Wednesday, January 27, 2010

Is Health Care Too Big to Fix?

Now that the health care bill has been soundly defeated by the election of a single individual to the Senate, the Democratic party is fleeing the House and Senate health care overhaul bills like rats from a burning ship. Sadly Republicans, too, are staying silent with (so far) few rushing forth with their alternative solution to counteract the impasse:
Senator Dianne Feinstein, Democrat of California, said Democrats were assessing their options on health care. “It’s a timeout,” she said. “The leadership is re-evaluating. They asked us to keep our powder dry.”

Mrs. Feinstein said Congressional leaders should simplify the gigantic health care bill and try to pass parts of it that would be understandable to the public. But she also acknowledged that the odds were long for a far-reaching measure. “I think big, comprehensive bills are very difficult to do in this environment,” she said.

The Senate Republican leader, Mitch McConnell of Kentucky, said White House comments on health care suggested Mr. Obama was not listening to the American people.

In Elyria, Ohio, on Friday, Mr. Obama said he was not going to “walk away” from the fight for major health legislation. If the bill becomes law, White House officials said, Americans will see its benefits and will embrace it.

But Mr. McConnell said, “This a clear sign that the administration has not gotten the message, that it’s become too attached to its own pet goals, that it’s stuck in neutral when the American people are asking it to change direction.” He said Mr. Obama should “put the 2,700-page Democrat health care plan on the shelf” and “move toward the kind of step-by-step approach Americans really want.”

Republicans, however, have not come forward with any new proposals, and Mr. McConnell has said he hopes the health care bill is now dead.
Which leads to an ominous question: is health care really too big to reform? With all the special interests at play, all it takes is one well-respected 93 year-old surgeon general to come out and ask some pointed questions to Congress and the President about their actions, and people take notice.

No matter how you cut it, overt rationing of health care benefits is political cyanide. What both parties now understand is the deeply personal nature of health care paired with the special interest affilitations they must nurture have mixed to create an undrinkable potion to assure relection.

So don't look for massive health care overhaul anytime soon. Instead, it will be peacemeal - bit by not-so-tiny bit. Like doctors taking a five percent cut rather than 21%, medical device companies taking a $20 billion tax instead of $40 billion, pharmaceutical companies having to accept competition from overseas, insurers forced to cover cover more of the populace or face extinction, hospital payments continually reduced, and patients having to pay more and getting less. It's our only way forward.

And while these changes will not be very popular to most, the current debate has not been without its benefits. People now understand what's a stake. Health care and its associated costs aren't going away. As the Congressional Budget Office has reminded us:
"...fiscal policy is on an unsustainable path to an extent that cannot be solved by minor tinkering. The country faces a fundamental disconnect between the services the people expect the government to provide, particularly in the form of benefits for older Americans, and the tax revenues that people are willing to send to the government to finance those services. That fundamental disconnect will have to be addressed in some way if the budget is to be placed on a sustainable course."
For now, the people have spoken clearly. We'll have to settle for a slower step-by-step approach. But this issue will not be so easily tabled.

Thanks in part to the internet, we've seen that health care reform has become deeply divisive issue, separating socioeconomic and generational interests. The reality of funding such a massive overhaul without affecting health care benefits and taxes remains a huge challenge. But this division has also made it clear that a one-fix-does-all approach that replicates similar entitlement programs that are already fiscally unsustainable isn't going to work with Americans.

Perhaps we should survey the other countries with viable health care plans and make a case for using the best ideas of the best models out there. Perhaps in this way, we should use a hybrid approach to reform based on data, rather than a special interest path to reform based on scare tactics. Oh, we might have to settle for more than one option for care delivery, like every other successful country in the world with health care for their populace has done, but would that be so bad?

Of course not.

But then, looking to others besides special interests for help at constructing such a model hasn't ever been our modus operandi, has it?

-Wes

39 comments:

Keith said...

The health care bill was killed by a lack of understanding by most measures I have seen. While it has been touted in polls that a majority of people were not in favor of the bill, very few have taken the time to really understand what it all meant. Instead, most people have gathered their information and opinions from the 30 second sound bites on TV which cannot begin to describe what is included in the bill. The only analysis I have seen has been in the written press which we know most people don't seem to pay attention to these days.

Kaiser did its polling that showed the same negative opinion of the bill, but as they described to peeple what was actually in the legislation, the poll swung to a positive opinion. If you ask 100 ignorant people what they think of some issue, what do the results really tell you except msot people are ignorant of the short and long term issues involved in health care?

I found the same phenomena with my patients, who I informally asked what was in the bill. Most had a great deal of difficulty explaining all the pieces of the legislation.

While not a perfect piece of legislation, it would of moved us further to a sustainable health care system; instead with no action, we will get just what you have suggested; a steady racheting down of payments to providers as the only weapon that payers will have to combat rising costs. We will still see mountains of waste for worthless procedures and medications instead of payments for those treatments that offer the best return for the money.

While everyone worries about the goverment running the health care system, does anyone really think the marketplace/insurance companies really would do a better job if left to their own devices? I, for one, am waiting till we have the same economic debacle like that brought on by the bankers, but this time it will be the health care industry creating the crisis.

Andrew_M_Garland said...

To Keith,

Would you post a link to the official summary of the health care bill? I wasn't aware of one. I would realy like to know what is in it, along with the costs that have been identified.

You could link to an unofficial summary, but that would support the idea that there is no readable official description of what is in it.

To Dr Wes,
I wonder, do you know of a summary?

Anonymous said...

I think the often heard complaint from the American public pretty much says it all as to their understanding of what is being attempted with health care reform: Don't touch my Medicare and don't let government run health care. Or how about their opinion that we have the very best health care in the world? Do they have any idea of where we rank according to WHO? Unfortunately many Americans get their information from Fox News, which should be renamed "Unrelenting Proproganda". Oh, they're mad alright. But they have also made it quite clear that they don't want to be bothered with thoughtful discourse. No, let's hear it for "death panels" and whatever drivel Beck had to say that day. Keith has said it all much better than I, and I suspect Mr. Garland has SOME idea of what is trying to be accomplished. One thing though...we all agree that we have terrible unemployment. Don't we realize that those people and their families are losing health insurance? Finally, you say the Congressional Dems are like rats deserting a sinking ship, not a pretty picture. But many more of us may join that exodus when we discover that is exactly where we find ourselves - on a sinking ship captained by the Palins, the Becks, and a SCOTUS that overturns what little financial election law we've managed to pass.

CriticalCareRN said...

Keith - To believe that this president did not explain health care reform enough, and we just did not understand it, is really condescending and arrogant. Perhaps you believe, like he sems to, that if he had spoken more slowly, the ignorant American populace would have played along? He and his party spent the majority of their first year talking about health care, ad nauseum, ad nauseum. If it didn't fly with Americans, it's because they heard an administration that didn't even understood what THEY were talking about, not because Americans are just too dumb to get it.

I would love to know how Kaiser "explained" the bills to swing the opinions toward the positive. If you tell people the CBO says it will cut the deficit, decrease premiums, and cover millions more people it sounds great!! It's the means to those ends which are both sticky and complex.

