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By Andre Picard
The Globe and Mail
Thursday, Feb. 25, 2010

Danny Williams has the unquestionable right to get medical treatment in the United States.

But the ignorance and arrogance Mr. Williams displayed in making the decision to get heart surgery in Miami Beach is staggering.

As the Premier of Newfoundland and Labrador, he is one of the stewards of the medicare system.

The least we can expect from a political leader is some leadership and sound reasoning. What we got instead were inanities like: “This was my heart, my choice and my health.”

Mr. Williams went on to tell The Canadian Press: “I did not sign away my right to get the best possible health care for myself when I entered politics.”

The clear implication of that statement is that the surgery he sought in the United States was not available in Canada, and that health care in this country – and cardiac surgery in particular – is inferior.

That is utter nonsense on both counts.

Further, no one has suggested for an instant that being a politician somehow condemns one to a gulag of second-rate care. That is a straw man, and a flimsy one at that.

What we should expect from our politicians, however, is a degree of transparency and an ability to make evidence-based decisions.

Opting for a life in politics does not prevent you from making choices like going to the United States for care, but it does imply an obligation to explain your actions.

Skulking off to Miami, then petulantly refusing to detail why, just doesn’t cut it. At the very least, Mr. Williams owes his employers (the public) explanations about his health and his absences from work. Like other employees, he also deserves time off to recover.

Of course, there are those who say: “Leave the Premier alone. It’s his money, and his health is none our business.”

That he is wealthy enough to afford to pay for heart surgery – the procedure can cost from $25,000 to $50,000 – is irrelevant. So is the fact that he recovered at his Florida condo.

What is our business is how and why a politician makes a decision that clearly has social policy implications. In this case, the personal is political.

Evidence-based decision-making is fundamental to the delivery of good health care, on a personal as well as a systems level.

If our politicians do not know how to use evidence to make decisions rationally, is it any wonder our medicare system is adrift?

Let’s look at the evidence.

Last spring, during a routine check-up, Mr. Williams’s doctor detected an abnormality, a heart valve that wasn’t closing properly. The condition required only monitoring.

Eight months later, in December, 2009, the Premier was told the problem had become more severe and required surgery soon, though not urgently.

Like all patients, Mr. Williams wanted the best surgery available – meaning prompt treatment and a good outcome, with minimal complications and a relatively easy recovery.

He was offered the standard treatment for his condition, mitral valve repair. The surgery requires that the breastbone be cracked. which suggests longer recovery time.

Mr. Williams, wisely, sought a second opinion. Every surgery patient should.

The Premier was told the mitral valve could also be repaired with minimally invasive surgery – with smaller incisions and no cracking of the chest, suggesting less recovery time.

Up to that point, Mr. Williams did his homework relatively well. But then his decision-making went off the rails.

He contacted Lynn McGrath, a Memorial University alumnus who is a cardiovascular surgeon in New Jersey.

Dr. McGrath recommended a surgeon at Mount Sinai Hospital in Miami who does minimally invasive surgery, Joseph Lamelas.

While these men are excellent health-care practitioners, they know little about Canada’s health system.

Had Mr. Williams asked his questions of the right people, he would have learned what procedures are offered in Canada, and that cardiovascular outcomes in this country are as good as in the U.S., and often better.

The surgery that Mr. Williams wanted and was medically appropriate was not available in St. John’s, but is available in at least seven Canadian cities.

(And let’s dismiss quickly the suggestion that every procedure should be offered in small centres like St. John’s. In surgery, high volumes translate into better quality and safety, so it is wise to bring patients to central locations.)

If he’d sought advice in Canada, Mr. Williams would also have learned that minimally invasive surgery, despite the hype, is not necessarily the best option for his condition.

In the U.S. system, marketing, newness and profit margins too often trump evidence.

Mr. Williams’s sin was not in going to the U.S. for surgery, it was in acting on partial information, uttering untruths about the availability of care, and smearing – however inadvertently – Canada’s health system in the process.

The Premier said he did “some checking,” but the reality is that he depended on the old boys’ network and on prejudices about Canada’s health system instead of readily available evidence.

Sadly, this is often how decisions are made by the politicians who are stewards of our health system, and we all suffer for it.

Health care in this country is good, but it would be better if we acted more often with our heads than with our hearts.

http://www.theglobeandmail.com/life/health/williamss-heart-surgery-choice-was-based-on-ignorance/article1480937/

By Robert Kuttner, Co-Founder and Co-Editor of The American Prospect
The Huffington Post
February 28, 2010

In all of the debates about health care reform, one of the stubborn realities is that neither the Obama plan, nor any of the Republican alternatives, will seriously alter the trajectory of relentless cost-escalation in health care. If you look at the Administration’s own projections of federal deficits in the next decade and after 2020, virtually all of the alarming growth in deficit spending is Medicare and Medicaid.

