Chapter – Page 771

Gruber Doesn’t Reveal that 21% of MA Residents Can’t Afford Health Care

By: emptywheel
FireDogLake
Friday January 8, 2010

I was intrigued to see Gruber link–in his response to Ben Smith–to his May 2009 analysis of how to measure affordability for a national healthcare reform plan. After all, I’ve been debating with people who love to cite Gruber on affordability for months, and I’ve never seen them cite it. Now there are several reasons they might not want to rely on this paper. It might be that he starts out by arguing that you can still call something “affordable” even if it isn’t affordable for everyone.

In considering affordability for a group, we need to establish a sensible benchmark whereby insurance is considered affordable if “most of” a group can afford it. We can disagree about what “most of” means, but it would be wrong to define “most of” only as “very close to 100%.”

This, of course, accepts as a baseline some continued medical debt (at least) or even bankruptcies in your definition of “affordable.”

Or maybe it’s the fact that Gruber insists that health insurance (not care) be considered as the same kind of necessity as food and shelter.

Second, it implicitly assumes that health care is less important than these other categories; that is, that if individuals have to spend their resources on these other categories, then they should not have to spend resources on health care. It is unclear why health insurance should take a lower position on the priority scale than other necessities.

But the thing I’m most troubled by in this paper is something Gruber neglects to mention: real data from MA on the number of people who forgo necessary medical care because it is not affordable.

In March 2009–two months before Gruber wrote this paper–MA released the first results [PPT] of how that state’s health care reform had improved access. It showed that 21% of the total population–and even 12% of children–forgo necessary medical care because they cannot afford it. Of the 21% forgoing care, most (something like 18 or 19%) have health insurance–but it is health insurance they can’t afford to use. In a paper contemplating what constitutes affordability for a national plan that resembles the MA plan in many ways, Gruber uses national Kaiser/HRET data, rather than the MA data that is much more directly on point.

Now, I might excuse other analysts for ignoring the MA results, except for two things. First, Gruber boasts of his involvement in the MA program as part of his explanation for his qualifications for the HHS contracts.

Throughout this year I have provided technical assistance to the administration and to Congress with my micro-simulation model, as well as based on my experience as a member of the Massachusetts health connector board.

Also, when the facts from MA suit his argument, he uses them, as he did in a November analysis of how much the Senate plan would reduce premiums.

So rather than looking at a real world study showing what happens when a program very similar to the Senate plan goes into effect–which shows that a significant number of people can’t afford to use their health insurance–here’s what Gruber says about how out-of-pocket expenses affect affordability.

A very conservative response would be to say that a plan is only affordable if the premiums plus the maximum out of pocket exposure does not exceed available resources. This is very conservative because while premium payments are certain, out of pocket payments are not, and a sizeable majority of enrollees will not reach the out of pocket limit.

Moreover, there is a strong argument that out of pocket costs should not be incorporated into a discussion of affordability of insurance. After all, individuals face more out of pocket risk without insurance than they do with coverage. Thus, if an individual is very ill and faces large out of pocket costs under an insurance plan, they would have faced at least those same out of pocket costs, and likely more, had they remained uninsured. So it would be wrong to say that those out of pocket costs were responsible for making insurance unaffordable. That is, it is nonsensical to argue that very sick individuals cannot afford insurance because they will have large out of pocket costs under the insurance plan; indeed, the problem is that these individuals cannot afford not to have insurance.

This is analysis that Jonathan Cohn, with data from Gruber, expands upon here.

But it all comes back to that underlying premise. So long as you define “affordable” in such a way that accepts ongoing medical debt for at least some of your sample in your definition of affordable, then this approach–looking at total risk, rather than whether insurance equates to care, makes sense. It transforms the question of whether health care (not health insurance) is affordable into one that measures degrees of indebtedness for using health care.

But then again, that’s what a lot of bill apologists do: consistently oversell what this kind of reform does, by conflating health insurance with health care.

http://emptywheel.firedoglake.com/2010/01/08/gruber-doesnt-reveal-that-21-of-ma-residents-cant-afford-health-care/

Is Stanford tainted by accepting Pfizer money?

