Thursday, October 20. 2011
I spent the last four days observing the notorious US health care system in action. My wife underwent surgery, and I mostly hung out, observing. I had been reading more than my share of nightmare stories, but it all went about as well as it could. The case was complicated, but the surgeon and her team seemed to understand it and appreciate the intricacies. The surgery itself went quicker and smoother than anticipated, and the projected three day hospital stay was cared for with patient confidence. There were a few problems that cropped up -- too-frequent oxygen saturation warnings, nausea coming out of the anesthesia -- but they were recognized and sorted out. The nursing staff was far more attentive than I recalled from ten years ago when my parents had extended hospital stays, or my wife's previous surgery when she was booted out of the hospital with unseemly (and as it turned out unfortunate) haste. The room was private, and I was invited to stay as long as I wanted -- 24 hours a day. I even found the nurses asking if there was anything they could do to help me. I managed to be present pretty much every time a doctor came by, and every step was intelligibly explained. It helped that my wife was fully cognizant of the whole process, and always knew what she needed to work on when to make progress. In short, it was pretty close to ideal: the way a hospital should work. No doubt the bill was damn expensive, but I didn't get the sense of wasted effort or overtreatment.
It no doubt helped that the surgery was a well understood procedure, and that the treatment was very closely aligned with it. My wife had no significant illness going into the surgery. That is, for instance, a very different situation from the one where my father entered the hospital with MDS, being treated by a staff of cardiologists who had no idea what they were up against, who made one mistake after another before they finally dumped him off on a doctor who had a clue. Or I could dredge up other cases from my own limited personal experience. (E.g., when my father spent four days in surgical ICU due to a lung infection that defied their treatment until it was fully cultured and identified. Or when my father-in-law was prescribed a drug for an eye problem but given a drug that crashed his blood sugar level, which then resulted in several days of unpleasant tests investigating his presumed hypoglycemia.)
Still, it isn't hard to imagine lots of things that could have gone wrong here that didn't. For one thing, the hospital had instituted a software system that tracked drug doses and interactions -- probably the samd system the VA hospitals are famous for: it slowed the nurses down repeatedly scanning patient and drug barcodes, but it eliminates errors that elsewhere are astonishingly frequent (I recently read as much as one per patient per day). The ratio of nurses to patients was higher than I had ever seen outside of an ICU. We never had to wait more than 1-2 minutes after calling a nurse, and they were never in an excessive rush to go elsewhere. Occasionally I would step out into the hall and see one at a computer . . . looking at what appeared to be continuing ed materials.
I suspect that this was a rare case where business competitiveness served to improve the care level: well-insured patients could choose to come to this hospital vs. the other competitor, and for the types of surgeries this particular ward handled there was enough profit to be made to reinvest some in quality service. So to some extent you can chalk this experience up as a victory for the American system (although as my wife is on Medicare I don't give any credit to the private profit-seeking insurance companies). Still, this doesn't argue that health care reform is not necessary. Rather, this reminds us that a reformed system has to maintain this sort of quality level, and to extend it more evenly and equitably. And it reminds me that it can be done, for even if this particular case represents a shrewd business decision on how to run a wing as a profit center, one key reason it succeeded is that the people working there were free to serve without having to constantly recalibrate their actions in favor of padding the business' bottom line.
Personal note: we're back home today. My wife still has a ways to go to get back to normal, but that seems certain to happen in due course. And I need some sleep, but that too will happen.
Tuesday, September 27. 2011
Op-ed in the Wichita Eagle this morning, by Dr. Margaret Flowers: Medicare for all would save lives and money. Flowers is co-chair of the Maryland chapter of Physicians for a National Health Program (PNHP), a minor celebrity for getting arrested protesting in Washington trying to get single-payer back on the Democrats' agenda. (See her interview by Bill Moyers). She's in Wichita today, to give a talk at the Murdoch Theater tonight.
I'm going to quote the whole piece below, but break it up so I can get some words in edgewise. What she has to say is fundamentally right but incomplete and inadequate, so I want to build on that.
I believe the "37th" figure is rank based on average longevity -- one of many measures where the US has mediocre performance. The rub there is "average" given how inequitably health care services are distributed among Americans. Of course, most Americans think they're well above average, and they're right that the stats are distorted by those who aren't. It's just that they have trouble understanding how easily, and how arbitrarily, one can slip and fall into the other. Reminds me of the DC sniper story: one moment you're out on a routine shopping trip, next you're cut down by an invisible assassin's bullet. Isolated individuals can get fired, lose their insurance, suffer a debilitating illness or accident, go bankrupt, almost as suddenly.
Last time I checked, the health care sector accounted for 18% of GDP, with 20% projected not too far off. Back when Clinton tried to pass his scheme in 1993-94 the number was 14%. It's a bit simplistic to translate these figure to the current budget quandry -- only part of the total health care bill goes to the government, and most of that goes to Medicare and Medicaid which are funded on a different set of books -- but the longterm prognosis is bleak: the industry is set on a path to devour the economy, and while it's not clear where the choke point is, it's clear that something has to give sooner or later. You can't sustain infinite growth indefinitely, yet the logic of the investors demands that they try.
It's worth noting that until 1990 Switzerland had virtually the same health care cost structure that the US had, with both pulling away from the rest of the world. But where the US continued on its profit-seeking path, Switzerland clamped down and forced its private insurance companies to be run as non-profits, and that simple act stabilized their cost structure. Switzerland still has the world's second most expensive health care system, but as a percentage of GDP is is virtually the same as it was in 1990. As T.R. Reid shows in The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, there are lots of ways to manage health care costs without giving up progress and quality, but the essential element of all of them is to limit profit-seeking.
The ACA does provide some measure of cost controls -- enough to claim to be revenue-neutral while providing insurance for many more people than are currently covered. (I don't know where this "23 million uninsured through 2019" figure comes from -- that's way more than I had been led to believe, although it's always been clear that the ACA scheme wouldn't provide universal coverage.) The main problem is that by leaving most people without any sort of non-profit health insurance option the profit-seeking private insurance companies will have no competition and therefore very little restraint on their ability to increase costs.