Interestingly, the CBO also said (directly from D. Elmendorfs blog)

"The same SUBSTANTIAL DEGREE OF UNCERTAINTY that surrounds CBO and JCT’s estimates of the impact that the proposal would have on insurance coverage rates and the federal budget also accompanies this analysis of the proposal’s effects on premiums."

"It is unclear whether such a reduction in the growth rate could be achieved, and if so, whether it would be accomplished through greater efficiencies in the delivery of health care or would reduce access to care or diminish the quality of care."

"These longer-term calculations assume that the provisions are enacted and remain unchanged throughout the next two decades."

I have never been able to find the Senate bill online. I have perused the House bill, and its mind numbing length and impossible rhetoric. Even though I am not a lawyer or a physician, I find it impossible to believe that anybody can read that whole bill and be certain they truly grasp how each thing will impact the system as a whole. My suspicion is that they can't. How can people believe that it is possible to write such massive, massive legislation and know they not only grasp what all the outcomes of that legislation will be, but that they can guarantee those outcomes and avoid many huge negative unintended outcomes predicted that could make it worse?

I also fail to see how there is a valid, predictable, claim that either of the current bills would have moved us further toward a sustainable health care system.

While drug companies get the freedom to gouge consumers for decades to come with non-Medicare drugs.

Adding millions of regular consumers into a system already facing physician shortages - and with a rampantly out of control tort system that fails to promote physician recruitment and retention - leading to further risks of error and an even worse scenario for physician recruitment and retention into the system.

While we tax drug companies and device companies - will they just accept those taxes, or charge more for their services in the end? I don't know, but it's worth thinking about.

What of actual Medicare reform?

cont...

CriticalCareRN said...

But, most importantly - I fail to see how these bills addressed the real reasons why we consume such a higher percentage of GDP per capita on health care compared to other countries.

Are we going to legislate away a higher elderly population who happen to be big consumers of health care?

Are we going to legislate away the highest obesity rates in the world, including children?

link:

http://www.nationmaster.com/graph/hea_obe-health-obesity

Are we going to legislate away the fact that the WHO stated just last year that Americans consume more alcohol, tobacco, heroin and cocaine?(clearly our laws are not working with that).

link: http://www.cbsnews.com/stories/2008/07/01/health/webmd/main4222322.shtml

Are we going to legislate away our higher number of auto accidents?

link: http://www.nationmaster.com/graph/hea_mot_veh_dea-health-motor-vehicle-deaths)

Are we going to legislate away our higher number of rapes?

link: http://www.nationmaster.com/graph/cri_rap-crime-rapes)


Our highest overall number of total crimes rates?

link: http://www.nationmaster.com/graph/cri_tot_cri-crime-total-crimes

Our higher gun violence rate?

link: (http://www.nationmaster.com/graph/cri_gun_vio_hom_ove_hom_rat_per_100_pop-rate-per-100-000-pop)

Our higher rates of child maltreatment related deaths?

link: http://www.nationmaster.com/graph/hea_chi_mal_dea-health-child-maltreatment-deaths

Our higher rates of teen on teen violence?

Our higher rates of plastic surgery consumption?

link: http://www.nationmaster.com/graph/hea_pla_sur_pro-health-plastic-surgery-procedures)

Our higher teen pregnancy rates?

link: http://www.nationmaster.com/graph/hea_tee_pre_percap-health-teenage-pregnancy-per-capita)


When violence happens, health care gets consumed. When people ingest toxins, or otherwise treat their bodies badly, health care gets consumed. When bodies age, health care gets consumed. When there are accidents, or high numbers of risky behaviors leading to accidents, health care gets consumed. We can STOP covering people for things, and we can STOP paying for things, but when will our citizens STOP needing so much more than people in other countries?

It sounds quite glorious to tell physicians to just stop doing things that don't make people healthier, and if that were a black and white problem with a black and white solution, I am sure it could be done.

This speaks nothing of the fact that I would like to know if Canada. etc. and other countries include costs for Rx in their GDP per capita on health care as we do?

When foreigners come here, which country includes that cost in their total annual number?

I would like to know how much other countries spend treating illegal immigrants compared to U.S.

I would like to know how much they spend on education for professionals, including nurses, techs, etc.

I would like to know how much they spend versus the U.S. treating multiple ethnicities with multiple genetic challenges.

I would like to know how many foreign language interpreters their providers must employ.

I would like to know how many unions they have forcing unreasonable demands on hospitals, and forcing them to continue to employ bad staff.

I would like to compare the patient non-compliance rates too.

I wish we looked more closely at France's system. They ranked number one on the WHO list (but the U.S. ranked number 1 on the only thing hinting at actual "quality" of care - "Responsiveness"). From what it seems, they have universal coverage with a vibrant private insurance system. Few are covered by the government. Doctors and patients have freedom of choices. They have a well controlled tort system, and they seem to have gotten administrative costs down so low you don't see administrative staff much. They have huge problems too, but at least it seems worth looking into.

CriticalCareRN said...

Wes - I wish you would ask the question - to Keith and others:

Why is it that some people think the only choices we have are government run health care or leaving marketplace/insurance companies really left to their own devices?

Again, why not look to France for some clues?

The American government consumes and egregiously mismanages BILLIONS of taxpayer dollars each - they're so much better than the private industry? We are all blatantly aware of their corruption and conflicts of interest too.

It has taken less than 50 years for the business model of Medicare to be turned upside down and wreak havoc on both our financial and health care delivery system. Their administrative costs are clearly way too low if if they fail to check a good portion of their claims while billions of taxpayer dollars get funneled away to crooks.

Why do people think the answer to the problem is more government?

Also - Why do the people who currently want our system to be government run like Canada, etc. happen to be the same people who oppose tort reform that puts some sanity into our current tort system - like they have in those very countries they claim to wish to emulate?

Is it because they want taxpayers to pay for their health care - no matter how badly they treat their bodies, or how many risky behaviors they participate in - AND be free to catch some change from the system through a non-negligent unintended outcome? I am just curious?

Keith said...

Andrew,

You can pull up the full bills at www.opencongress.org. They have both the senate and house versions availible.

Critical care nurse,

Here is the link for your viewing to the Kaiser study I referenced:
http://www.kff.org/kaiserpolls/8042.cfm

It demonstrates how opinion turns more positive as people understand the various components of the legislation.

By the way, despite the torrent of news reports claiming that the American people are soundly against the legislation, the Kaiser poll in January shows an even split with more people for the legislation than those against (42% for and 41% against). Not exactly the overwhelming opposition that has been represented in the media.

All these polls simply ask if you are for or against the health care legislation, so that if you randomly select people and ask them what they think of the bill, they tend to react according to their political bent and their preconceived opinions. If they tend to listen to nothing but Fox News, they are undoubtedly receiving a slanted and very biased (although I am sure fair and balanced!) view of the legislation with little mention of the good aspects of the bill.

It is not arrogance or condescendence that is being exhibited, but an understanding that most Americans do not pay much attention to what is going on in Washington, coupled with our tilt toward getting most of our information from superficial news sources that do not do complete, balanced, and proper analysis of the issues. I would site the low voter turnouts for most elections in this country, and the demise of the newspaper industry as examples. Couple this with the rise of the cable news networks which fail to do much investigative journalism and prefer to spend hours on Michael Jackson and Tiger Woods stories instead of more important issues, and I would say you have good evidenc for a poorly informed electrorate.

