense to spread the cost to everyone.
The final issue that must be dealt with in the health care debate is cost, and this is a tricky issue also dealt with in this excellent essay and its analysis of the county that provides the most expensive health care per person in the country.
The problem is that doctors have an economic incentive to over-do medicare treatment. They are paid per visit/per surgery/per drug prescription.
One example:
"Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars."
But cost and quality do not go together:
"This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care."
and
"That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes."
and finally:
"As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future."
Health care is an intensely complicated and important subject. It deserves pragmatic and careful thought and discussion. As human beings we tend to think through issues with ideological blinders. Lets not be ideological about our health.
Obama is not trying to completely overturn health care from something we have now to something much, much different. He's trying to improve the system incrementally, slowly, in hopes of moving it toward something better. This is the right approach. Health care makes up 20% of our economy, we spend something like $2 trillion dollars on health care costs every single year. And the cost is going up. Because costs are going up faster than inflation and because costs are so expense, we desperately need reform. Health care expenses, more than anything else, is the biggest threat to our nation's long term solvency. But because its so complicated, we need to move reform incrementally, and that's exactly what Obama and Congress is looking to do.
And we need to move reform incrementally because that is the only sane way to do it, and incrementally is the usual way its been done. This really thoughtful essay on health care reform spends some time on how other countries went about providing universal access to its citizens.
"Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy."
and
"This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.
Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. The system provides more than thirty-five million hospital stays a year, sixty-four million surgical procedures, nine hundred million office visits, three and a half billion prescriptions. It represents a sixth of our economy. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have."
and his take on Massachusett's plan is enlightening:
"Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents. It didn’t organize a government takeover of the state’s hospitals or insurance companies, or force people into a new system of state-run clinics. It built on what existed. On July 1, 2007, the state began offering an online choice of four private insurance plans for people without health coverage. The cost is zero for the poor; for the rest, it is limited to no more than about eight per cent of income. The vast majority of families, who had insurance through work, didn’t notice a thing when the program was launched. But those who had no coverage had to enroll in a plan or incur a tax penalty."
And the vast majority of those folks who live there don't want to go back.
The problem is that those who oppose reform make arguments that just don't make sense. Calling Obamacare socialist or worse.
I was recently sent this youtube link with John Stossel's take on health care. And he constantly kept comparing health care with cars or food. And providing a false choice between what we have now and Soviet Union socialism. Providing Michael Moore as the one opposing voice. Cherry picking facts about specific short comings of the Canadian system. John Stossel is a libertarian ideologue. Nothing wrong with that, but we need to have a sensible discussion on this issue. Stossel made some interesting points, but he also failed to address many of the specific problems with our system, problems he even brings up on this show.
And Stossel offers one of the most sensible voices of opposition to health care reform. Most are just nonsense, plain and simple.
I hope that we can all agree that everyone should have access to health care. The US system has, more or less provided a model for it over the years, and its largely a patchwork. Medicare for the elderly , medicaid for the poor (systems most similar to Canada's), veteran's have their system (a system modeled after the UK's). Most everyone else is covered through an employer provided insurance. And a big employer acts in many ways like a government would. Big companies have enough employers to be covered by a single insurance company (I have a choice of two) and negotiate a single rate for all of its employees regardless of a person's health. And they won't be kicked out if they get expensive. I haven't tested this yet and I'm not sure about it, but generally speaking I think employer based insurance will cover even pre-existing conditions?
I say I'm not sure because I have a diabetic daughter. If I lose my job (and my insurance) should I pay for COBRA (which is very expensive and would quickly eat away my savings) to avoid having an insurance gap? I think so, but I need to find out for sure.
But there are millions of Americans who are forced into the individual markets because they are either self-employed or work for an employer who doesn't provide insurance. Many others lose their insurance when they lose their jobs. Employer based plans are no-where near optimal and we need to either augment it with something else.
In my opinion, any health insurance plan must have the following attributes:
1) Cannot kick someone off the plan as soon as they get too expensive.
2) Cannot kick someone off the plan because of pre-existing conditions.
3) Uniform premiums to everyone regardless of health.
4) Everyone most be required to have insurance.
5) The poor must be given assistance so that no one is unable to afford coverage.
This is the basic model of the Massachussett's plan. And its a good one.
The fact is that currently insurance companies have an economic incentive to kick people off their plans if they get expensive. They'll make the applications confusing and complicated, and they'll allow you to pay the premiums, but if you get diagnosed with an expensive to treat illness, your application will be scrutinized to find a reason to kick you out.