There are various approaches to containing Medicare/Medicaid costs -- all unpopular with vendors who are conditioned to feel the pinch even before it arrives -- but the most serious attacks on Medicare have been schemes to increase costs, mostly by pushing Medicare recipients into private insurance plans. The so-called Medicare Advantage plans were a prime example. Obama's offer to raise the eligibility age for Medicare is even more ominous. The rationale there is to move costs off the federal budget and onto people who will wind up paying much more -- in their lives even more than money.
Medicare does bear some responsibility for rising health care costs, especially early in its history from 1965 into the 1980s: by agreeing to pay "customary" fees to hospitals and doctors they basically handed out blank checks, which vendors took advantage of to constantly roll up prices much faster than the inflation rate. By the 1980s, prices had risen so much that the government started to impose restraints. At the same time, the industry was becoming more profit-seeking, with vendors working persistently to game their way around the rules.
On the other hand, Medicare is vastly more efficient than private insurance companies, imposing much less overhead -- close to 3% vs. 30% for private insurance companies.
There's no doubt that a single-payer insurance system would be the single most effective way to improve our current health care industry, and that it would be the single most important step to solving the longterm problems endemic to the current system. As we generally understand the term, it also represents an important commitment to universal health care, and all that implies -- the sense that as a people we share responsibility for each other's welfare, and that as a democracy we believe that the government exists to serve the people and take purposeful collective action for our behalf.
That last sentence, of course, is anathema to the faction of the American people known as Republicans. They've lately been obsessed with disempowering people -- with scaring poor people away from the polls (where they might vote their self-interest), with busting unions, with preventing people from appealing to the regulators and/or the courts for protection from corporate abuses. They're upset that banks should be limited from scamming customers, or each other. And they'd rather die than cramp the freedom of the health care industry to price gouge, overtreat, undertreat, or commit the occasional malpractice. They won't even allow Medicare to negotiate the price of drugs -- just send more blank checks.
The biggest advantage of single-payer is simplification: everyone gets the same insurance, so nobody has to market a bunch of differences; every vendor gets paid filing out one standard set of forms, instead of having to work up different coding schemes one for each separate insurance company each with its own schedules and formularies and pencil pushers dedicated to the easiest way to improve the company's bottom line: by denying benefits. You also get rid of the collection agencies pursuing bills the insurance companies denied, and the bankruptcy lawyers. This also eliminates the need for vendors to overcharge paying customers for those who don't pay, which starts to bring prices back in line with costs.
Universal coverage also solves a lot of problems. It means, for instance, when when you're wheeled into the emergency room, the first person you see is someone trying to help you, rather than trying to pick your pocket. (A big problem now is emergency rooms dodging patients so they don't get stuck with the bill.) It means that your car insurance costs will drop since one can safely assume that future medical costs will be covered. It means that malpractice damages will be reduced (for the same reason, although not having to cover the lawyer's premium is a bonus). It means that people can move more freely from job to job, can retire early, or can afford to start new businesses without worrying about losing their coverage.
So single-payer insurance with universal coverage would produce an enormous cost savings right from the start. It would also eliminate one of the main forces behind the persistent inflation of costs -- the private profit-seeking insurance companies -- and it would provide the basis for negotiating fair and manageable compensation for the vendors. But to get there, we have to get past the political obstacles, which is mostly the desire of a certain political party (and a few of its admirers in the "loyal opposition") to preserve a system of larcenous capitalism exploiting our deepest health fears, and their key ploys: that everyone should pay their own way, that no one (other than the companies) should organize, that progress is magically linked to free enterprise, that trampling on the prerogatives of billionaires will destroy "our way of life," that your democratically elected government is set on killing you first chance they get. It shouldn't take much thought to realize that all this is nonsense -- which is a good part of the reason they work so hard to keep you from thinking.
I meant to get the above done and posted before the lecture, but ran out of time. Big crowd. Bottom floor was about 80% full when we got there, so we went up to the balcony, which wound up about 30% full. Flowers dispelled most of my reservations. She advocated something more than current Medicare for all, calling for an Expanded & Improved Medicare which among other things would dispense with the co-payments and limits of the current program. (Those seem to be carved out mostly to support private secondary insurance programs. People who buy such insurance often feel like they're paying for their own insurance when they're actually just tipping a company that assumes virtually no risk.) Especially when reformers talk about cost control, people get nervous that their benefits will be cut -- ignoring that the cost controls of private insurance companies are far more restrictive, and much harder to appeal, than anything Medicare might do. Still, my recommendation is to pitch single-payer less as a way to manage costs and provide universal coverage than as the essential way to improve health care quality.
Flowers actually did a pretty good job of explaining why this is so. She pointed out that under the current system many people are overtreated, many are undertreated, and many are mistreated. A single-payer system would provide more consistent coverage, more consistently in line with evidence-based best practices, with greater transparency. She called for efforts to realign doctors' incentives with better outcomes -- no simple task, but the focus should be less on paying doctors more for the desired results than on disinteresting doctors from the financial impact of their treatment options. She called for better resource planning, noting that it is more effective to have centers in a given area specialize than to have them compete across the board, adding excess capacity which they then have a stake in filling up. She fielded a question on malpractice, correctly noting (as I did above) that bad outcomes wouldn't have to be budgeted ahead of time, and that there were other ways to limit the expense. She suggested paying centers to maintain a given level of capacity regardless of utilization instead of having them risk overbuilding then have to figure out how to make it pay off.
Someone asked about high technology driving costs up, and she covered various aspects of this, especially how patentability distorts pharmaceutical research. She pointed out that most of the real research is public-funded, especially by NIH. She didn't go as far as I would in eliminating patents and promoting more competitive sourcing, and she didn't point out how proprietary research has been used to hide drug defects, and how this in turn has led to massive class action suits that have cost companies billions of dollars (as well as patients thousands of lives -- another area where reform promises to improve quality).
She also pointed out that the health care industry, huge as it is, only affects a limited aspect of public health: much more important is a clean environment, safe workplaces, education, good food, security from crime and violence, the sense of shared responsibility that comes with an equitable society -- not her phrasing but that's the gist of it. So a political system that has been captured by corporate profiteers has not only turned health care into a system for reaping enormous profits but has done so by corrupting the very nature of democracy. Change the latter and fixing the health care system becomes easy; fail to do so and the system will lurch on until it falls apart, to our great horror.