Using a Pfizer Grant, Courses Aim to Avoid Bias

By Duff Wilson
The New York Times
January 11, 2010

Stanford University on Monday will announce plans to develop new continuing education programs for doctors that will be devoid of the drug industry influence that has often permeated such courses.

The work is being done with a $3 million grant — from the drug maker Pfizer.

Dr. Philip Pizzo, dean of the Stanford medical school, says Pfizer will have no say on how the three-year grant will be spent. The university plans to set up unbiased programs of postgraduate education on the Stanford campus rather than the industry-selected topics of the past that have been presented to rooms full of doctors at hotels and resorts.

“It’s a fundamental change,” Dr. Pizzo said Sunday, criticizing the drug industry for poisoning educational programs with marketing messages and doctors for “complicity” in taking speaker fees and expenses-paid trips. He called the grant “a novel rebooting.”

Pfizer, in a statement, said it wanted to help redefine how continuing medical education was financed to ensure the independence and patient benefit of the programs, which most doctors are required to take to maintain their state medical licenses.

“The announcement is self-satirizing,” said Dr. Adriane Fugh-Berman, a Georgetown University medical professor who has researched and written about industry influence in continuing medical education. “Pfizer’s interest in better ways to manipulate physicians is well-known.”

Dr. Fugh-Berman said that Pfizer has major products in two of the four areas that the Stanford press release suggested might be pursued: smoking cessation and heart disease.

Dr. Arnold S. Relman, a former editor of The New England Journal of Medicine, a Harvard professor emeritus, an outspoken critic of industry conflicts and a friend of Dr. Pizzo, said he could not understand the rationale behind the arrangement.

“If it is true — a big, big if — but if it is true that this money is being given without any strings at all and without any obligation on the part of Stanford to please Pfizer, then it’s arguable that it’s O.K.,” Dr. Relman said.

“But it’s just not a good idea for a profession that says it wants to be independent and trusted, a reliable source of information to the profession and the public about drugs, to take money from the drug company under any conditions.”

http://www.nytimes.com/2010/01/11/business/11drug.html?ref=health

Comment:

By Don McCanne, MD

Stanford’s Dean Philip Pizzo has a well deserved reputation for taking principled stands on the ethics of medical education and health care in general. This agreement to accept the Pfizer grant only on the condition that its use in their CME program be exclusively controlled by Stanford, without further input by Pfizer, is another step towards Dr. Pizzo’s goal of a system largely freed from the albatross of ethical compromise.

Are there any reasons that Stanford should not have accepted these funds? The first and most obvious reason is that this expense for Pfizer will be passed on to patients in the form of higher drug prices, already a serious problem that policy makers face.

Also, since Pfizer can deduct this as a business expense, the tax subsidies that we are providing are being turned over to Pfizer, which has control over how to distribute those funds. Do we really believe that a private, investor-owned pharmaceutical corporation has a greater ethical sense and wisdom in determining the use of our taxpayer funds than would our own public stewards? Likely Stanford will make very good use of the funds, but of the options for use of the taxpayer-funded component, is that the best use? It doesn’t seem right to turn that decision over to Pfizer, especially when it appears that the CME programs may still support Pfizer products, but only if Stanford decides so (certainly an ethical problem if and when it comes time to renew the Pfizer grant).

CME programs provide a social good: better health care for everyone. Public funding would prevent such ethical compromises and would help to ensure that CME programs have a mission to improve patient care rather than a mission to advance the pecuniary interests of pharmaceutical and medical-tech firms.

The ethical premise behind the concept of a single payer national health program – an improved Medicare for all – resets the primary mission for our entire health care system from one of private entrepreneurialism to one of service for the benefit of patients.

Dean Pizzo is to be admired for trying to achieve the best under the confines of our current dysfunctional system. You work with what you have, until you have something better.

The greater significance of this anecdote is that the rules under which we operate are wrong, and we need to change them, not just work within their confines as Congress is trying to do. We need a single payer monopsony that belongs to all of us – the people of this nation.

Health Care in Norway: Part 1

By Maggie Mahar
Health Beat Blog, January 06, 2010

“Aker University Hospital is a dingy place to heal. The floors are streaked and scratched. A light layer of dust coats the blood pressure monitors. A faint stench of urine and bleach wafts from a pile of soiled bedsheets dropped in a corner.”