And that’s only the public part of the health care bill. In 2009, total health care costs increased to 17.3 percent of GDP, with escalating premiums eating into both corporate profits and worker take home pay. The consensus among the usual policy experts is that there is no good solution. The march of technology and demography will just continue to raise health costs.

But you can reach that conclusion only by ignoring how the rest of the club of affluent countries manages to insure everyone for 9 or 10 percent of GDP, and have a healthier and longer-lived population, to boot. They do it, of course, through universal, socialized insurance.

There is no single formula. The Canadians do it with a single payer system for the insurance part, but physicians are private. The Brits have an integrated National Health Service. The Germans achieve near-universal coverage through a system of nonprofit health insurance plans.

What every other nation has in common is that they have taken the commercialism out of their health systems. As a consequence, they can direct health spending to areas of medical need rather than letting the market direct health dollars to areas of greatest profit. And with everyone covered, they can use highly cost-effective strategies for prevention, wellness, and public health. That’s how you cover everyone for ten percent of GDP.

Our one island of single-payer medicine, Medicare, is phenomenally popular — so popular that the Republicans’ most effective attack on the Obama plan is that it would divert some money from Medicare. The Republicans, on the one hand, fiercely attack “government-run health insurance,” while on the other they defend Medicare (which they would just as soon privatize).

But most Democratic politicians and policy wonks behave as if the option of a national health plan simply did not exist. These blinders are the result of the immense power of the medical-pharmaceutical-insurance complex combined with a failure of political leadership. Sooner or later, mainstream politicians will stumble their way to some form of single payer because there are no good alternatives unless we want to spend half of our GDP on health care.

In that regard, the best things about the still inconclusive end-game of Obama’s efforts to enact his plan are that (1) the administration finally broke with the insurance industry, and (2) Obama is starting to get over the delusion of bipartisanship. So if we don’t need either Harry and Louise, or John Boehner and Mitch McConnell, as part of the health-reform coalition, we might as well do it right.

With Obama’s health summit behind us, there will now be a mad scramble for Democratic votes in the House and Senate to pursue the strategy that Obama should have used all along — a Democrats-only bill relying on 51 votes in the Senate via the reconciliation procedure.

The problem is that Obama may have missed the moment. The prolonged, enervating battle for health reform, using a badly flawed bill, has scared off both conservative and liberal Democrats in both houses. The bill is politically toxic to legislators facing re-election, for good reason. The original formula, designed to enlist insurance industry allies, required a mandate to purchase insurance, diversion of Medicare funds, and unpopular taxes. Now that Obama has broken with the industry, an entirely different formula should be possible.

Alas, we are too far down the present road to advance single-payer in this legislative session. The president has done nothing to move public opinion in that direction, and has backed away even from the truncated version of it, the so-called public option.

I would put the odds at about one in three of Obama succeeding. Several Democrats who voted for the House-passed bill in November by the narrow margin of 220-215 have now defected, and several more are increasingly gun-shy. I don’t much like this bill, but I still hope it passes so that the Republicans don’t get rewarded for their relentless obstructionism.

Win or lose, the next great push should be for single-payer, assuming Democrats have a working majority again in foreseeable future. Given the collateral damage of Obama’s strategy, that could be a long time coming.

Robert Kuttner is the author of the forthcoming book A Presidency in Peril (Chelsea-Green, March 2010). He is co-editor of The American Prospect and a senior fellow at Demos.

By Michael Hiltzik
Los Angeles Times
February 28, 2010

Angela Braly can’t kid me.

When the chief executive of gargantuan health insurer WellPoint (parent of Blue Cross of California) went before a congressional subcommittee the other day, she displayed all the smile-through-the-tears pluck of Annie looking to a sunny tomorrow or Scarlett swearing to God she’ll never be hungry again.

WellPoint didn’t really want to jack up health premiums on its customers by as much as 39%, she said — it had no choice. “We care deeply about our California customers,” she said.

But what she was really telling the committee members was this: “Please put us out of our misery.”

Braly explained that her company’s premium increases on individual policies were based on several circumstances: One, people are getting older. Two, people are becoming unemployed, and if they’re healthy they’re dropping out of the insurance pool. Three, the cost of diagnostic testing is soaring.

Implicitly, she begged for the government to help — put people back to work so they’re eligible for cheaper group plans, and clamp down on costs. (Not even the government can stop people for growing older.) Without that help, she intimated, premiums are going to keep rising sharply and WellPoint’s already meager profits are going to be hammered worse.

In delivering this appeal, Braly was forced to make an implicit admission that her industry almost never makes explicitly: The nation’s health coverage system is so hopelessly broken that even the health insurance industry can’t handle it anymore.