As to your points that we engage in self destructive behavior, it is a point well taken. I would argue that many of these behaviors you mention have been actively encouraged through marketing dating back to the sordid history of the tobacco industry. An equal amount of resources on the opposite side to teach people how many of these marketed products could pose dangers to ones health would no doubt help, but being the country that supports the corporate right to sell you things that are naturally bad for your health, we will continue to see lopsided encouragement of these destructive behaviors. Why else would bankers be able to sell people so many mortgages that they undoubtdly knew could never be repaid, fast food companies can continue to sell so many cholesterol and salt laden junk foods, casinos can continue to attract so many gamblers, and alcoholic beverage companies can push their products as fun and sexy (add cars and pharmaceuticals and you have all of tv advertising). Of course it is not goverments job to interfere with the free will of it's citizens to make stupid decisions or for corporations to make a good buck off these stupid decisions. So we allow less than honest advertisment of these articles of self destruction without equal rebuttal. The fact that people fall for this advertising adds to my sense that many in this country are not making very well informed and rational decisions.

Andrew_M_Garland said...

To Keith,
You are not serious. I am not going to pull up and read the 2000 pages of the bills, written in legalese.

A summary means a statement of the provisions, effects, and costs. An official summary would allow people with more time and knowledge than I have to validate that the summary captures the significant aspects of the bill. So, what summary can you refer me to?

I am concerned that the Congress has not produced such a summary. Congress has acted in all ways to hide what they are/were constructing. If a product is too complex for individual understanding, then people rely on the integrity of process and independent review. The process around the health care bills has been horrible.

I can build support for any bill by saying that whatever the cost, we will subsidize you and get the money from that other guy. Countries that provide free health care to everyone also ration that care through a bureaucracy. I can't be in favor of government control of healthcare when the other examples have worked out poorly.

To Anonymous (01/28 11:59),

The WHO health statistics are biased. The WHO itself ranks the US #1 in health care delivery that is important to patients. It issues another ranking of 37th because this quality of care costs more and is not delivered by government! Critics of US health care always refer to the 37th ranking. That is a pure political judgement by the WHO.

The offered arguments against the quality of US health care are based on flawed infant mortality and life expectancy comparisons, as CriticalCareRN has pointed out.

USA Healthcare is First - Infant Mortality is Low
My collection of public information to add to the debate.

William A. Jacobson at Legal Insurrection has looked at the health care bill language at random points. It is eye opening for the complexity and multiple questions at every part of the bill that is examined. The following link is to the last examination, and there are six others there.

Day 7 - Don't Wish Too Hard

CriticalCareRN said...

Keith - I don't currently have time to read the "explaining" of the bills done by Kaiser, but I really will and get back.

I am very interested to know if they only told people that the deficit would be reduced, that the CBO said premiums would go down, etc.

If you ADD the facts that the CBO also repeatedly says things like:

1. "The same SUBSTANTIAL DEGREE OF UNCERTAINTY that surrounds CBO and JCT’s estimates of the impact that the proposal would have on insurance coverage rates and the federal budget also accompanies this analysis of the proposal’s effects on premiums."

2. "It is unclear whether such a reduction in the growth rate could be achieved, and if so, whether it would be accomplished through greater efficiencies in the delivery of health care or would reduce access to care or diminish the quality of care."

"These longer-term calculations assume that the provisions are enacted and remain unchanged throughout the next two decades. However, the legislation would maintain and put into effect a number of procedures that might be difficult to sustain over a long period of time."

"...the budgetary impact of broad changes in the nation’s health care and health insurance systems was very uncertain."

All this PREDICTION and UNCERTAINTY at nearly a trillion dollar cost, HOPEFUL savings, and a possible risk for damaging the quality of care and access to the system. The CBO has a history of grossly underestimating things. These statements from the CBO jump out as HUGE red flags to me, particularly in such MASSIVELY GIANT pieces of legislation.

I also wonder:

Did Kaiser also explain that if Medicare gets cut to physicians, cardiology practices will close, and more providers will likely stop taking Medicare patients, as we already see on the horizon?

And, did they explain that when practices close, it affects non-Medicare patients who see those doctors too?

Did they also explain that if they DON'T cut Medicare, the bills costs rises half a trillion dollars?

Did they explain that while they keep promising to allow people to keep their insurance plan and their doctor, they also take away the Medicare Advantage Plans from people who like it. And, we tax the "cadillac" plans at a huge rate for people who currently love their plans (well, except for the big Democratic lobby interest, the unions).

And, while we push out providers, fail to recruit more, and close down practices, people who love their current doctor - may, in fact, lose that doctor. In fact, did they explain that while reimbursements drop with government funded patients, some doctors say they will switch their practices to boutique medicine altogether?

Did they explain all that, I wonder??

On the WHO study:

In the WHO 2000 study of health care systems, 5 indicators were addressed. The indicator of system "Responsiveness", which is the closest to hint to quality of care, is where the U.S. ranked NUMBER 1. The category of "Responsiveness" included these two things (taken directly from WHO website):

1. Respect for persons which includes:

- Respect for the dignity of the person.

- Confidentiality, or the right to determine who has access to one's personal health information.

- Autonomy to participate in choices about one's own health. This includes helping choose what treatment to receive or not to receive.

2. Client orientation includes:

- Prompt attention: Immediate attention in emergencies, and reasonable waiting times for non-emergencies.

- Amenities of adequate quality, such as cleanliness, space, and hospital food.

- Access to social networks - family and friends - for people receiving care.

- Choice for provider, or freedom to select which individual delivers one's care.

CriticalCareRN said...

Keith, et al.

Not that this is important really, but despite my current strong dislike for a president that I now see as arrogant, fear mongering, hypocritical and dishonest - I am, regretfully, one of the people who voted for him. I used to love him. I have actually never voted for a Republican, YET. That is about to change, possibly for a very, very long time to come.

CriticalCareRN said...

Keith - Also, I don't think people are consuming too much food, alcohol, tobacco, etc., because they're stupid...Obama is case in point - After all, he was a long time smoker, but he's not dumb. I know a lot of drinkers and obese people who are quite intelligent.

People know these kinds of things are unhealthy, and they don't do it from lack of knowledge or understanding, they do it for entirely different reasons than that.

CriticalCareRN said...

Keith - I have had time to look through the Kaiser link. I did not find the actual wording of the questions to gauge how they "explained" what's in the bills. They just listed "mandates coverage", "insures 31 million people", "expands Medicaid", etc. But, these things are not so black and white like they seem to try to portray.

If you just tell me a new piece of legislation is going to insure 31 million people, I would say, YES!!

If you tell me it will do that by mandating they buy expensive policies or face a penalty if they don't, I say NO.

If you tell me that nearly half of those newly insured comes from a massive entitlement expansion, and I understand that Medicaid is paid for by taxes through the states already hurting financially - and that expansion costs are largely incurred by those states, I would say NO.

And if I further understood that providers who accept Medicaid are so grossly underpaid that they accept only a few insured by Medicaid and then close their practices to new patients, creating an environment where there is already competition for the few new patient provider slots, I would say NO.