The simple fact is the young and healthy have to subsidize care for those who are old and sick. If you have a system where the healthy choose not to pay for it, it becomes prohibitively expensive for those who need it. Since everyone is going to get old sometime, it makes some sense to spread the cost to everyone.
The final issue that must be dealt with in the health care debate is cost, and this is a tricky issue also dealt with in this excellent essay and its analysis of the county that provides the most expensive health care per person in the country.
The problem is that doctors have an economic incentive to over-do medicare treatment. They are paid per visit/per surgery/per drug prescription.
One example:
"Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars."
But cost and quality do not go together:
"This is a disturbing and perhaps surprising diagnosis. Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest fifteen per cent of the country—$6,688 per enrollee in 2006, which is eight thousand dollars less than the figure for McAllen. Two economists working at Dartmouth, Katherine Baicker and Amitabh Chandra, found that the more money Medicare spent per person in a given state the lower that state’s quality ranking tended to be. In fact, the four states with the highest levels of spending—Louisiana, Texas, California, and Florida—were near the bottom of the national rankings on the quality of patient care."
and
"That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits. In recent years, we doctors have markedly increased the number of operations we do, for instance. In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans. No other country does anything like as many operations on its citizens. Are we better off for it? No one knows for sure, but it seems highly unlikely. After all, some hundred thousand people die each year from complications of surgery—far more than die in car crashes."
and finally:
"As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future."
Health care is an intensely complicated and important subject. It deserves pragmatic and careful thought and discussion. As human beings we tend to think through issues with ideological blinders. Lets not be ideological about our health.
Tuesday, March 17, 2009
Health Care
If you're interested in health care, listen to this really great podcast on Fresh Air. Its in two segments, the first, a New York Times reporter talks about how her brother who suffered from kidney failure was denied coverage by the insurance company he'd been paying insurance premiums on. The second segment is an interview with a health care economist who discusses what's potentially ahead for our health care system.
What about our current system is deplorable:
1) Different patience get charged different rates based on the negotiating positions they happen to be in. Medicare and Medicaid insurance claims actually pay less then the cost to service the patience under those systems. Those under the single payer system pays a lot more....
2) Having your insurance tied with your employment is a horrible system. You lose your job, you lose your insurance and if your forced to go uninsured for some period of time and want to buy back into the system, you are at risk if you have pre-existing conditions. This sort of insurance is a complete accident, by the way, the came to us in WWII. During the war, government limited how much companies could pay employees in wages, the goal was to suppress wages during a severe labor shortage, when demand for goods were high and many of our workers were fighting and dying in Europe and Asia. To entice workers, employers started to offer health insurance, and that is the system we've lived with all of these years.
3) Insurance companies are in the business not to pay for claims, forcing doctors and hospitals to constantly haggle over payouts. As a result, the US pays by far the most for health care costs of any country in the world, but we are at the bottom in general satisfaction of our health care, and we are not near the top in the results we get out of the system (e.g. life expectancy, etc.)
4) If you are uninsured or under-insured, and you get sick with say diabetes, we do a terrible job in making sure you can pay for preventive care. But if the disease progresses far enough, when the treatment becomes really expensive, government will step in and finally pay for care...
Solutions - Obama has some nice solutions
1) He's going to extend government backed insurance plans (like Medicare and Medicaid) to a broader population - so that health insurance is more broad based, affordable and available to everyone. So that anyone, even those with pre-existing conditions can be treated.
2) Private insurers won't like option 1) because they fear they won't be able to compete with a plan that is backed by the government - and they are probably right, so there's a good possibility that 1) could lead us to a government provided single insurance coverage similar to Canada's or Europe's system over time.
3) Because of 2), what will instead happen is that private insurers will agree to new reforms in the way they handle health insurance:
a) They will no longer be able to deny coverage to folks with pre-existing conditions.
b) They will have to offer consistent and constant rates to everyone.
c) For options a & b to be profitable for insurance companies, government law will have to change requiring everyone - even the young and healthy to have health insurance. Otherwise the young and healthy won't pay for it until they need it, and insurance companies will no longer be able to deny them coverage. This system would bankrupt coverage.
4) Americans face a cognitive dissidence with regard to health insurance - we expect hospitals to take care of us say if we are injured in a car accident, but we don't want government to force us to buy health insurance. If we demand treatment when sick or injured, we have an obligation to pay into the system that provides this care.
5) Right now is our best and perhaps only chance to reform our health care system - we have a motivated president who has smart policy proposals in place. We are experiencing a massive economic crisis, where people for the first time in a long time are legitimately afraid of losing their jobs and their health care. The politics is moving toward a place to make reform possible. Let's hope it happens.
And that fools like Glenn Beck who seriously believes Obama is leading our country down a path toward totalitarianism won't kill sensible health care reform...