Thursday, January 20. 2011
I know we've been hearing about this happening for the last couple of weeks, and nothing is more inevitable than the entire House Republican caucus voting in lockstep with their one homogenized mind, but still I felt shock when they passed their health care reform repeal. How can anyone be so ignorant as to think that returning to to the status quo ante solves our health care problems? Or even crazier, that there were no problems pre-Obama? There are lots of problems with the Obama reforms, but none will be solved by repealing the law. Indeed, the need to spend political capital to defend the law makes it all the more difficult to fix the real problems that remain.
The saving grace, of course, is that with a Democratic majority in the Senate and a Democratic president, actual repeal has no chance: it is basically a symbolic gesture, a way of reminding us of the Republican commitment to letting the health care system run as a racket. Indeed, the main point of the Republicans' anti-regulation, pro-business agenda looks to be the elimination of all constraints on corporation efforts to rip consumers and workers off. This rarely happens more explicitly than in their fight against consumer protections against the finance industry, although you see it in everything they do, from loosening up pollution restrictions to protecting corporations from being sued for their malfeasances to letting every profit-seeking company in the health care industry shake you down in any way they can imagine.
Living under Republican power -- and I remind you I live in Kansas -- is a lot like trying to navigate through a squalid neighborhood ruled by gangs. Once they bought the idea that greed makes the world go round, indeed that it makes anything and everything all right, they concluded that the sole purpose of government was as a patronage racket -- reward one's friends, and render everyone else powerless so the no one can stand up to the plunder.
That may seem like an extreme charge, but it's hard to find any more benign explanations. Sometimes they cloak their agenda in platitudes, but often they just let it all hang out. If they ever manage to do what they say they want to do, that will be the end of anything approaching affluence in America, indeed the end of civil society.
This at least is something the Democrats can rally around, like a few other Republican targets (like Social Security). Still, a better offense would help the defense. The main thing that's happened since health care reform passed here in Wichita is that one of the largest physician groups, Wichita Clinic, has sold out to Wichita's largest hospital business, Via Christi, while Gallichia Hospital -- the most reputable of the physician-owned hospitals -- has sold out to HCA, which runs Wichita's other major hospital, Wesley. This concentration gives the big hospitals more political muscle and less competition. The sellers, of course, make more money than they could make running their own businesses because the buyers know they can make even more running their monopolies. And the money comes cheap to the buyers because the government is holding interest rates down, allegedly to stimulate the economy and create new jobs. And that they're failing should be no surprise: concentration invariably eliminates jobs as well as driving up costs for everyone, undermining competitiveness and costing more jobs.
One thing Obama could do to fight back is to fight the mergers and acquisitions that are concentrating corporate power -- there are, you know, already laws on the books against that sort of thing, even if they've rarely been enforced since Reagan. Another thing would be to start the campaign for extending health care reform beyond 2012 -- to get a public option to ensure competitiveness, to finally take on the drug companies, and some more easy targets. He needs, after all, to rally voter turnout for 2012, so it's time to start promising something more than stale compromises.
A couple related links:
Monday, March 22. 2010
Matthew Yglesias: Perspective: Our fevered, overworked pundit, who has taken to describing Congress members who'd much rather have single payer or at least the "public option" but are nonetheless willing to vote for the compromised health care reform bill as supporting the pundit's position, waxes:
Aside from that it's not done until it's finally signed, and that I haven't noticed any progressive presidents in decades -- it's not clear that we even have one now -- this is pretty ripe. I, too, am glad the bill passed -- err, I, too, supported Yglesias's position -- and I'm not sure that anything much better could have been passed, but the whole campaign strikes me as a failure of imagination and courage on the part of people who should have known better and could have campaigned for a much better bill. As it is, a lot remains to be done. I especially hope they can push some of the changes forward so we don't have to wait for 2014 to get any relief.
I don't mind if Obama and the Democrats take more credit than is due here, especially in forums where Republicans are present as they've become completely unhinged over the issue. Still, it's worth noting that the stocks of most major insurance and pharmaceutical companies went up today on the news.
Friday, January 22. 2010
Glenn Greenwald: Blame the all-powerful left! Buried deep in this is the point I made a couple of days ago. I think it bears repeating (and repeating and repeating):
The main point of the article is the repeated charges, especially by right-wing Democrats like Evan Bayh, that Obama's problem is that he's fallen under the spell of "the furthest left elements" of the Democratic Party. As Greenwald documents, this is based on "exactly nothing" -- other than the idiot repetition of a line that strains credulity even when mouthed by Republicans.
Paul Krugman: Do the Right Thing: At last reckoning, the Democrats still had a majority in the House of Representatives. A majority -- less than the official party majority, but still a majority -- have even voted for a health care bill at least somewhat to the left of the one the Senate voted for 60-39. That bill was in fact so "moderate" that it was approved by Lieberman, Nelson, Bayh, and others who repeatedly held it up. One had hoped that reconciling the two bills would have resulted in one slightly better than the Senate bill, if not as much better as the House bill. But now that the Senate Republicans are free to wreck any bill, that option no longer works. But what would work would be for the House to pass the Senate bill as is, avoiding the need to reconcile versions. All we need for that is for the same Democratic majority to approve the weaker Senate bill as approved the stronger House bill. Do that, and Obama will have something significant to show for all his mealy compromises and uninspired leadership. Do that and the Democrats can claim to have delivered the one thing their base wants more than anything else. Don't do that and all the House Democrats will have to show their base is that they don't have any principles, and America that they don't have any guts. I wouldn't bother lobbying any Republicans on this: all they've shown is that they'd rather break America than let the Democrats get credit for facing up to a major problem. But go after the Democrats with everything you got. Any Democrat who refuses to stand up for this bill doesn't deserve the party's ticket. Or the party doesn't deserve its supporters.