If I further understood that providers are increasingly opting out of Medicare/Medicaid because of reimbursement problems - and while we push 15 million more patients onto Medicaid/SCHIP - the competition for those slots gets hugely worse.

And, again, if you tell me the CBO says it will bring down the deficit, I would say YES.

If you tell me that the CBO ALSO said everything I posted earlier and that the savings are a prediction with a substantial degree of uncertainty, and that it may bring down quality and decrease access, but the costs are a sure thing...I would say NO.

These things just aren't so black and white. And, I think it's the "between the lines" part that Americans actually do see a little bit better than Obama wishes they did.

CriticalCareRN said...

Keith - Also, regarding your comment about bankers lending to dead people...It is my understanding that that happened from government interference. It was the government who said, "hey, you need to start lending to people who otherwise would not be able to purchase a home", so as to get the poor into home ownership. Prior to that, they were not lending to such high risk people.

I think it's government interference that helped jump start that problem.

Keith said...

Andrew,

My apologies. I thought you asked for a link to the entire bill. You might want to check out the Kaiser Family Foudation web site for some of the analysis you want. It is referenced in my last post.

Critical care nurse,

We can argue till doomsday what may or may not be the effect of this health care legislation. Let's face it; we are conducting one big sociological experiment and projections 10 years out by the CBO or anybody do not have much meaning. What we do have is models of health care in other countries that suggest good health care can be delivered at more reasonable prices and to the entire citizenry. I often ask my paatients who have had experience with health care in these countries their opinion and they seem uniformly pleased with their systems of health care but often can reference specific issues of wait times, etc. that prove a nuisence. The legislation as I see it moves us toward a health system much like Germany or France (by the way Frances health system has broad choice of providers and jointly publicly and privately financed, very similar to the proposed legislation).

The central problem I see is public policy changes in the past years that have accelerated concentration of wealth in this country. Coupled with rising health care and post secondary education costs, we have priced many of our citizens out of the market for these products that ultimately allow them to be more productive citizens. If current trends continue, we will perpetuate the 2 tier system fo health care with gleeming hospitals with waterfall amenities and flat screen TVs next to public hospitals using scant resources to serve those priced out of the market. What Obama is doing is attempting to establish some rebalancing of this trend, allowing for goverment to provide necesary subsidies to allow people to attend college and to get health care without going into bankruptcy. The problem has been the unwillingness of those of greter means to healp finance these subsidies through increased taxation. Failure to perform this rebalancing will ultimately result in great social upheaval and I fear a country that none of us will enjoy living in.

Good countries provide their citizens with the tools to succeed; we don't and blame those who can't on their lack of ambition. I don't buy this argument. I think we allow too much concentration of wealth and do not invest enough in the early infrastructure that allows people to climb out of poverty and succeed.

Bottom line, we can't keep doing what we are currently doing; it will make fixing the problem even more difficult. We need health reform NOW!

CriticalCareRN said...

Keith,

France has a very low population of their people insured through their government. The vast majority of their citizens hold private health care policies. Huge expansions of people getting their insurance through the government is one of the things I strongly oppose in this legislation.

Moreover, the French are less obese, drink, smoke, drugs, less teen pregnancy, less auto accidents, less violence, etc.

Again, when violence happens, health care gets consumed. When people ingest toxins, etc., health care gets consumed. When accidents, or high risk behavior happens, health care gets consumed. One of the big reasons we consume a lot more health care than France, is because our behavior warrants it.

Moreover, I would like to know how much money French taxpayers have to put toward their military, foreign aid, etc. How much did their taxpayers give to Haiti versus the U.S. Were they willing and/or able to give $100 billion dollars to third world countries because of climate change problems? These are the kinds of things I would like to know, too.

You may want this country to morph into the welfare nations of Europe, but, thankfully, it does not look like most in America do. There is a reason why we are the wealthiest nation in the world - it's called productivity and you only reduce it when you take away people's ability to EARN money by working hard for it. I will give you that there is also a problem with greed and waste in this country. A lot of that greed and waste is included in our federal government - like 60-90 billion taxpayer dollars lost each year to crooks because they don't check the claims, and that's a good reason their "administrative" costs are so low. What of their billion dollar lobby money and campaign funds they raise - why not tax that at 50% too?

You - "we do not invest enough in the early infrastructure that allows people to climb out of poverty and succeed"

Again, directly from Elmendorf's blog:

"The country faces a fundamental disconnect between the services the people expect the government to provide, particularly in the form of benefits for older Americans, and the tax revenues that people are willing to send to the government to finance those services. That fundamental disconnect will have to be addressed in some way if the budget is to be placed on a sustainable course."

This country just elected a president whose main mantra, repeated hundreds of times, was that he would not raise taxes on 95% of Americans. It's not just the wealthy who do not want higher taxes. So, should we raise the tax on the wealthy 10, 20, 30, 50% to support everyone? With single payer, is EVERYBODY willing to accept a 30-50% raise in their taxes to support such an expensive endeavor? When our country hits a big recession, and the government can no longer afford those services and cannot increase taxes more to pay for it, what then? Raise taxes in a bad economy, or drastically cut services?

People from other countries who say their system is better likely never needed any of the services that are largely rationed. They likely did not have major pain that needed a hip replacement and they had to wait 8 months in horrible pain. They see our system as worse, because we have people going bankrupt because of an illness - and that frightens the hell out of everyone. I agree with what they hate about our system, and I want to fix that too. But, not by jumping from the frying pan into the fire - transferring rationing from one entity to another, and making that rationing even more tragic.

continued below.....

Andrew_M_Garland said...

To Keith,
You said: "We can argue till doomsday what may or may not be the effect of this health care legislation. Let's face it; we are conducting one big sociological experiment and projections 10 years out by the CBO or anybody do not have much meaning."

You still aren't serious. The reason we can "argue till doomsday" is that you aren't presenting more than your opinion, with no facts or analysis. You still have not presented or pointed to a summary. I don't think you told your patients to analyze the Kaiser survey. CriticalCareRN and I have taken a look, and I see no analysis of proposals, details, costs, and benefits. Just a survey that amounts to "would you like more free health care" and "does it concern you if the costs go up".

Somehow, your support for health care reform is bound up in increased taxation on the rich to level the outcomes for everyone. You call it rebalancing. So, health care reform should be called the "The Income Rebalancing and Taxation Act of 2010", in your view. Plus, it is somehow related to supporting more college education and infrastructure renewal.

We aren't even having an argument. That would require that you present facts to discuss. So far, your position is that we should hand all power to the state, prevent accumulation of wealth that is "too much" in your opinion, collect much more taxes, and bask in the beautiful country that this will build. And, this is a glorious and desperately needed experiment, with an outcome that we can't now predict. But, we should not worry, because we probably will become France.

Your use of language is inexact. You said "we are conducting one big sociological experiment". The correct phrase is "we are conducting one big socialist experiment".

I don't think that you are furthering your cause.
An anonymous poster can add information to a discussion.
An identified poster can give an opinion, backed up by whatever real identity he has.
An anonymous poster who gives just an opinion adds little.

CriticalCareRN said...

As far as the wealthy supporting the poor, while I concede there are problems with the tax codes that allow the outrageously wealthy (Oprah's, Brangenlina's, Michael Jordans, etc.) to bring their effective rates down way too low, our tax code is extremely fair to the poor.