The good news (or bad news depending on your perspective) is that Beck and Limbaugh are leading the Republican party toward marginalism. But a marginalized Republican party might give Obama the space he needs to reform health care.
So, maybe I should say, keep it up Beck and Limbaugh, you're turning off Americans by the day.
What about our current system is deplorable:
1) Different patience get charged different rates based on the negotiating positions they happen to be in. Medicare and Medicaid insurance claims actually pay less then the cost to service the patience under those systems. Those under the single payer system pays a lot more....
2) Having your insurance tied with your employment is a horrible system. You lose your job, you lose your insurance and if your forced to go uninsured for some period of time and want to buy back into the system, you are at risk if you have pre-existing conditions. This sort of insurance is a complete accident, by the way, the came to us in WWII. During the war, government limited how much companies could pay employees in wages, the goal was to suppress wages during a severe labor shortage, when demand for goods were high and many of our workers were fighting and dying in Europe and Asia. To entice workers, employers started to offer health insurance, and that is the system we've lived with all of these years.
3) Insurance companies are in the business not to pay for claims, forcing doctors and hospitals to constantly haggle over payouts. As a result, the US pays by far the most for health care costs of any country in the world, but we are at the bottom in general satisfaction of our health care, and we are not near the top in the results we get out of the system (e.g. life expectancy, etc.)
4) If you are uninsured or under-insured, and you get sick with say diabetes, we do a terrible job in making sure you can pay for preventive care. But if the disease progresses far enough, when the treatment becomes really expensive, government will step in and finally pay for care...
Solutions - Obama has some nice solutions
1) He's going to extend government backed insurance plans (like Medicare and Medicaid) to a broader population - so that health insurance is more broad based, affordable and available to everyone. So that anyone, even those with pre-existing conditions can be treated.
2) Private insurers won't like option 1) because they fear they won't be able to compete with a plan that is backed by the government - and they are probably right, so there's a good possibility that 1) could lead us to a government provided single insurance coverage similar to Canada's or Europe's system over time.
3) Because of 2), what will instead happen is that private insurers will agree to new reforms in the way they handle health insurance:
a) They will no longer be able to deny coverage to folks with pre-existing conditions.
b) They will have to offer consistent and constant rates to everyone.
c) For options a & b to be profitable for insurance companies, government law will have to change requiring everyone - even the young and healthy to have health insurance. Otherwise the young and healthy won't pay for it until they need it, and insurance companies will no longer be able to deny them coverage. This system would bankrupt coverage.
4) Americans face a cognitive dissidence with regard to health insurance - we expect hospitals to take care of us say if we are injured in a car accident, but we don't want government to force us to buy health insurance. If we demand treatment when sick or injured, we have an obligation to pay into the system that provides this care.
5) Right now is our best and perhaps only chance to reform our health care system - we have a motivated president who has smart policy proposals in place. We are experiencing a massive economic crisis, where people for the first time in a long time are legitimately afraid of losing their jobs and their health care. The politics is moving toward a place to make reform possible. Let's hope it happens.
And that fools like Glenn Beck who seriously believes Obama is leading our country down a path toward totalitarianism won't kill sensible health care reform...
The good news (or bad news depending on your perspective) is that Beck and Limbaugh are leading the Republican party toward marginalism. But a marginalized Republican party might give Obama the space he needs to reform health care.
So, maybe I should say, keep it up Beck and Limbaugh, you're turning off Americans by the day.
Saturday, November 22, 2008
My daughter has diabetes, all eyes on Barack Obama and his health care bills
The past few days have been a pretty emotional time. Its definitely not an easy thing to hear that that your six your old daughter has been diagnosed with a lifetime chronic illness for which there is no cure, for which she will have to take shots with every meal, for which she will have to count carbohydrates every time she eats and try to match the precise amounts of insulin to match those sugars so her body can get the energy she needs.
We now face a lifetime of blood sugar measurements, worrying about blood sugar too high or too low, worrying about whether an unsuspecting Sunday School teacher gives her a cupcake without telling us... Lots of people worry about this, so definitely we're not alone, we're far from unique. But it is a lot to take in.
But more than that, I've always had job anxieties. I grew up with my dad counting on the fact that he had healthy children because there were many times we lived lives without health insurance, taking trips across the boarder to get dental work done in a third world country with third world prices.