Krugman adds this on his blog:
One more point: although I'd be happy to see the Senate bill passed by the House and signed by Obama -- if served up on a silver platter, he'd at least do that much, wouldn't he? -- it's not at all clear that Obama's habitual rejection of leftist proposals has done him any good. Maybe it's politically determined by the intransigence of the Republicans and the clout of established interests -- the health care industry accounts for about 18% of US GDP, and the finance industry for a bit more, and if you give extra weight for profits over the last 10-20 years you can add to those figures. But genuinely leftist proposals would in many cases have more resonance with more people than those who identify themselves as leftists: they build on a sense of justice and fairness, they hold established interests responsible for their transgressions; they are simpler, they make more sense, and they are more likely to actually work.
To take one example, Obama's hands-off approach to Big Pharma deprived him of using one of biggest, most obvious villains in the health care costs death spiral. (Instead, Billy Tauzin came back at the last minute demanding even more patent extensions, threatening to withdraw his lobby's hitherto useless support.) But there are plenty of more examples: get tougher on the banks, deflect the deficit projection gibberish by raising taxes on the rich, get out of Afghanistan, and scale back the incredible waste that is the US Department of Defense.
Funny thing is that if he actually moved left it wouldn't change the Republicans line one iota. But it would give him something to stand up for.
Thursday, December 24. 2009
I, for one, am pleased that the Senate passed any kind of health care reform bill. Without the reforms it is virtually impossible for me to buy functional insurance at virtually any price. I wish the bill covered more people more affordably. I wish the bill did a much more aggressive job of tackling the critical problem in the system here, which is profit-seeking by virtually everyone involved. This has led to fragmentation and unnecessary complexity, to obfuscation and propagandizing. This leads patients to not understand when they do or do not need treatment, making critical decisions based on all sorts of things that should be secondary or irrelevant. This tempts doctors to give more or less or just different treatment than the patient actually needs. This leads drug companies to mislead us on medications, including covering up major harm. This has led to all sorts of things that have very little to do with promoting public health. Most impressively of late this system has done everything within its considerable power to corrupt political discourse. That anything positive has come out of it is remarkable.
I've been thinking about the health care system for a long time now. I have some pretty straightforward ideas about how to fix most of the problems, and they led me to favor different solutions from the one that Congress settled on. Everyone likes their pet ideas, and I'm no different in that respect, but T.R. Reid's recent book is helpful in showing that there are actually many variations on health care system that all work much better than the one we have, both in terms of lower costs and better outcomes. In theory, I'm inclined to favor a "Beveridge Model" system like the UK has (or like the US provides through the Veterans Administration), where all services are government run. But the UK system tends to be underfunded, resulting in longer delays and fewer options than we are used to (assuming you have reasonably good insurance here in the US). Especially in terms of availability and flexibilty, it looks like the best health care systems in the world are in France and Japan, which use private insurance and providers, but regulate them severely, in effect squeezing the profit motive out of the system. This has led to great cost efficiencies in the systems: for example, an MRI that costs over $1000 in the US costs $100 in Japan -- a situation which allows Japanese doctors to order more MRIs and still save money. But the various systems aren't exclusionary: it's easy to imagine a UK-type system pursuing upstream supplier costs like the Japanese do. It's easy to imagine a Canadian system with adequate funding for specialists: in fact, that's what the US Medicare system does.
Reid offers good and bad news on prospects for change in the US. He shows two examples of systems that were similar to ours (profit-seeking, out-of-pocket) up to 1994 but were then changed successfully: Switzerland and Taiwan. In the Swiss case, the main change was to require private insurance companies to refund any profits. Before the change, Switzerland had the second most expensive health care system in the world at 11% of GDP, just 1% behind the US. Fifteen years later, Switzerland is still second, still at 11%, while the US GDP cut has boomed to 17% and is still headed up. Taiwan did a bit more, and got better results: they adopted a Canadian-style single payer scheme. The good news here is that such change is possible. The bad news is that in both Switzerland and Taiwan the changes were pushed through by conservative political parties, preferring to compete with the left-liberal parties by adopting progressive change on their own terms. In both cases, the decision was arrived at not just politically but morally: in both cases, even conservatives agreed that equal access to health care should be a right for all people, not just for those who can afford it. Of course, that's not bad news for Switzerland and Taiwan; it's bad news for us, where even the Democrats have trouble articulating health care as a fundamental right, and where Republicans are nothing short of shameless. Not a single Republican voted for health care reform this year, despite the numerous deals that Obama negotiated with the AMA, the pharmaceutical industry, and other lobbyists, despite the fact that insurance company stock prices rose on passage. The Republicans have moved past their usual stance of sucking up to industry; on health care they're into pure ideological malevolence. So the near term prospects for conservatives doing anything responsible are close to nil.
For a taste of Reid's book, look here.
Matthew Yglesias: Mitch McConnell's Proud Unipartisanship. Quotes the Republican Senate Minority Leader:
And they say generals always prepare to re-fight the last war. Republicans remember how their intransigent opposition to Clinton's 1993 health care reform effort was followed by Republican wins in the 1994 congressional election, so they figure what worked then will work now. That strikes me as monumentally stupid, both as a political strategy and as a reading of history. The single biggest difference is that Obama passed his bill whereas Clinton failed to get his bill out of committee. Clinton's failure looked incompetent, then when he walked away from the bill like some embarrassing road kill, he gave Democrats little reason to expect more from him. On the other hand, Obama persevered, against tough odds, and he comes out of this with something to defend.
At most, the defeat of health care contributed some moment to the Republicans in 1994. Their big issue was the corruption of Congress under long-term Democratic rule, and it was largely H. Ross Perot who turned the tide in their favor. After that they used every trick of incumbency to hang onto narrow margins until 2006 when their own corruption finally sunk them. During the 15 years between Clinton's failure and Obama's success, Republican intransigence and blindness has allowed a predatory health care industry to increase its share of GDP from 12% to 17%, during which time more and more people were unable to buy or afford insurance, bankruptcies proliferated, and the US sunk further and further on most international metrics of health. Those are costs that fall not just on the poor and working families; they cut into business profits and burden manufacturers, who in turn cut real wages and/or export jobs. Against these trends, the Republicans have done nothing, turning a blind eye to greed and a cold heart to suffering and fear. They've made a lot of noise, and worked themselves up into a frenzy, but it's all been negative, paranoid, surreal. Aside from their fanatic base, will anyone else believe them? Why would anyone else trust them?