This is how an Associated Press story, published in the New York Times last week, begins. The next sentence comes as a surprise:

“Look closer, however, at a microscopic level, and this place is pristine. There is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated hospital of Europe, North America and Asia this year, soaring virtually unchecked.

“The reason: Norwegians stopped taking so many drugs.

“Twenty-five years ago, Norwegians were also losing their lives to this bacteria. But Norway’s public health system fought back with an aggressive program that made it the most infection-free country in the world. A key part of that program was cutting back severely on the use of antibiotics.

“Now a spate of new studies from around the world prove that Norway’s model can be replicated with extraordinary success, and public health experts are saying these deaths–19,000 in the U.S. each year alone, more than from AIDS–are unnecessary.

“‘It’s a very sad situation that in some places so many are dying from this, because we have shown here in Norway that Methicillin-resistant Staphylococcus aureus (MRSA) can be controlled, and with not too much effort’,said Jan Hendrik-Binder, Oslo’s MRSA medical adviser. ‘But you have to take it seriously, you have to give it attention, and you must not give up. . . . ‘

“Norway’s model is surprisingly straightforward.

“– Norwegian doctors prescribe fewer antibiotics than any other country, so people do not have a chance to develop resistance to them.”

Many antibiotics simply are not available.

When Dr. John Birger Haug opens the dispensary at Aker hospital, one sees “a small room lined with boxes of pills, bottles of syrups and tubes of ointment. What’s here? Medicines considered obsolete in many developed countries. What’s not? Some of the newest, most expensive antibiotics, which aren’t even registered for use in Norway, ‘because if we have them here, doctors will use them,’ he says. . . .

“Norway responded swiftly to initial MRSA outbreaks in the 1980s by cutting antibiotic use. Thus while they got ahead of the infection, the rest of the world fell behind.

“In Norway, MRSA has accounted for less than 1 percent of staph infections for years. That compares to 80 percent in Japan, the world leader in MRSA; 44 percent in Israel; and 38 percent in Greece.

“In the U.S., cases have soared and MRSA cost $6 billion last year. Rates have gone up from 2 percent in 1974 to 63 percent in 2004”

Could the Norwegian solution work here? Yes—if patient safety came first in U.S. hospitals.

Why am I so sure?

“In 2001, the CDC approached a Veterans Affairs hospital in Pittsburgh about conducting a small test program. It started in one unit, and within four years, the entire hospital was screening everyone who came through the door for MRSA. The result: an 80 percent decrease in MRSA infections. The program has now been expanded to all 153 VA hospitals, resulting in a 50 percent drop in MRSA bloodstream infections, said Dr. Robert Muder, chief of infectious diseases at the VA Pittsburgh Healthcare System.

“It’s kind of a no-brainer,’” he said. ‘You save people pain, you save people the work of taking care of them, you save money, you save lives and you can export what you learn to other hospital-acquired infections.’”

It should come as no surprise that the VA, the least “corporate” sector of U.S. health care, has adopted the Norway model. VA docs don’t take gifts or consulting fees from Pharma. The VA itself has an evidence-based formulary. Unlike Medicare, it does negotiate for discounts on drugs—and achieves substantial savings.The VA isn’t competing with other hospitals. It doesn’t worry whether “consumers” will go elsewhere. It worries about what is best for “patients.”

Although it may seem a “no-brainer,’ the Norway solution has not been widely adopted in rest of the U.S. health care system. AP reports: “Dr. John Jernigan at the U.S. Centers for Disease Control and Prevention said they incorporate some of Norway’s solutions in varying degrees, and his agency ‘requires hospitals to move the needle, to show improvement, and if they don’t show improvement they need to do more.’”

And if they don’t?

“Nobody is accountable to our recommendations,’” Jernigan told AP, “but I assume hospitals and institutions are interested in doing the right thing.’”

Of course U.S. hospitals shouldn’t be asked to follow safety guidelines. That would constitute government intervention in U.S. health care. We pride ourselves on our laissez-faire approach to medicine, letting each hospital set its own priorities. In Norway, apparently public health is a priority. In the U.S. power resides with the hospital lobby.