The people at the low to middle end of wealthy are the ones who do not have the investments of the grossly wealthy to bring their effective tax rates down really low. I am not advocating that they do, I am pointing out that the tax codes really benefit the grossly wealthy and the lower ends of wealthy are paying a high percentage to income for taxes. But, the bottom line is that the wealthy already do support the very poor to a large extent.

Check out the CBO website on household income tax info:

http://cbo.gov/publications/collections/taxdistribution.cfm

Note from the CBO reports that:

Share of total federal tax liabilities:

1979 lowest quintile = 2.1
2006 lowest quintile = 0.8

1979 highest quintile = 56.4
2006 highest quintile = 69.3

Share of individual income tax liabilities:

1979 lowest quintile = 0.0
2006 lowest quintile = -2.8

1979 highest quintle = 64.9
2006 highest quintile = 86.3

Beginning year 1987, the lowest quintile began getting money without putting in money. Beginning year 2002, the lowest and second lowest quintiles were both collecting money without putting money in.

This seems quite fair to the poor (or unfair, depending on whether you think teaching a man to fish, or giving a man a fish is better). And perhaps our system even attempts to help fund their way out. Poverty continues not because we are not throwing enough money at it. It continues for a multitude of reasons.

Look closely at the Detroit city school district. Millions of state and federal dollars pumped in, only to be robbed by crooks high up in that system - bringing it to the verge of total bankruptcy and ruin.

Just because I am strongly opposed to government run health care, and this administrations steps toward that end, and I strongly oppose these bills, does not mean I think the system is great and we should leave it alone. I acknowledge we have huge problems that need to be addressed. But, I also think there are many, many great things that must be preserved and we should focus on fixing what's bad.

France also seems to have found a way to reduce their administrative costs considerably - they have near instant payment processing. Again, there are things that absolutely would not translate to our population, but I do agree we could at that system for some clues on a few things to bring down costs without disrupting our quality and innovation.

And we are going to do a nearly 1 trillion dollar experiment on our health care system that could make many things much worse? The costs may come down, savings on premiums maybe down 1 to 3%, nothing to address citizens high need for health care due to violence, accidents, behaviors, etc. but the costs of the bills are for sure, well except that they could be much higher than anticipated - and a greater than 2000 page experiment at that - to me is just plain crazy and irresponsible in my opinion. These bills are nowhere near the center politically. It reflects quite left of center, in my opinion.

- clearly, brevity is not my strong suit ;-)

CriticalCareRN said...

Anybody -

Off health care subject - But I would like to see if there is any correlation between the growing number of citizens collecting from our tax system without also paying in, and the growth and perpetuation of poverty.

If people are taken care of, they may be less motivated to work their way out of poverty?

Hence, throwing more money in over time and still not enough getting out. The more we do for people, what they must learn to do for themselves, do we just help perpetuate the problem?

The fastest cure for liberalism is for the government to come after your money. When the government tells someone like Rosie O'Donnell that she can only keep 30% of her earnings, AND that she has to have an income earning potential cap of $500 thousand dollars for the sake of others needs - I predict a speedy bolt to the right!!!

Keith said...

Andrew,

If you just took the time to look a little further at the Kaiser site, you will find an interactive comparison tool which will give you a complete summary of the house and senate bill.

Please don't start with the socialist/communist argument, which seems to be the argument of choice when we attempt to do anything that involves goverment action. It is a poor and fallacious argument. Are Great Britin, France, Germany, and Canada all considered socialist states in your mind. After all they all have govermnt managed health care systems that provide health insurance for all their citizens!

Critical Care Nurse,

Frances system is funded by an almost 20% tax on income. More than 80% of its citizens have the public plan, although many buy a supplemental plan to cover co-pays. Kind of sounds just like Medicare. Oh, and everyone is required to have insurance.

You can also read about the Mass. health care plan at the Kaiser site. Mass. now has only 2.7% of its citizens uninsured. It is stuggling, given the recession to keep up with the costs, and interestingly enough, is moving away from a system to pay fee for service reimbursement to provider, instead opting for global payments to accountable health provider organizations; something that is part of the reform proposals passed by the Senate and House.

Andrew

Maybe you can give me some facts to support your position. I seem to be the only one providing links to studies, yet you accuse me of just offering my opinion.


Critical care nurse,

You accused me initially of being condescending and arrogant for sufggesting most pople are not well enough informed about the health bill. Now I can accuse YOU of the same behavior for suggesting the poor may be less motivated if we give them health care. If you examine that Kaiser site as well, you will find that more than 60% of the uninsured are low to middle class WORKING people who can't afford the cost of insurance on thir measley salaries, most of which seems to be ending up in the pockets of Wall Street Bankers and such, who have seen their incomes shoot through the roof over the past 2 decades.To suggest that people will stop putting forth effort if you give them reasonable health care sounds like French aristocracy. What did she say? "Let them eat cake!"

PS Would you quit your job if your health care was not tied to your job?

Andrew_M_Garland said...

To Keith:
It seems that it wasn't worth your time to present that link. I did find it:
Summary of the Affordable Health Care for America Act (H.R. 3962)(PDF)

It seems to be a reasonable summary from my quick review and what I know from reading. It shows some of the complexity, but none of the controversy. It is a start.

Keith said:
===
Please don't start with the socialist/communist argument, which seems to be the argument of choice when we attempt to do anything that involves goverment action.

Are Great Britin, France, Germany, and Canada all considered socialist states in your mind? After all they all have govermnt managed health care systems that provide health insurance for all their citizens!
===

Yes, they are socialist to a degree greater than the US (so far). Don't you consider yourself a socialist? You want people with larger incomes to support people with lesser incomes, the "balancing" that you talk about. You are willing to control the entire health care market to insure that wealthier people get the same care as the less wealthy. Why aren't you proud of that position?

Socialism isn't everything that involves government action. It is the policy that people with more money have somehow achieved success by harming those around them. So, the state should collect that money and do better things with it. The state decides what each person should consume, in a fair and just way, leveling the differences between people. Isn't that what you want? Isn't health care just a good beginning toward that end?

As for my position, it has taken all of this discussion for you to send me to the summary I originally asked for. What little argument I make comes from material at the two links I posted above:
========
The offered arguments against the quality of US health care are based on flawed infant mortality and life expectancy comparisons, as CriticalCareRN has pointed out.

USA Healthcare is First - Infant Mortality is Low
My collection of public information to add to the debate.

William A. Jacobson at Legal Insurrection has looked at the health care bill language at random points. It is eye opening for the complexity and multiple questions at every part of the bill that is examined. The following link is to the last examination, and there are six others there.

Day 7 - Don't Wish Too Hard
========

CriticalCareRN said...

Keith - Andrew provides links too. And you have only provided Kaiser repeatedly, and one opencongress, unless I missed some others.

Having read the first link you provided from Kaiser, I do not find them a credible resource. They just presented few word phrases open for misinterpretation. You can keep using them as your resource, but they are not a forceful resource in my opinion.