I'm not saying the Democrats have no problems. They have all of our problems: continuing pointless wars, economic rot, solutions that don't go far enough. But they can point back to the wreckage of Republican rule, which is all the more credible given that the best the Republicans can claim is that Bush screwed up because he was a big spending big government closet case. And they can point to their own pragmatic moderation, which gets real (but modest) results without upsetting the Establishment. The Democrats would have it made if the Establishment showed them equal respect, but even so, the Republicans seem determined to make sanity the issue the next couple of election cycles turn on. The last time they exposed their conservatism so nakedly was Goldwater.
Paul Krugman: Simulating Single-Payer. A little economic analysis arguing that Hackerish health care plans, like the one in Massachusetts and the one the Senate just passed, approximately simulate single-payer plans: "just imperfect, somewhat inefficient ways of simulating the results of a single-payer system." This is basically the same thing as we get out of Reid, who shows time and again how universal coverage ("community rated") private insurance systems approximate the behavior of single-payer systems. You can take this as reason not to get too disappointed that Obama and the Democratic leadership didn't stick their necks out for a real single-payer system. On the other hand, the inefficiency is likely to be more than "somewhat," and the imperfections glaring. It all depends on how strictly regulated the insurance companies are, and how efficiently the market can be made to work. Up to now the key to profits has been inefficient markets: opaqueness at every stage, lack of standardization in billing, uncertainty in payments, complexity everywhere, monopoly rents nearly everywhere. There is a lot of room here for savings without sacrificing one iota of service, but I expect the interests to fight efficiency as doggedly as they've fought equality. Single-payer may not in principle be any more efficient than a well-managed private system like in Japan. But single-payer would be much simpler, and would show political will to make it work. And while it may not have been politically practical, the main reason is that leaders who know better didn't have the guts to go for it.
Sunday, September 13. 2009
Some other books that I've noted in my book prospecting notes but (generally) haven't explored further. Listed alphabetically by author. A couple go beyond the politics of health care to get into the practice, but I usually drew the line short of there. Some deal with suspicious public health issues, and some of those are suspicious in their own right. Some push right-wing or status quo-ist agendas, some ideologically (e.g., Cato Institute) but most with a financial stake in their scheme. A small number of more general political books are listed where they seem to be especially relevant (e.g., Rahm Emanuel's The Plan), but not many. I've skipped over most books published before 2001, except when they seem to have historical value. There were a rash of books that appeared during 1992-94 that are presumed hopelessly dated. There was a slight uptick around 2004, and again from 2006 on when it started to look like a Democrat might be elected president in 2008 -- although more than a few of those books were meant to ward off Republican agendas like HSAs and CDHC.
I've added notes to some where I thought helpful, but have let most explain themselves through their titles. Several books have book page links. I've eliminated all of the superfluous titles (mostly MD) on author names.
The more I look, the more such books I find, although many of them seem outside the bounds of good taste or immediate relevance. Selecting a short reading list is impossible. I have only read 3 of these (the Bradley and Hacker links, and the first Atul Gawande), plus 7 of the 9 books I reported on yesterday (1 link was based on a review, one more on an excerpt). And I have a few more books on hand if/when I get time for them: Brownlee, Mahar, Starr, the second Gawande, Groopman; and I have Kawachi/Kennedy and the first Wilkinson on order. Reid's new book looks promising, and Rothman is a historian I've long admired tackling an important subject. Hardly makes me an expert, but it does suffice to cover much of the story. It also helps that I've read quite a bit of the background history and theory; also that I have more personal experience that I really want to think about. I've been thinking that health care would make a good subject for a case analysis in my book on how to think about public policy. The exercise of dredging up all these books makes me realize that there's an even bigger gap here for a book that can triangulate between the practice of health care, the business and politics around it, the social and philosophical concerns of patients, and the technology. Will have to think more about that.
Saturday, September 12. 2009
I overheard most of Obama's health care speech the other night. I usually duck political speeches, but it came on during a break in the music, and I wasn't much enjoying the music. Seems like he made the basic case clearly, although he didn't go very deep, in large part because he's not trying to fix very much. I heard one peculiar round of boos, but didn't catch what occasioned it -- maybe that Rep. Joe Wilson flap. And I heard three or four more boos, clearly coming from Laura in the TV room. I agree with her that the only way to actually fix the system is to wring the profit incentives out of it and to restore a professional ethic of care giving, and that the first step should be to institute single-payer insurance. Obama's credentials as a progressive and for that matter his reputation as someone with a grip on reality were tarnished by his eagerness to make light of single-payer. He also came up short on two other key points: one is whether government can run programs that serve the people, which is really a key article of faith for anyone who professes belief in democracy; the other is deficits question, where the right answer is: we'll spend what we need to spend to provide everyone with quality health care, and if that's more than is in the current budget we'll raise taxes to cover it. But then, as I said, Obama wasn't trying to fix very much. And if he manages to make it possible for someone like me who can afford to buy health insurance but can't find any insurance company willing to sell me a policy, I at least will be pleased. On the other hand, lots of other people will remain disappointed. One thing for sure is that Obama won't be the last president to attempt to reform the health care system. Even if he delivers what he's promised, he'll leave plenty more to be done.
Over the last few weeks, I read three health care books I found at the library. I've read more over the last few years, and have more on tap. The books are:
Some older books that I read and commented on earlier:
Malcolm Gladwell: The Moral-Hazard Myth. An article published in 2005, in part a review of the Uninsured in America book cited above. When I originally posted a quote from the article, I didn't bother tracking down the URL, but now I've found the piece online. Part of the quote deserves reiteration (the only thing that has dated it is that the costs are even more outrageous now):
I started assembling a list of miscellaneous books related to health care policy issues, starting with my previous book prospecting blogs. Wound up with a pretty long list, which probably needs a few more notes, so I decided to hold it back. Tomorrow, maybe.