Moreover, U.S. patients would not be satisfied with a hospital where the floors are “streaked and scratched” and dust is visible on the blood pressure monitor. They would rather die of an MRSA infection in a seemingly immaculate private room with view.

http://www.healthbeatblog.com/2010/01/health-care-in-norway-part-1-.html

Health Care in Norway: Part 2

By Maggie Mahar
Health Beat Blog, January 06, 2010

The story of the “Norway Solution” to hospital infections reminded me of a letter that I received in the fall, written by Svein U. Toverud, a Norwegian who lived in the U.S. from 1969 to 2003. While he was in the U.S. Toverud taught medical and dental students pharmacology at the University of North Carolina, Chapel Hill, and received medical care there. When he returned to Norway in 2003, he had an opportunity to reflect on the difference between health care in Norway and in the U.S.

I have been meaning to publish this letter for the last two months, but the battle over health care reform intervened. So many lies, so much misinformation. Blogger could barely keep up.

At the moment, I am just a bit weary of Washington’s war on health care reform. (Yes, I mean “on”). So many seem bent on “winning” what they perceive as best for themselves or the small group they represent. Narrow self-interest carries the day.

To be sure, a core of courageous legislators fought hard for the public good, and they won on some important points. Insurers will no longer be able to shun the sick. Most low-income and lower-middle income families should be able to afford care. But, by and large, this fight has not been about patients or medicine. It has been about money and politics as liberals and conservatives battle to see who will hold power in Washington over the next three years. The differences run deep, and are not limited to the Capitol. The electorate is more polarized than at any time since the 1960s.

This can be seen as progress. For years, it was difficult to distinguish liberals (a.k.a. the “New Democrats”) from conservatives (a.k.a. Republicans), and the idea of “values” rarely entered into the discussion. But today the argument has come down to bedrock values: conservatives emphasize the rights of the individual, and, in particular, the rights of wealthy individuals to conserve and preserve their wealth and power. Progressives would like a more egalitarian society, and they are trying to learn how to think collectively—though, in that regard, they still have quite a ways to go.

I think that Washington may have taken reform as far as it can for the time being. I suspect that we now need a reform movement outside of D.C. I’ve been reading Marshall Ganz, and thinking about what a movement would really mean. It would be something quite different from the political coalitions that were formed to support change in Washington. It would be more like the civil rights movement: it would be designed to educate. It would not rely on Focus Groups to find out what people want to hear. It would tell them the truth. It would need passionate leaders who are ready to act and begin to reform the system from within, without waiting for legislation. Doctors, nurses, public health experts and other health care professionals know, better than anyone, just how and where our system is broken. It they would put self-interest aside, they could lead.

But today, I decided to take a break from the war at home and contemplate health care in Norway—a country where medicine is patient-centered. There, health care is not a commodity that you “market” to “customers.” It’s a service, delivered with an eye to husbanding resources while providing safe, high quality care to “patients.”

What stands out in Svein’s letter is how egalitarian the system in Norway is. All citizens and residents are insured. Health care is financed through tax revenues, and taxes in Norway equal 45 percent of GDP. (In the U.S. total taxes collected by state, local and federal government add up to about 33% of GDP).

In return, Norwegians receive generous benefits and are free to choose their own doctor.

Norway’s very practical and rational system makes better use of medical professionals: midwives deliver most babies. Nurses make home visits to the elderly and the chronically ill, saving the cost of nursing homes. Surprisingly, even doctors make home visits—in the middle of the night, if necessary. The system is designed with the patient in mind, but experts make the final medical decisions based on medical evidence. Patients must get a referral from a primary care physician before seeing a specialist. A board of experts decides which drugs are available at no charge. And, as noted in Part 1, some antibiotics are not registered in Norway. Public health trumps Pharma sales.

While at UNC Chapel Hill, Svein was seriously ill and received some of the best health care available in the U.S. Returning home, he reflects on health care in Norway, where everyone has access to very good care.

Norwegian Health Care

by Svein Toverud

My wife, an American, and I, a Norwegian, lived as a couple in Norway from 1956 to 1969 and again from 2003 until the present time. In the intervening years we lived in Chapel Hill, NC, so we are familiar with the present health care in the US. Personal medical challenges have caused us to be intimately familiar with both health care systems. In the US we were advantaged by comprehensive health insurance provided by my employer. We have been afforded exemplary care in both systems. In this brief essay I offer a description of our experience in Norway with the intent of providing some balance to the health care debate.