Her testimony, and other statements she and other WellPoint executives have made, suggests that insurers can’t profitably manage through periods of high unemployment. They can’t price policies in a way that keeps healthy young people in the same pool as older people, producing a mockery of the very point of indemnity insurance. Despite a decade of unobstructed consolidation, which was sold to regulators as a way to control healthcare costs by creating mega-insurers like hers, her industry can’t control healthcare costs.

Braly’s words are a reminder of the most important unasked question in the entire healthcare debate: What do we need insurance companies for, anyway?

The only way insurers can remain profitable at all is by selling healthy people on policies that don’t offer much coverage at all, while squeezing older, less healthy people remorselessly so they either pay for most of their care out of pocket or get priced out of the insurance market completely (thus becoming a burden for taxpayers).

In short, this is an industry that acts as if it will have trouble making money unless regulators allow it to cover only injuries suffered by a young single male hit by an asteroid.

Meanwhile, however, it fritters premium income away on expenses generated largely by corporate initiatives having nothing to do with healthcare. WellPoint spent $2.6 billion repurchasing its own shares last year. This was such a good deal for shareholders that its board recently authorized spending an additional $3.5 billion for the same purpose. None of those dollars, it should go without saying, will be available for delivering healthcare to customers.

It would have been marvelous and uplifting if all the participants in Thursday’s health reform summit in Washington understood that as well as the insurers themselves.

Instead, the health reform obstructionists, who mostly belong to the Republican Party, mouthed the same tired and irrelevant bromides. They yammered about blocking malpractice lawsuits, even though the evidence shows that malpractice litigation, including the “defensive medicine” it foments, accounts for 2% to 3% of the country’s annual healthcare bill of $1.7 trillion. (Arguably a small price to pay, at that, for the value of giving patients injured by malpractice redress for their injuries.)

They returned again and again to the old chestnut about allowing insurers to sell policies across state lines. President Obama, to his credit, understood that absent minimum coverage standards this would lead insurers to race into whatever benighted states were willing to remove all coverage standards just to compete for, say, WellPoint’s headquarters. No one in any state would be able to buy a policy worth a tinker’s damn. The reform opponents greeted his explanation like the deaf adder in Psalm 58: They just stopped their ears.

So it’s worth scrutinizing Braly’s words for a reminder of what really needs to be fixed.

In that Wall Street conference call, Braly and her WellPoint management team observed that the company had lost 1.4 million subscribers, or 4%, during 2009. Much of that was because of layoffs by employers who offered WellPoint policies to their workers. That became a big problem for the insurer because of federal COBRA rules allowing laid-off workers to continue their group policies if they pay the full price themselves. Who does that? Only people with sickness in the family, which skewed WellPoint’s medical spending higher.

As for the 39% California premium boost, the House subcommittee released e-mails in which WellPoint executives discussed how to moderate rate increases by creating “look-alike plans . . . with a benefit or two removed” so they would seem cheaper, like a cereal company dropping its prices by a few nickels but putting less cereal in the same size box. Is there any surprise that, in this era of intolerable premium increases, the average deductible on WellPoint’s policies has risen by 20% over the last two years? (One WellPoint policy in California carries a family deductible totaling up to $40,000 — that’s not a misprint.)

Braly in her testimony assured the subcommittee that even with the latest California rate increases, “a 40-year-old woman in Los Angeles can obtain coverage with a $1,500 deductible for as low as $156 per month.”

She didn’t specify what kind of coverage. So let’s check out what her company offers. Leaving aside whether that 40-year-old woman might have a preexisting condition that would drive up her premium or make her uninsurable — anything from diabetes to a history of hay fever — the insurer’s California package with a $1,500 deductible requires the customer to pay up to 70% of the cost of “covered services,” including routine mammograms and Pap tests, plus as much as $500 a day for hospital stays.

Maternity isn’t covered at all, so our 40-year-old Angelena better have gotten her lifetime childbearing out of the way before picking up the phone to sign up.

“Our plans fit the way you live,” the CoreGuard brochure says. What it really means is: You better fit the plan, or you’re out of luck.

Shouldn’t that have been on the agenda at the Washington summit?

Michael Hiltzik’s column appears Sundays and Wednesdays. Reach him at michael.hiltzik@latimes.com, read previous columns at www.latimes.com/hiltzik, and follow @latimeshiltzik on Twitter.

Copyright © 2010, The Los Angeles Times

http://www.latimes.com/business/la-fi-hiltzik28-2010feb28,0,1011707.column

By Bruce Bartlett
The Wall Street Pit
Feb 27, 2010

There’s been a bit of a debate going on in the blogosphere lately about whether the Democrats should have proposed a more limited health reform plan in the first place. Such a plan might have gotten some Republican support or at least led to less intense Republican opposition and both improved the health system and given the Democrats a badly needed victory. The plan they proposed instead was too big to pass, so the thinking goes.