Tuesday, August 25. 2009
George Lakoff: The PolicySpeak Disaster for Health Care. Useful and somewhat insightful critique of how Obama and most of those who more or less support him speak about the health care issues -- not that I'm not annoyed with the insinuation that it's all a matter of framing. The masses may only respond to political issues in emotional terms, but there's still something to be said for rationally figuring out the policy details. Of course, the left is at a disadvantage here, as in virtually all policy debates, both because we have some good faith in democracy and because we actually intend to accomplish something worthwhile. The right, with no interest in either, is free to kick our asses, but they've hardly been geniuses in this shouting match: they repeatedly come off as ignorant, hysterical, and mean, and in some ways we're best off just to let them destroy themselves. Lakoff has a knack for finding an important point then losing it on his first stab at reframing:
Morality isn't the right word here, but he's close. The basic fact is that if you can put a price on surviving an illness or injury vs. dying, that price would gladly be met by anyone able to meet it. It's easy enough to see that we value our own lives and most likely the lives of the people we love most more than money. Focus on cost runs against this instinct. (A curious turnaround, actually, since it is usually the moneygrubbing right that lectures us on how little we can afford to pay even for the most basic necessities of those most desperately in need.) That's why we should focus first on quality care and keep that from slipping regardless of cost, only secondarily looking at cost as an aid to being able to do more thing better. On the other hand, following Lakoff's suggestion and decrying insurance companies as deathmongers isn't even true -- at most you can say they are indifferent to deaths because their fiduciary responsibility is focused on profits.
So, sure, we can do a better job of talking in this campaign, but what would help more than better branding and wordsmithing would be a better solution to the problem. In fact, a good start would be to actually understand the problem, which quite simply derives from the commercialization of health care. That part is simple enough, but the industry is so huge and varied that no one realistically wants to try to wring out all of the commercialization. The single-payer advocates are only going after the insurance companies, which is a big and pernicious target and one that could most easily be dispensed with, but that leaves the actual providers, who have plenty of their own problems. Arnold S. Relman, in A Second Opinion, wants to go further and reorganize the providers into non-profit PGPs, which also makes sense, but is a much bigger task, is very likely to be disruptive, and still leaves the drug and tech companies free to scheme. I'd go after them too, and I got a few more things on my list too, like information architecture, training more professionals, and educating people to make smarter health decisions. But more than all that, you need to get people to recognize that professional virtues are more important than acquiring money. The essential reform of the system is to get to the point where your doctor values your health more than his own pocketbook. That's not impossible, but it's pretty hard to do in America these days.
Matt Yglesias: The Psychology of Health Reform. Back to reality, this quotes an article by James Suroweicki on the psychology of loss aversion, then adds a couple of points that are probably more important. I'll add that a key part of why the "public option" is so critical to those of us who think reform is not just a good idea but a dire necessity is that -- exactly contrary to so many folks on the other side of the divide -- we can't stand the idea of ever again being subject to a corporate bureaucracy where our health and welfare is treated as a zero-sum game. We at least know that even mediocre government bureaucracies in theory work for us. We can at least appeal to them, and it helps knowing that the coverage we need isn't coming out of their pockets -- it's actually coming out of our own, but cushioned by the fact that in a public insurance scenario everyone helps everyone out.
Ironically, the other side is equally convinced that it is the government that is arbitrary and capricious, attributes which they may or may not also recognize in the companies. (Some may hold to the fantasy that a free market forces companies to respond to the demands of customers, but there is no free market for health insurance -- nothing even remotely resembling one.) This is one reason why the real debate isn't over health care: it's over democracy. One side insists that the government can never be trusted with anything so important as health care. The other takes a similarly jaundiced view of companies, except insofar as they are regulated by laws enforced by government. Moreover, it sees government as the only agency that can represent the interests of the broad public in a society that is otherwise dominated by business. The Republicans have tied themselves to the mast of Ronald Reagan's dumb joke about the scariest words in the English language being "I'm from the government, and I'm here to help." The fact of the matter is that whenever anything goes seriously wrong -- a hurricane, an earthquake, a terrorist attack, a bunch of bankers swindling themselves into a drunken tizzy -- even Republicans descend on Washington looking for a bailout. There actually isn't anything wrong with that: many problems, especially really big ones, are by far best handled by government. Health care is one of those problems, but if the Republicans admit it they'll lose their whole shtick. So they stick to their guns and suffer, their only comfort being that others suffer worse.
Paul Krugman: Obama's Trust Problem: The news today (i.e., 5 days after this column appeared) is that Obama will renominate Ben Bernanke for a second term as Fed Reserve Chairman. Bernanke hasn't been as bad as a lot of Bush appointees, but part of that was circumstance -- he was nominated as a hawk against inflation, but he spent most of his term in a deflationary recession where his instincts were unneeded and could do little harm. On the other hand, past Fed chairmen have repeatedly been able to hold the economy in a death grip. If you're a president who is committed to trying to stimulate enough growth to actually improve the welfare of the people who voted for you, you'd think you'd want a Fed chairman who'd see eye-to-eye with you on that. Obama could in theory appoint anyone he wants, so why not come up with someone more in line with his programs and ambitions? I don't know what the thinking is here, but it sounds like Obama did this to reassure the banks and investors. That's what his team has done consistently ever since they took office, which is why we've had bailouts without any meaningful reform. Same thing has happened all across the board. Obama was elected as antiwar but he's presdided over business as usual in Iraq, an escalation in Afghanistan, and budget increases for the defense industry. The only other issue as important to his voters is a massive overhaul of the health care racket, and there he's made a series of inside deals with the AMA and PHARMA to cut back on any meaningful reform while the Republicans have had a field day with their unanswered hysterical nonsense. Obama's offer to drop the public option in favor of non-profit co-ops is one more example of his willingness to knuckle under. Krugman notes:
What's left of Obama's plan is a set of private insurance company regulations that would be better than the present situation but will almost instantly translate into significantly higher insurance prices, which will make universal care all that harder to achieve, and leave us in pretty much the same mess we've been entrapped in for several decades now. That may eventually turn into a make-work program for future Democrats, given that the Republicans have no ideas and no desire to actually address any real problems. But with 60 Senators and a big majority in the House you'd think now would be the time to do something. It's not happening, and a big part of the reason is that it doesn't look like Obama's fighting to make things happen or stand up for things he certainly knew before the election were right. Krugman again:
Time: Top 10 Health-Care-Reform Players: Just a list, but gives you a sense of the obstacle course.