Every Norwegian citizen or legal resident is entitled to receive services from the National Health Service supported by the national government and funded by taxes. Our first encounter with the NHS was the free prenatal care offered by a Health Care Center for Mothers and Children, staffed by a gynecologist, pediatrician, nurses and a dentist prior to the birth of our first child, and then our next three children. These centers are present in most communities in the country. Prenatal care can today also be obtained by gynecologists/obstetricians in private practice who receive full reimbursement from NHS while the patient pays only a nominal fee.

Babies are born in public hospitals, delivered by well trained midwives free of charge. Experienced obstetricians are always available at no additional cost in case of complications. All health care for children until age 13 is free. After that age there is a small fee for each service. Children receive free dental care until age 18. Orthodontic care is partially covered, and the extent of coverage depends on the severity of the malocclusion. Dental care for adults is not covered by NHS and is provided for the most part by dentists in private practice.

Regular health care (office visits) for the adult population is provided primarily by private practicing physicians who have contracted with the NHS to provide care for a given number of patients in their local community. At the beginning of each year the physicians charge a small fee for each service until the patient has met a deductable of $300 after which subsequent services are free. These physicians (“contract physicians”), many of whom have a specialty in family medicine, are also committed to participating in a system to provide emergency home visits at night. My own experience with this part of the service illustrates its efficiency and benefits. While suffering from a cold I suddenly developed labored breathing one night, called the medical emergency number and talked with a nurse who said she would send an ambulance right away. The emergency medical technicians arrived within 30 minutes, did their examination and made the p
resumptive diagnosis of pneumonia, and contacted the physician on call that night. He arrived within the hour, confirmed the diagnosis of pneumonia and started me on penicillin which he had with him. I was saved a trip in the ambulance, exposure to other patients in the emergency room at the local hospital, as well as hours of anxiety. My “contract” physician took over the care the next day.

There is free choice of “contract” physicians and people can change physicians if they choose. Specialists are usually contacted after the “contract” physician has written a referral , and again patients can choose their own specialist. After the initial referral patients can continue seeing the specialist without involving the “contract” physician. The specialists are also reimbursed by the NHS.

When hospitalization is required for further examination or a surgical procedure, patients have free choice of hospitals anywhere in the country.

Waiting lists for certain hospital procedures do exist but have been reduced over the last several years. Access to hip replacement is the most difficult and the waiting period varies now from 18 weeks at the most experienced hospital in Oslo to 3 weeks at a smaller hospital 80 miles north of Oslo. The PHS usually does not pay for elective surgical procedures outside the country. I did receive emergency arthroscopic surgery on a knee while working as a visiting scientist at the Karolinska Hospital in Stockholm, Sweden after paying only a nominal fee. The health Services in Sweden and Denmark are very similar to that of Norway.

Physical therapy and occupational therapy, when recommended by the “contract” physician or a specialist, is provided free or after payment of a small fee. While recovering from a knee fracture suffered in a car accident I was even entitled to free physical therapy in my home.

Norway has made extensive use of visiting nurses (RN and LPN) in the home for chronically ill people or the elderly at no cost, and has consequently kept many people from having to be admitted to nursing homes, thus saving health care costs. Many communities allow a temporary stay (up to 3 weeks several times a year at no cost) in a nursing home of a person who requires daily care but is still being cared for by a spouse in the home. This respite care allows the caretaker spouse to travel or simply be free of the daily chores for a few days.

Drugs prescribed as essential treatment of chronic illnesses are provided free at any pharmacy. As long as new drugs have been approved by a national board of experts as essential treatment they can be provided free even when the drug is expensive. I was diagnosed with the wet type of macular degeneration in one eye two years ago and have been given 16 treatments with the recently developed drug Lucentis which costs the hospital over $300 per treatment. So far the treatment has been effective.