Our health care system sucks, agreed? I now live in a world, where if I lose my job and have trouble getting another one, not only will I lose my health insurance and potentially lose affordable access to insulin and suringes and blood sugar measurement tools (I'm sure there are always was to get what I need, so I'm not too worried except I'm sure I'll have to fight for everything I get), but I will have a very hard time getting Lizzie back into the health insurance system at least at affordable rates. Because health insurance companies don't want someone on their rolls that may have a lifetime of medical costs. Maybe I'm wrong with this, but that's my impressions right now.
So, I'm pretty happy right now, more happy than I was before, that Barack Obama won the election. This election matters more to me now than it did before. Because we need a health care system for everyone, we need insurance that doesn't kick folks with chronic disease out of the system.
I have now moved from the camp where I've been subsidizing some of your health care to the camp where I need you to subsidize some of mine. I know its easier to want a little societal welfare when you need it than when they want you to provide it.
But right now, I want a health care system where the healthiest of us are paying a bit more, so that the sickest don't have to pay so much. A little socialist of me? Maybe, but Darwin doesn't have to be right. We should not want to live in a world of "survival of the fittest", we should want a world where survival is an option for everyone.
And one more thing, for the un-initiated, type-1 diabetes is where the pancreas just shuts down and stops producing insulin. There's no known cause, no known cure. It can happen anytime and has nothing to do with the person's lifestyle pre-diagnosis (at least nothing that we know about). People think of it as an auto-imune disease, where the body starts attacking the cells in the pancreus that produce the insulin. I'm only just learning this sort of stuff, though, so maybe more later.
At any rate, this is a bit of my post-diabetes commentary with a little political spin (everything is politics with me).
We now face a lifetime of blood sugar measurements, worrying about blood sugar too high or too low, worrying about whether an unsuspecting Sunday School teacher gives her a cupcake without telling us... Lots of people worry about this, so definitely we're not alone, we're far from unique. But it is a lot to take in.
But more than that, I've always had job anxieties. I grew up with my dad counting on the fact that he had healthy children because there were many times we lived lives without health insurance, taking trips across the boarder to get dental work done in a third world country with third world prices.
Our health care system sucks, agreed? I now live in a world, where if I lose my job and have trouble getting another one, not only will I lose my health insurance and potentially lose affordable access to insulin and suringes and blood sugar measurement tools (I'm sure there are always was to get what I need, so I'm not too worried except I'm sure I'll have to fight for everything I get), but I will have a very hard time getting Lizzie back into the health insurance system at least at affordable rates. Because health insurance companies don't want someone on their rolls that may have a lifetime of medical costs. Maybe I'm wrong with this, but that's my impressions right now.
So, I'm pretty happy right now, more happy than I was before, that Barack Obama won the election. This election matters more to me now than it did before. Because we need a health care system for everyone, we need insurance that doesn't kick folks with chronic disease out of the system.
I have now moved from the camp where I've been subsidizing some of your health care to the camp where I need you to subsidize some of mine. I know its easier to want a little societal welfare when you need it than when they want you to provide it.
But right now, I want a health care system where the healthiest of us are paying a bit more, so that the sickest don't have to pay so much. A little socialist of me? Maybe, but Darwin doesn't have to be right. We should not want to live in a world of "survival of the fittest", we should want a world where survival is an option for everyone.
And one more thing, for the un-initiated, type-1 diabetes is where the pancreas just shuts down and stops producing insulin. There's no known cause, no known cure. It can happen anytime and has nothing to do with the person's lifestyle pre-diagnosis (at least nothing that we know about). People think of it as an auto-imune disease, where the body starts attacking the cells in the pancreus that produce the insulin. I'm only just learning this sort of stuff, though, so maybe more later.
At any rate, this is a bit of my post-diabetes commentary with a little political spin (everything is politics with me).
Friday, October 31, 2008
What I just learned on Health Care
1. The US currently spend $2 trillion/year on health care, much more than any other country in the world. There's plenty of money to make all sorts of changes in this area.
2. On top of that, government is heavily subsiding our health care system, big government already has its hands all over our system.
3. John McCain's plan is a big improvement over our current system. Barack Obama's plan is a much, much bigger improvement over our current system. Basically, our current system sucks.
4. If we could just get over our hang ups with big government, we would open ourselves up to major improvements in health care. You simply cannot have a fair, equitable and just system without government involvement. Our current system would be much, much worse if government wasn't involved. Get over it people.
2. On top of that, government is heavily subsiding our health care system, big government already has its hands all over our system.
3. John McCain's plan is a big improvement over our current system. Barack Obama's plan is a much, much bigger improvement over our current system. Basically, our current system sucks.
4. If we could just get over our hang ups with big government, we would open ourselves up to major improvements in health care. You simply cannot have a fair, equitable and just system without government involvement. Our current system would be much, much worse if government wasn't involved. Get over it people.
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