But I ask Kaiser this question...Their 60% of the uninsured are working Americans who can't afford health insurance...How many of that group have a $200 thousand dollar home, 30 thousand dollar cars, nice clothes, vacations, private school tuition, etc. I am not saying they should not have those things, I am saying there is more to look at other than just "they work and they still can't afford it". In fact, in my family, we have a family where both adults drive a hummer, have a beautiful home, but no health insurance.

Also - Look into how many of the uninsured includes people who qualify for Medicaid, but do not sign up for it. I have heard over 10 million, but I don't know if that is true.

The plain truth is this: It has taken less than 50 years for the business model of Medicare to turn upside down, see 37 trillion dollars in unfunded liabilities, put itself in the position of being forced to choose between remaining solvent or seriously hindering access for patients, etc.

Americans do not elect politicians who will substantially raise their taxes, and that's not just the wealthy. Americans do not want their taxes raised, and that's not just the wealthy. Again, we just elected a president promising ad nauseum not to raise taxes on 95% of Americans.

You are right about the French system having people with public insurance only and people with their supplemental private plan. I misinterpreted the data that I read, thank you for correcting me.

continued below....

CriticalCareRN said...

continued from above...

But, again, is EVERYONE in this country willing to give 20-30% or more of their paycheck for health insurance for all? You can't do it just by raising the taxes on the wealthy. The wealthy are already supporting the poor to a degree. That cannot be logically argued against. The Congressional Budget Office reports that is what is happening. I am not saying that is good or bad, I am saying it is true and therefore nobody can suggest the wealthy are clearly not already assisting the needs of the poor.

My question about the system perpetuating poverty was posed as a question - I don't know if there is a true correlation, but it seems a logical possibility worth investigating.

I did not connect that argument with "we shouldn't pay for the poor's health care". I wasn't talking about health care at that time, I was talking about the wealthy already funding needs of the poor. The possibility that people might be inclined to choose the path of least resistance may be offensive, but it is still worth investigating.

Did you see the movie "Precious", where her mother screams at her to forget about college and just get her ass down to the welfare office and collect her check? That girl needed assistance and the mindset to get out of poverty, therefore an education, for sure. I am all for contributing to that. But maybe there comes a point where people decide it's just easier to remain in poverty, they're used to it and they can still get what they most need at the basic level - and so they teach that to their young? Rather than teaching them to fight the hard fight to get themselves out? I am not suggesting it's easy. Working the way up the socioeconomic scale is not easy for anybody, least of all the poor. It should, however, be EARNED by hard work - that was the point of the founders, I believe.

Do not misinterpret what I am saying, I am not saying stop giving the poor what they need, like health care. I am saying the problem is more than just money, and to just continue to throw more money at it, may not be the effective solution.

And, again, compared to the French who pay almost 20%, Americans smoke more, drink more, eat more, shoot each other more, etc., etc. Meaning, our health care NEEDS are higher than theirs to begin with. Our taxes to support it would have to be much higher too.

I wish we could change the situation with CEO's collecting huge amounts like they do. I don't know that taxing their bonuses is the correct answer? Most of that bonus money should go back to the investors, not to the government. But attacking, dismantling, and penalizing the concept of wealth because poverty continues in this country should not be the answer to that problem or any other problem with poverty. Wealth is not a bad thing!! It does GREAT things for our country, including providing assistance to the poor.

Interestingly, candidate Obama was against Massachusetts model of mandating health insurance and penalizing people. Here's a clip of him saying that:

http://www.youtube.com/watch?v=0foRt63g100&feature=player_embedded

Anonymous said...

OK guys. Everyone is throwing out a lot of info and I don't know how much to believe and which sites to trust. But I gotta ask: France doesn't smoke as much as the US? Now, I need some backup on that! I was there last summer and my anecdotal evidence was that 80% of the adult population smoked. Sorry for the small quibble, though it does cause one to question the proffered facts.

Anonymous said...

Mr. Garland,

WHO is biased? #37 is based on political postering? Do you also believe the United Nations is out to take over the world? Show me some hard evidence, sir. Otherwise your argument is nothing more than your opinion.

Anonymous said...

Mr. Garland,

I just took a look at the Legal Insurraction blog. Sorry, sir. This guy belongs on Fox news. He matches their criteria of "fair and balanced".

Keith said...

Andrew and Critical Care Nurse,

Are you guys double teaming me?

Andrew,

I don't like labels like liberal/conservative /socialist. One can be a fiscal conservative but a libral/socialist regarding social issues for instance. And in the present political enviorment, these terms have negative connotations depending on which side of the spectrum you are on.

My personal belief is that we are actually paying for all this health care anyways. The utter lack of primary care for the Medicaid and uninsured population means they often wait for health care till the major complications set in and then they have to go to the hospital for much more expensive care. Health care organizations have to increase their rates to compensate for these added uncompensated costs that show up as higher health care premiums (a hidden tax if you will). Here in Chicago, we have a very expensive county health system and Chicago spends alot on a city system of health clinics. These are taxed more overtly. So it make more sense to me to require people to have some basic health insurance, particularly if they can afford it, so the costs of an unanticipated illness can be recovered instead of paid by you and I.

My socialist bent is predicated in the fact that the playing field for many is unequal. If you are born into poverty, you will likely be taught in a second rate school system in a gang infested neighborhood, limiting your chances to succeed. Instead of assuring adequate funding for all our schools here in Illinois, we prefer to have places where the wealthy can congregate and send their kids to top notch schools, while the poor are largely sequsterd in low income neighborhoods in Chicago. That way we can ignore the problem and more easily blame their plight on studpidity, laziness, and lack of common sense. If not for this uneven playing field (why else is corporate America still largely populated by white men; are we the chosen race/sex?), I could argue that those who fail should be entitled to substandard health care. I seriously doubt that most people choose to be poor if given the choice between working and living on foood stamps.

Critcal care nurse,

You are already giving almost 6% of your pay to support Medicare, and Medicaid is probaly one of the programs adding to the federal deficit since we are unwilling to pay for anything that helps those lazy poor people.

And please tell me why we eat more, smoke more, shoot each other more? What do the French know that we don't? How to live a happy life without chasing the almighty Franc?

Pointing out what Obama said during the campaign does make him look two faced. But then we have the new senator from Mass., Senator Brown, who ran on his opposition to the current health bill, but voted for the Mass. plan. The federal plan has more similarities to the Mass plan than not, so what is good for Mass. citizens is not for the rest of the country?

CriticalCareRN said...

Anyonymous 05:53

I got that information on US smoking from a CBS news article reporting on a World Health Organization report from 2008.

Here is the link to that article:

http://www.cbsnews.com/stories/2008/07/01/health/webmd/main4222322.shtml

A quote from that article:

"Tobacco use was also most common in the U.S. (74%), followed by Lebanon (67%) and Mexico (60%)." from that article.

I have never been to France to have an anecdotal experience. Honestly, I generally trust CBS news reports. Maybe I shouldn't? Or, maybe they combined marijuana with cigarettes and that increased the U.S.?

Keith -

I am sure the French are overall happy people, as are Americans. But I wouldn't hold too much weight on French people's "happiness" levels.

I have read more than one report on their lack of happiness with their country, etc.

http://www.telegraph.co.uk/news/1577166/French-morale-hits-a-new-low.html

quotes from that:

""morale of French households" is at its gloomiest - minus 34 points - since the study began in 1987."