As a double amputee in a wheelchair I have received a number of free benefits including a light-weight wheelchair that can be taken in and out of the trunk of our car, an electric wheelchair that allows me to travel outdoors even on snowy and icy roads in the winter, access to transport in my wheelchair in a van to physicians or hospitals for a small fee until I have met my annual deductible after which the transport is free. This service is available to any person unable to use public transportation. In addition every year I receive 80 trips in a wheelchair van for leisure purposes, such as attending cinemas, theaters, restaurants, anywhere in the city of Oslo with my wife or other attendant for a small fee, approximately 10% of a taxi fare.

Svein U. Toverud, DMD, PhD, Professor emeritus, Department of Pharmacology, School of Medicine, University of North Carolina at Chapel Hill.

Last week, I received a very sad e-mail from UNC’s Dr. Nortin Hadler, who had introduced me to Svein Toverud via e-mail. On Christmas Day, Toverud suffered a massive stroke and died on December 28. (A CT scan confirmed the extent of the damage.) Hadler described Svein as a wise and gentle man. I wish I had had an opportunity to meet him.

http://www.healthbeatblog.com/2010/01/health-care-in-norway-part-2-.html

In Britain or France, my aging mother would have gotten better health care

By Sara Mansfield Taber
The Washington Post
Sunday, January 10, 2010; B01

In the final months before her death in May, my mother kept her shoes on all day, even when napping. She had to — at her assisted-living facility in Mitchellville, Md., three certified nursing assistants looked after 39 residents. My mom couldn’t depend on one of them to have the time to put her shoes on when she needed to get out of bed. Only in the mornings and evenings, when one of her private aides was with her for about 30 minutes, did she have personalized care.

Disabled by heart disease, two hip replacements and depression, my mother was often groggy when I visited. She needed me to take her hand and pull her up so she could grab the bed rail and maneuver into a sitting position. Though she brightened when I told her stories about her grandchildren over lunch in the facility’s dining room, her joy vanished as soon as we returned to her unit. A blank look on her face, she would lay back on her bed, prone and helpless.

Like many American women of my generation, I struggled to figure out how to best care for my aging mother. As the end neared, I compared notes with my friends Fiona and Juliette. Fiona lives in Canada, but her mother lives in their native England, while Juliette lives with her mother in their family home in France. How could we establish safe and comfortable environments for our ailing mothers? How could we find high-quality medical care within reach of their incomes, and our own? And how could we preserve their mental health and sense of well-being while limiting our stress?

My mother’s plight made my stress considerable. Each month, Lois Taber paid $4,069 to reside in her assisted-living community, $1,400 for private aides and an average of $140 for medications. Just before she died at age 82, she liquidated assets from her 401(k) to pay for a $5,800 hearing aid. At $169.50 per ride, the retirement home’s fee for transporting her to medical appointments was prohibitive. Other than Medicare, my mom had no government-subsidized elder-care services. Already, the lack of affordable in-home support had forced my parents to leave their beloved house in Chevy Chase, Md., to receive the basic care they needed.

Overseas, things are different — that is, better. In England, which has a national health system similar in structure to our Veterans Affairs system, Fiona’s mum, Pat Reid, suffers from disabling arthritis and diabetes, and cannot move without great pain. But a government-supplied home health aide visits Pat at breakfast, lunch and dinner every day. This costs the family 120 pounds a week (approximately $785 per month), a little more than half of what my mom paid for private aides. Lower-income patients receive this service free. The National Health Service provides general practitioners, nursing care, ambulance services, diabetic clinic visits, medications and hospitalizations for no charge. Doctors and nurses make home visits.

In addition, Pat’s son Simon, who has no work at the moment and lives in his mother’s converted garage, receives 50 pounds a week (about $325 per month) from the government to help him look after her. With this government support, Pat is able to stay in the home where she lived with her husband for more than 35 years. The cost of her care is well within her monthly income of 2,000 pounds.

In France, Juliette’s maman, Madeleine Fournot, has Alzheimer’s disease. She receives assistance via a national health reimbursement system similar to Medicare as well as through a special program for the elderly and disabled called l’Allocation Personalisée à l’Autonomie (“Personal Autonomy Allocation”). Since the government refunds 560 of every 1,200 euros Juliette spends on her mother’s medical expenses, she is able to hire a caregiver who looks after her mother around the clock 3 1/2 days per week. This allows Madeleine to stay in her suburban Paris home, where her family has lived for three generations, and provides Juliette a regular respite from elder care.