Friday, August 21. 2009
Two things from the Wichita Eagle worth pointing out. The first is Richard Crowson's editorial cartoon:
Crowson was retired last year when the Eagle decided they didn't need original editorial cartoons, then finally brought back on a very infrequent basis. For more, see Crowson's blog.
Bill Roy: Health care rationed based on ability to pay: One of the best opinion pieces I've seen on the health care town halls. Lynn Jenkins defeated Democrat Nancy Boyda in the 2008 election, running as a "moderate" Republican (versus a rather uninspiring one-term Blue Dog Democrat), but since she got in her record has been indistinguishable from the other Kansas Republicans: conservative Jerry Moran and rabid fascist Todd Tiahrt (both running for Sam Brownback's senate seat). Roy is a retired MD who served two terms in the House, then lost two very narrow statewide Senate races against Bob Dole. I'm tempted to quote the entire piece, but here's just the start:
Read the whole thing.
By the way, I've started Arnold S. Relman's A Second Opinion: Rescuing America's Health Care. Thus far, it is one of the best books I've seen on the subject. More on that later.
Thursday, August 20. 2009
Matthew Yglesias: Republicans Calling for Super-Majority for Health Care. I take it the political winds are changing. Maybe some of the insane opposition is blowing back. Maybe some of Obama's deals with the powers that be are bearing fruit. A while back Jim DeMint was saying that failing to deliver on health care would be Obama's Waterloo. Now he's saying that if he passes a bill without broad Republian support, the Democrats will never win an election again. Here we see Enzi and Grassley, who seem like rather arbitrary picks as the party's designated negotiators, pleading for a bill which only the 20-25 most hopeless Republicans will oppose. I think it's clear now that the Republican Party from top to bottom will say and do anything to derail any kind of reform -- a point made clear in Yglesias's last paragraph:
Friday, August 14. 2009
From TPM: Throw Mama from the Train:
Broun is getting ahead of himself here. Not only it he assuming that the government's going to health care at such a detailed level that they'll routinely overrule doctors, he's assuming that the Republicans are going to be running the government.
Republican vehemence over health care seems to be coming from a deeper point in their reptilian brains than their usual desire to help rich businesses fleece poor customers. They seem to recognize that if government is ever trusted to run anything as critically important to voters as health care, they'll never win another election.
One thing that is certain is that Broun's concern has nothing to do with mama. Preserving the status quo leaves these life or death situations in the hands of the private, profit-maximizing insurance companies. In fact, if health insurance reform fails, the private companies will be all that much emboldened in their search for profits.
Wednesday, August 12. 2009
Fred Mann: Tiahrt gets warm response at area town halls. Similar reports on Reps. Jerry Moran and Lynn Jenkins. On the other hand, the sole Kansas Democrat in the House, Dennis Moore, called off his town hall meetings after receiving death threats. (Scott Roeder, the guy who assassinated Dr. George Tiller, resided until his arrest in Moore's district.) Tiahrt is the worst of the worst. People urge us to write to him, call, go to his events, but he's so far gone it's pointless trying to reason with him. I've seen him do his town hall thing, and it's a complete waste of time -- one reason he hears so little reason. Still, there is something relatively new here: his crowd is getting out in front of him, pulling even harder to the right:
In some sense this doesn't matter, because Tiahrt is already bought and paid for. But it's starting to look like Obama's has lost not just the fight but his political courage. It's hard to sell a bill full of compromises and loopholes designed to undo the benefits originally promised. It's hard to sell a bill when you yourself admit that something else -- single-payer -- would do the job better.
Robert Reich: How the White House's deal with Big Pharma undermines democracy. As bad as the private sector health insurance companies are, it's not obvious to me that they are the biggest problem, either in terms of health care quality or excessive cost. Big Pharma is way up there, and the megacorp profit-oriented health care providers may even be further up there. The main reason I see for focusing on insurance first is that it not only solves a couple of major problems -- lack of coverage for people who have inadequate insurance and no coverage at all for large numbers of people excluded from the present system -- but that beyond solving those problems it provides purchasing power leverage on the rest of the system. The other nice thing about the insurance companies is that we don't need them at all, so cleaning up that problem should be relatively simple. On the other hand, the health care providers are needed -- the workers, anyhow, if not all the financiers -- which makes it harder to sort out. Drug companies are in between, but the problems can easily be separated out. For starters, rewrite patent law to eliminate monopolies and to regulate drug prices. More importantly, publicly fund research and development, and make all of the planning, procedures, and testing transparent, so you can put an end to drug companies spinning test results and covering up problems (cf. Vioxx). And put some strict regulations on drug industry marketing; better still provide transparent public forums for disseminating information about drug performance. One goal here is to make all drugs generic, reducing the industry to manufacturing. And make this system international, so that research, development, and manufacturing anywhere in the world is available anywhere in the world. Even with new investment in R&D, these few simple changes should result in savings of 50-75% of what is currently spent on pharmaceuticals. That in itself would be a big chunk of cost savings which would help out everywhere else.
The same sort of thing can be done with any other medical technology. One big thing that drives up the cost of health care is that nearly all of the new technologies and procedures are monopoly-priced under patent protection. Which is to say that every new whizzbang development gets to ask the question: how much is your life worth? Most are marketed with ridiculous gross margins, the most successful ones becoming huge bonanzas. Public funding of research and development would if anything outproduce the current private system. For one thing, it would encourage competing groups to build on each other's work. Public testing would make it possible for anyone to spot a problem and come up with a better solution. One of the big hidden costs of the current system is liability: what it costs when a product does unexpected damage. That costs would get wrung out of the system real fast.
Admittedly, private insurance has some easy cost targets too: they currently spent something like 30% of their gross on marketing and administration, whereas a single-payer system like Medicare only spends 3%. The difference could easily pay for universal coverage. But that sort of change is more than Obama will allow himself to consider. Instead, he's pushing a set of regulations on private health insurance which will make it less unpalatable but also more expensive. Then he's shackling those reforms with a requirement that they be deficit-neutral, which opens his whole program to charges that he'll inflict some combination of higher taxes and service restrictions. Cutting this deal with Big Pharma just digs himself a deeper hole.