As a purely political matter, I think this analysis is wrong. The real problem, in my view, is not that the Democrats’ ambitions were too large, but rather that they were too small. In particular, I think they erred by not making the case for a single-payer system in the first place. Had they done so, the plan they eventually developed would have appeared to have been a modest alternative.

I say this not because I favor a single-payer health system—although I don’t fear such a system particularly, either. Rather, it’s because I understand political dynamics—you often have to ask for twice what you want in politics in order to end up with half of what you need at the end of the day. The great mistake that administrations of both parties often make is to put forward plans that have no bargaining chips or fallback positions built into them. The various trade-offs inherent in any major policy initiative were made within the administration rather than between Congress and the administration. This meant that the administration’s initial proposal was really its bottom line position; it had nothing to negotiate with and once the inevitable compromises started, the logic and integrity of the proposal quickly collapsed.

Also, I think administrations are sometimes unclear in their own minds about what precisely they are trying to accomplish. In terms of health reform, Barack Obama’s main campaign promise was to “bend the curve;” i.e., cut the growth rate of total health spending to a sustainable level. But this cannot be done without abolishing or at least severely scaling-back the tax exclusion for health insurance—a sacred cow only slightly less sacred than the mortgage interest deduction. Unfortunately, John McCain made this the centerpiece of his health reform plan during the campaign. In order to score some cheap political points, Obama opposed it. So when the time came for him to propose a health reform plan of his own, the central element that needed to be there for the plan to reduce costs was off the table.

Without some way of scaling back private health spending through the tax code, the only real alternative is essentially a single-payer system such as they have in virtually every other major country. I think a strong case could have been made for such a system on cost control grounds alone. Yes, this would have meant rationing, but it wouldn’t necessarily have meant that health outcomes would be worse. The people of France, Switzerland and Germany are not less healthy than Americans. (I don’t have space to do a detailed international comparison of health outcomes, but I would note that infant mortality is a pretty basic measure of a national health system’s quality and according to this CDC study practically every major country has significantly lower infant mortality rates than we do.)

Yet every major country spends very significantly less of its national output on health than we do. As Table 1 shows, we spend five percent of GDP more than the country with the second-highest level of health spending as a share of GDP. Five percent of GDP is about $700 billion that Americans could be spending on new homes, cars and clothing, nice restaurants, paying off bills or anything else they can imagine. Instead, that money went to doctors, hospitals, pharmacists and insurance companies. If we only spent as much as Japan—a country known for having an excellent health system and a healthy population—we would have eight percent of GDP, about $1 trillion, to spend on anything we like.

Table 1. Total Health Expenditures as a Share of GDP, 2007 (latest available)

Of course, many will assume that we can’t afford a single payer system without vastly increasing government spending. What they probably don’t realize is that we are already spending a vast amount on health through government as it is for programs like Medicare and Medicaid. As Table 2 shows, only eight other countries have government spending on health greater than we have, and most of those spend only a trivial amount more.

Table 2. Public Health Expenditures as a Share of GDP, 2007 (latest available)

Moreover, I believe these data substantially understate the total amount of health spending that flows through government because I don’t think they account for the revenue loss associated with tax expenditures for health insurance and care. These are very substantial, as shown in Table 3.

Table 3. Federal Corporate and Individual Tax Expenditures for Health, 2010

If the tax expenditures for health were included in overall health spending, then public expenditures in the U.S. would be at least 1.3 percent of GDP higher and private spending would be concomitantly lower (to avoid double counting). (Keep in mind that to the extent that state and local governments also exempt health expenditures from taxation, the total tax expenditure would be a couple of tenths of GDP higher.) If that were the case, we would be spending as much as France does.**

To wrap up a post that has already gone on much too long, what I am trying to show is that for no more than we are already spending on health through the government we could have a single-payer system no worse that those that exist in almost every other major country. My point is that this is an option that the administration should have at least floated and on which we should have had a national debate. I don’t think Americans would have embraced such an option, but as I said at the beginning it would have clarified the debate by focusing on the overall cost of our health care system—which I believe is far too great for what we get in return—and made reforms such as those that the Democrats have put forward seem modest by comparison. That would have improved their political chances of success.

** I don’t know to what extent other countries also have tax expenditures for health that are not included in the figures for total health spending. However, a new OECD study suggests that they are small or nonexistent. Of seven countries studied (Canada, Germany, Korea, the Netherlands, Spain, the U.K. and U.S.), four had no tax expenditures for health at all and the two others that have them have revenue losses as a share of GDP less than a third of ours. See Tax Expenditures in OECD Countries (Paris: Organization for Economic Cooperation and Development, 2010), p. 224.

http://wallstreetpit.com/17869-the-single-payer-health-debate-we-should-have-had