Madeleine receives one free doctor’s visit per month, and the doctor makes house calls when needed. Four days a week, a physical therapist visits her, charging a one euro co-pay per visit — less than the cost of a cup of coffee on the Champs-Élysées. Because Madeleine is on blood thinners, a hematology technician comes each week to check her blood levels. If she is in bed when he arrives, she can stay snug under her covers while he takes the sample. All medications related to Madeleine’s Alzheimer’s are free, as is transportation to her neurologist in Paris. Her doctor simply fills out a form stating that she cannot stand without assistance, and she is reimbursed for the 30-minute taxi ride into the city.

Other services available to Madeleine include daily medication-administration house calls by a trained nurse, daily meal service (a three-course lunch and soup for dinner) and a specially designed activity program for Alzheimer’s patients. The total monthly cost of Madeleine’s care is 1,500 Euros, or $2,205.

I am struck by all that Fiona’s mum and Juliette’s maman can take for granted. They enjoy access to services far beyond free and full medical and prescription drug coverage. In England, my mother’s $5,800 hearing aid would have been free. While Mum and Maman get house calls from their doctors and cash compensation for family members who care for them, I often had to take time off from work — an expensive proposition for a self-employed psychologist and writer — to help Mom. Taking her back and forth to her medical appointments ate up entire days and, with her disabilities, she could barely get in and out of my car. This was hard work, not quality time with an aging parent.

Mom, Mum and Maman were not very different people. All three married civil servants, led middle-class lives and retired on government pensions. Pat and her husband, a BBC editor and translator who escaped five Italian prison camps during World War II, sought to create a peaceful life for their children. After her husband died, Pat took a job on the local council for village planning. Madeleine spent most of her middle years in Afghanistan, where her husband was posted with the United Nations. My mother worked in orphanages and schools in Asia, Europe and the United States as she followed my father, a CIA officer, across three continents. All three women eventually became widows and developed significant medical problems. Illness and enfeeblement limited their lives, and they came to require help with their daily activities.

There, the similarity ends. As seniors, each woman’s quality of life was shaped by her government’s health-care policies. The services offered to older people in Britain and France seem, to this American observer, straightforward, logical and humane. These countries provide the basic help their elders need to remain in their homes and in their communities, close to family and friends. It upsets me to think how much more peacefully my mother’s life might have ended had she had the support available to older people in Britain and France. Why should Mum and Maman be able to grow old at home, but not Mom?

Many Americans protest that Europeans pay high taxes for medical care. It is true that people in other countries pay more in taxes, but, between out-of-pocket expenses and private health insurance premiums, many Americans spend much of their tax savings staying alive. Of course, high-quality health care costs money. Treating Mom like Mum and Maman is expensive. But Pat and Madeleine both have much lower living and medical expenses than my mother had, and, unlike Americans, they never had to pay for health insurance in their prime.

If our taxes were somewhat higher but we received dependable services that enabled us to spend less out of pocket on doctors’ visits, medications and nursing care — services that helped us remain independent, at home, and that reli
eved our families of financial and emotional burdens — wouldn’t peace of mind outweigh the additional cost?

My mother, a physical therapist and teacher with a blow of cumulus hair, was a hard-working person whose motto was: “If, at the end of the day, I can say I’ve helped someone’s life to be better, then I’ve had a good day.” It would have been nice if, at the end of her days, she could have taken her shoes off.

Sara Mansfield Taber, a psychologist and writer, is the author of “Bread of Three Rivers: The Story of a French Loaf.”

http://www.washingtonpost.com/wp-dyn/content/article/2010/01/08/AR2010010803586.html

Illinois governor names Dr. Quentin Young state's health advocate

Quinn names state's public health advocate

WBBM Radio, Jan. 10, 2009

CHICAGO — Gov. Pat Quinn has named Dr. Quentin Young as the state’s Public Health Advocate, according to a release from the governor’s office Saturday. Dr. Young will develop wellness and education programs to help improve the health of the residents across Illinois.