Personally, I would prefer an approach where we started talking about how the system fails qualitatively, then figure out how to improve on that, introducing savings only once we ensure that no quality will be lost. This means educating people pretty much from scratch about how it all works, and how it currently malfunctions. At some level Obama must understand this, but instead of tackling the problem head on, he keeps trying to skirt past problems by making deals with established interests. That's why he keeps losing. That's why it feels like we wound up with the Clinton administration we voted against.
Saturday, August 1. 2009
Phillip Longman: The Best Care Anywhere. This is actually an article from 2005, back in the dark (Bush) ages when nobody even considered the possibility of trying to do something to reform our mess of a health care system, but it's worth taking another look at now. It's about how a government agency carved off a single-payer population and provided them with a health care system with virtually no private sector participation. Free from the influence of private interests, the government only had to balance costs and benefits off. The result is the best quality, lowest cost health care system in America. That's what the Veterans Administration did. Longman went on to expand this article into a book, Best Care Anywhere: Why VA Health Care Is Better Than Yours (paperback, 2007, Polipoint Press).
This came about basically because of two moves by Bill Clinton: in 1994 he appointed Kenneth W. Kizer VHA undersecretary of health, and in 1996 he signed a bill to expand eligibility to all veterans, not just combat casualties.
A lot of details follow on just how this works, but much of it shouldn't be surprising. Most problems are easier (less expensive and more successful) to deal with when you catch them early, which became a focus. And health care is a team activity, so having one set of common electronic records both eliminates extra work and errors and lets everyone work on the same plan. They also took a look at evidence, identifying problems and checking what worked and what didn't. This is almost common sense when you're trying to provide quality health care, but it isn't always followed in the private health care system, where there's an overriding concern for profits.
Doctors write their orders into the electronic records system, and nurses check off every time they administer a drug or procedure. The system, by checking the patient ID and the drug/procedure, has virtually eliminated routine mistakes.
Of course, you don't automatically get superior health care by turning it over to the government. It also takes management skill, professional dedication, adequate funding, enough time to review cases and refine and improve methods. You could duplicate many of these methods with private health care providers, especially if you can develop a portable system of records and a system of reviews and accountability that can be shared everywhere. You also need to do as much as you can to isolate medical decisions from the profit machinations that inevitably come with private sector companies. (No one denies that profits are powerful motivators, but nothing is clearer than the fact that optimal health outcomes and optimal profit outcomes have nothing in common.) Public financing of as much shared infrastructure as possible would help -- indeed, would be essential -- with private providers. Open source software is one key element here: it makes adoption practically free, while keeping all of the technology transparent so it can be critiqued and improved by users all over the world. Freely published academic research is another. A single-payer insurance system would also help to push best practices throughout a private provider system.
Lots of lessons here, but the most important one is that the pursuit of best practices and quality outcomes also works best as a cost containment system. In fact, it's the only cost containment methodology that doesn't sacrifice quality. Moreover, by focusing on quality first, we have an answer to everyone worried more that reform will diminish quality, as well as an answer to the bean counters.
Friday, July 31. 2009
Dan Eggen: Industry is generous to influential bloc. Uh, what was it I was saying about the Blue Dog Democrats and health industry money?
Andrew Leonard: The worst healcare reform option: Doing nothing: Links to Ezra Klein on Bill Kristol, Jonathon Chait on Martin Feldstein, and a Bloomberg article by Matthew Benjamin and Brian Faler, which among other things cites an estimate that unreformed and unchecked health care expenses will hit 20% of GDP by 2018. (Again, think of the whole national economy being strangled and swallowed by a giant boa constrictor.) Conclusion:
Paul Krugman: Why markets can't cure healthcare. A brief primer starting with Kenneth Arrow's classic paper, "Uncertainty and the welfare economics of health care. This has been discussed many times before -- Robert Kuttner wrote a whole book on it, Everything for Sale: The Virtues and Limits of Markets. The bottom line is that there is no theoretical and no historical/empirical basis for thinking that the present problems of the US health care system can be remedied by any sort of free market approach. You'd have to be stupid and/or blindsided by money to think otherwise.
Krugman has had a lot of good health care blog entries lately, as well as several columns, especially this one:
Paul Krugman: Health care realities. Krugman has been a steady voice on this issue, and this column hits many of the basics: at least as regards insurance and the government, as good a place to start as any. Read it. If I started quoting, I'd quote it all.
Nate Silver: Yes, the GOP's still out of touch. Quotes GOP Rep. Tom Price (R-GA) on how "nothing has had a greater negative effect on the delivery of health care than the federal government's intrusion into medicine through Medicare." Then does some polling, showing: 60 percent of people participating in Medicare rate it 9 or 10 on a 10-point scale (84 percent 7 or better) vs. 36-40 percent approval of private insurance plans; that 77 percent would like to see Medicare expanded to people aged 55 and older; that 58 percent would support Medicare-for-all (i.e., single-payer). That you can't find similar percentages in Congress is solely attributable to the influence of money there.
Matt Yglesias: Health insurance industry's strategic bribery. Good chart here, showing how the health insurance industry has spread its money around. Sure, the rich have a general Republican bias, but every year most of the money went to the majority party in Congress. The majority party is, after all, the one able to make or break the legislation that all that money rides on. Second point is that the totals have been going up and up, expanding even faster than the industry's take of the GDP. No breakdown here between liberals and Blue Dogs.
David Barstow: An Abortion Battle, Fought to the Death. Long New York Times piece on Dr. George Tiller and his struggles to keep his women's clinic open. Well on its way to book length. Barstow likes to characterize Tiller as a battler, one who fought back as much as he got. That's not really true. Tiller never killed anyone. Tiller didn't go around harrassing other people and their businesses. Moreover, Tiller didn't just provide abortions. He was a doctor who cared for his patients, even when carring called for performing an abortion. For the rest of us, he stood up for rights that in theory we have but that in practice are under constant assault. We make a big deal when soldiers die for our rights in some far away country. Tiller died for us, defending us against a much more real threat.