"Collective pessimism is engraved in French culture. We are regularly found to be the most pessimistic nation in Europe"

"France is moving away from the nanny state towards more autonomy", said Mr Mermet."

"Some people are happy about this, saying it's better to be in charge of ones own life and destiny than to depend on others. But it is painful for some social categories and in general in France we're not used to it. So perhaps the pessimism is a sign that we want to delay its arrival,"

What I would want to know about France is, do their higher taxes impede employment levels? Do their higher taxes impede productivity GDP per capita? Do their higher taxes for health care put their health care system, and their economy, on a "sustainable" course? What about physician happiness? What about physician strikes? I would want to know those things too.

I think Scott Brown voted for the Mass plan because he believed it was a good idea at the time. But, it sounds like the plan in real form has shown that there are big problems - which Obama understood when he was campaigning. The fact that Brown speaks out against it now shows that he understands and recognizes the problems that have played out in "reality".

Last I heard, the Mass plan was already looking like it is unsustainable. ER's were reporting higher levels of use than before the reform. And, six county hospitals were heading toward bankruptcy for under funding.

link:

http://www.boston.com/business/healthcare/articles/2009/12/01/6_community_hospitals_sue_state_over_reimbursement_shortfalls/

You -

"...since we are unwilling to pay for anything that helps those lazy poor people."

Again, to suggest that we are not already helping the poor financially is preposterous to me. The facts just don't support that assertion. If the government is not using those tax dollars wisely, blame them, don't blame the people who are paying all the taxes.

Andrew_M_Garland said...

To Anonymous,

I said above: The WHO health statistics are biased. The WHO itself ranks the US #1 in health care delivery that is important to patients. It issues another ranking of 37th because this quality of care costs more and is not delivered by government! Critics of US health care always refer to the 37th ranking. That is a pure political judgement by the WHO.

I posted that far above, just for you. You could do me the honor of reading and remembering it.

The #1 rank is based on care delivered. The #37 rank is based on the higher cost. This is a political distortion. The common and incorrect complaint is that the US spends more than other countries, yet ranks 37th. Actually, we spend more and get more, as #1 in care delivery.

My basis for this is at the link I already posted.
USA Healthcare is First - Infant Mortality is Low

There is also info there about the differing cultures between the US and Europe: more shootings, auto accidents, heart disease, and recorded infant deaths in the US compared to Europe, all of which decrease average life expectancy, but are not related to poor healhcare.

I find it funny that there are frequent stories about how guns cause more death, auto accidents are a problem, and Americans are too fat, compared to Europe. But, when it comes to healthcare, these differences are not mentioned as causes for the differing mortality statistics. What do you think?

I'm sorry you don't like Legal Insurrection. I think the examination of detail in the healthcare bill is interesting and of great concern.

Andrew_M_Garland said...

To Keith,

Why do you hate the label Socialist? You like the Socialist program, and I would think that you would point proudly to Socialist successes (with some detail, thanks).

Thanks for your opinion. It would have more chance of swaying me if you could post the underlying analysis. For example, people often claim that more preventive care will cost less overall, because it will eliminate expensive visits to the ER. Actually, more preventive care costs much more overall, but it does lead to better outcomes.

Prevention Costs 8x As Much

CriticalCareRN said...

Andrew and Keith -

NO offense Andrew, but an article that says Fox at the top might not carry a bunch of weight since some consider it very biased (though, I have grown to trust Fox now a little more than MSNBC, which used to be my network of choice).

Here is a statement from the CBO on prevention costs.

"So a new government policy to encourage prevention could end up paying for preventive services that many individuals are already receiving—which would add to federal costs but not reduce total future spending on health care."

Here is the link to the CBO blog (Elmendorf's blog) with that statement. Prevention and Wellness are discussed in August, so it is way down the blog list.

http://cboblog.cbo.gov/?cat=5&paged=4

They do also talk about the value of investing in prevention, and even though it can cost more, they do seem to suggest it is worth the extra costs. At least that's how I read it.

Also Andrew - Clearly you and I are both scratching our heads by the fact that people just want to hold up the #37 ranking, higher costs, and lower longevity and high infant mortality, and never look any deeper than that - and just gasp in horror and say our health care system is horrible. Obama feeds into that, a lot.

Below is the WHO link, if anybody needs it. But directly from that link:

The 5 categories studied are:

1) Overall level of population health;

2) Health inequalities (or disparities) within the population;

3) Overall level of health system responsiveness;

4) Distribution of responsiveness within the population

5) The distribution of the health system’s financial burden within the population.

The US ranked number ONE on category 3. Specifically, WHO defines category 3 this way:

1. Respect for persons which includes:

- Respect for the dignity of the person.

- Confidentiality, or the right to determine who has access to one's personal health information.

- Autonomy to participate in choices about one's own health. This includes helping choose what treatment to receive or not to receive.

2. Client orientation includes:

- Prompt attention: Immediate attention in emergencies, and reasonable waiting times for non-emergencies.

- Amenities of adequate quality, such as cleanliness, space, and hospital food.

- Access to social networks - family and friends - for people receiving care.

- Choice for provider, or freedom to select which individual delivers one's care.


http://www.who.int/whr/2000/media_centre/press_release/en/index.html

The truth is, based on the statistics about how our society treats our bodies (and each other), it is no wonder we spend so much on health care and still struggle with longevity. Often, the "cure" for people lies more within themselves than the health care system. Longevity and overall population health cannot be solely the responsibility of a health care system. We ask our medical system to do more than any other medical system, and more than any medical system can do.

And, yes, don't get me started on why we have higher infant mortality rates. I am the mother of two year old triplets. I consumed five years of infertility treatments. I had a high risk pregnancy that could have yielded one, two, or even three infants born prematurely who could have died. Our health care system was outstanding in managing my high risk pregnancy, and I have three healthy two year olds. How many "octomoms" and John and Kate plus 8's are there in Canada, Europe??? And that is just ONE of the elements involved in that number.

Keith said...

I think the issue of increased costs due to preventive care depends how you define it. My own personal sense is that there are many diabetics, hypertensives and hypercholesterolemics that are not getting adequate treatment and follow up. These are where the biggest bang for the buck is in terms of preventing chronic renal failure (the two biggest causes in patients on dialysis) and treatment of cardiovascualar disease and such.

Also, more funds directed toward smoking cessation would provide huge returns (where did all that tobacco settlement money go!). Unfortunatley states have not spent it on public outreach and treatment because I fear they have become dependent on all the tax revenue they now get off of tobacco products.

Where you may get alot of increased costs is in the area of cancer screening, where there are significant false negative rates that result in more invasive and expensive testing. This has been the crux of the whole argument about screening women in their 40's as to whether this early screening results in more harm than good and represents a huge cost for little payback. After all, why not screen women in there 20's and 30's? I have seen breast cancer in these age groups, though rare. Where do you draw the cost/benefit line is the central question.

Bottom line though is what provides the best bang for your limited resources, and it may become an issue of deciding whether the data support a greater improvement in health collectively by early breat cancer screening vs say treating many incurable cancers with third line drugs that have enormous cost.

The argument is then often framed around the idea of the goverment limiting patients ability to obtain the testing they want. Nothing in any proposed legislation attempts to limit the availibility of patients to obtain any testing they desire! It is simply a question of who will pay the bill. I can tell you that I personally do not want to be part of that insurance pool where patients demand and get their insurance company to pay for unnecessay and frivolous tests and procedures. If patients want unproven or low yield procedures, then they should pay the brunt of the cost.

So the argument should not just be about preventive care, but all aspects of medical care and what proves most effective at maintaining good health.

Andrew_M_Garland said...

To Keith,

Thanks for your opinions on just about everything. You lost me when you wrote --
"I think the issue of increased costs due to preventive care depends how you define it."
-- and then failed to define it.

You ended with --
"So the argument should not just be about preventive care, but all aspects of medical care and what proves most effective at maintaining good health."

I am not energetic enough to discuss all aspects of preventive care, maintenance, and treatment.

- -
To CriticalCareRN,

It has been a pleasure to be in this discussion with you. You nicely present facts and links.

CriticalCareRN said...

Keith -

The problem I have with the debate about mammograms for women 40-50 is that they seemed to be evaluating apples with oranges.

If the question was this:

How many lives are saved doing this screening, versus how many lives are unnecessarily lost doing this screening and unnecessary testing....

THAT would be comparing apples with apples.

But they are comparing how many lives are saved doing this with how much more costs and how much unnecessary anxiety is happening.

In my opinion, you cannot logically compare lives saved a year from early detection through screening with anxiety and costs.

Deciding what testing will or will not be covered by insurance is essentially deciding what testing people can and cannot have. A lot of people cannot have mammogram screening if it's not covered by their insurance - because they can't pay for it themselves.

If the "Secretary", or the "Preventive Services Task Force", or whatever they call it, is going to decide what is most cost effective and therefore what should be covered in a minimum preventive plan, I do see them deciding who can have what test. I am not against establishing minimum coverage plans, I am just against a government agency doing it focused on cost effectiveness - the mammogram issue highlighting my concern for that. I do not want a government group to compare "cost effective" versus "life saving" for huge populations of people.

Keith said...

Critical care nurse,

So according to your argument, we have 25 million women, give or take, that cannot get mammograms now since they lack insurance. and availibility for women on Medicaid is not so great either.

You have actually hit upon the crux of the argument. oowe ration care on the basis of who can pay (our current system) or on the basis of who has the greatest need.

And where do you set the bar? Shouldn't we spend money screening women in their 30's if we can save one life? How about colonoscopies from age 40 on up? The skies the limit, I guess, if we can save just one life more than we lose, right? Meanwhile, we waste precious resources that could be directed to public health campaigns that would save many more lives than mammograms for women in their 40s. Maybe you should not look at this issue in a vaccum, but within the greater context of what would prove most beneficial to th most people.

CriticalCareRN said...

Keith -

Your argument does not make sense to me. Are you advocating for a health care system that focuses more on money than health care? Mammogram screening in that age group likely saves hundreds of lives a year.

But, YOU DON'T want to save more lives? How about if one of those females is your mother, your wife, your sister, your daughter? If one of those females turns 44, was low risk for breast cancer, did not get screening and now has breast cancer that could have made a huge difference if caught earlier - but it wasn't caught early because of a lack of screening - is that okay with you because it costs too much to screen women?

I have never defended the fact that we have too many uninsured. I have never deemed that acceptable.

But I do think your last post clearly describes the big difference between you and me. You are so angry that some don't have, that you are aiming that anger at those who do have. In your opinion, nobody should have the current mammogram screening standards, because others don't have it at all? On the one hand, you don't care if women die from lack of screening, on the other hand you are angry that women die from lack of access to health care. That is irrational to me. It just doesn't make sense to me.

Honestly, I think you will agree that our discussion has reached an impasse. My questions above can be taken as rhetorical. It was a great pleasure debating this issue with you.

Andrew - It was great having you in the discussion as well. Clearly we are like minded, and that is always nice.

- Jodi
CriticalCareRN

Keith said...

Jodi,

We may be at an impasse, but let me explain what you haave difficulty reconciling.

Resources are not infinite. If they were, we would not be arguing these points. The question I would pose to you is do you think you save more lives by paying for mammograms for women in their 40's or by increasing the pool of women in their 50's who currently do not have access to mammography? If your argument is that insurance coverage is important to making sure that mammography is affordable and acsessible to the under 50 crowd, why do we want to deny acceess to the significant numbers of the 50 million uninsured (this does not take into account Medicaid patients that may not have reasonable accesss) to this screening test in the 50 and over group, where the benefit is clear and pronounced?

I want what I beleive is the greater good. If the hard choice is offering unfettered access to the 157 million women after 50, or only to 100 million women who possess insurance, I will take the former as more likely to save more lives.

Everyday choices do not occur in a vacuum. Spend you money on one thing and you have less for another, unless you are fabulously wealthy. Hard health care decisions about what is reasonable to cover are difficult to make, because every disease has an advocacy group and a sad story of health care disaster. But we need to provide basic health to our population before we can argue for those things of less benefit. It is called rationing and we can do it overtly by determining what is proven and beneficial by science, or covertly by simply denying care to those who lack the means.

CriticalCareRN said...

Keith -

"do you think you save more lives by paying for mammograms for women in their 40's or by increasing the pool of women in their 50's who currently do not have access to mammography?"

That is not what the Preventive Services Task Force was asking. They were not comparing death rates with death rates. They were comparing death rates with anxiety/cost. I do not want a government task force evaluating and comparing death rates with cost. Death rates versus death rates is another thing.

Here are more videos showing Obama being two faced, for your viewing pleasure.

First he says, "I have not said that I was a single payer supporter..."

Then they show him years earlier saying, "A single payer health care plan, that's what I would like to see...."

http://www.youtube.com/watch?v=fpAyan1fXCE&feature=player_embedded

BUT, in the video following, he goes on to say in that same speech at the AFL-CIO saying, "single payer health care system, that's what I'd like to see. We may not get there immediately because first we've gotta take back the White House, and we've gotta take back the Senate..."

http://www.youtube.com/watch?v=fpAyan1fXCE&feature=player_embedded

Here is one (radical, no doubt, sorry, I hate that too), with Barney Frank saying the public option is the best way to a single payer system.

http://www.youtube.com/watch?v=p-bY92mcOdk&feature=player_embedded#

AND, here are the myriad of times he claimed how out in the open the health care debate would be. The public will see the choices being made. Did YOU get to watch the PhRMA deal be made? Did YOU get to watch the deal be made with Nelson, Landrieu, the unions? Someday we may even learn that the AMA support was bought off by a promise to allow them to maintain their monopoly over the CPT coding - but we don't know, yet.

Sorry, it also has a radical flavor in delivery, not my taste either.

http://www.youtube.com/watch?v=Api4fUziAnI&feature=player_embedded

-Jodi

CriticalCareRN said...

Correction to my comment above: They were comparing "lives saved" rates with cost/anxiety, not death rates versus cost/anxiety.

CriticalCareRN said...

Keith the link that shows Obama saying, "I have not said that I was a single payer supporter..." is here:

http://www.youtube.com/watch?v=0lScZwsQv2c&feature=PlayList&p=32A9085CCFBDC373&playnext=1&playnext_from=PL&index=61