In his position Dr. Young will focus on assisting residents in understanding health coverage provisions and help them better understand their public health rights, the release said. He will also work to ensure that public health reports are easily accessible and understandable. The position will be housed within the Department of Public Health and will utilize existing public health programs, staff and resources.

Dr. Young, 86, founded the Committee to End Discrimination, which would eventually help to desegregate Chicago hospitals. In 1964, he helped launch the Medical Committee for Human Rights, serving as national chairman for the group that would become the medical arm of the Civil Rights Movement.

He served as personal physician to Dr. Martin Luther King Jr. Dr. Young marched beside King in 1966 during a peaceful protest in Chicago, treating King’s wound when an angry spectator hit him with a rock.

Dr. Young served successfully as chairman of the Department of Medicine at Cook County Hospital, president of the Chicago Board of Health, and president of the American Public Health Association. Dr. Young founded the Chicago-based Health and Medicine Policy Research Group and co-founded the Physicians for a National Health Program. In 2001, a 78-year-old Dr. Young walked across Illinois with Quinn in support of quality healthcare for everyone.

Governor Quinn signed an executive order to create the position of Illinois’ Public Health Advocate on November 21, 2009. The office will recommend and facilitate the development of public health strategies designed to prevent, diagnose, treat, and cure diseases.

“Throughout his long and distinguished career, Quentin Young has stood up for patients everywhere,” Quinn said. “He will be a strong voice for Illinois families and will fight to ensure that everyone has easy-to-understand information about critical public health issues facing our state.”

http://www.wbbm780.com/pages/6079162.php

Illinois governor names Dr. Quentin Young state’s health advocate

Quinn names state’s public health advocate

WBBM Radio, Jan. 10, 2009

http://www.wbbm780.com/pages/6079162.php

Unions Rally to Oppose a Tax on Health Insurance

By STEVEN GREENHOUSE
New York Times, January 9, 2010

When millions of blue-collar workers were leaning toward John McCain during the 2008 campaign, labor unions moved many of them into Barack Obama’s column by repeatedly hammering one theme: Mr. McCain wanted to tax their health benefits.

But now labor leaders are fuming that President Obama has endorsed a tax on high-priced, employer-sponsored health insurance policies as a way to help cover the cost of health care reform. And as Senate and House leaders seek to negotiate a final health care bill, unions are pushing mightily to have that tax dropped from the legislation. Or at the very least, they want the price threshold raised so that the tax would affect fewer workers.

Labor leaders say the tax would hit not only wealthy executives with expensive health benefits, but also many rank-and-file union members who have often settled for lower wage increases in exchange for more generous health benefits.

The tax would affect individual insurance policies with annual premiums above $8,500 and family policies above $23,000, which by one union survey would affect one in four union members.

The House bill does not contain such an excise tax, and many House Democrats oppose adding it to the combined House-Senate legislation. But the tax is a critical revenue component in the Senate’s bill. If the bill does too little to cover its costs, it might be defeated. Many economists support the tax, saying it will help hold down costs.

With labor groups warning that the tax will infuriate a key part of the Democratic base — union members — President Obama has agreed to meet with several top labor leaders on Monday to address their concerns and try to defuse their anger. The group includes the presidents of the A.F.L.-C.I.O., Teamsters and the steelworkers’ and service employees’ unions.

But whether the tax is negotiable remains unclear. Not only has Mr. Obama specifically endorsed the idea, but the White House and Senate leaders see the tax as pivotal in paying for the health care overhaul and addressing runaway health care costs.

Many Democrats and union officials fear that if both sides dig in on the issue, it could create a rift between the White House and labor — with some union leaders hinting they might lobby aggressively against the entire health care bill if it contains such a tax.

Union leaders have repeatedly warned the White House about the strong rank-and-file dismay, which could hurt the Democrats in Congressional elections this fall, especially in battleground states like Ohio, Pennsylvania and Wisconsin.

Ron Gay, an AT&T repairman in Youngstown, Ohio, who spent much of the summer of 2008 urging co-workers to vote for Mr. Obama, said, “If this passes in its current form, a lot of working people are going to feel let down and betrayed by our legislators and president.”

The Congressional Budget Office estimates that 19 percent of workers — or about 30 million employees — would be affected by the tax in 2016. Economists say most of them would be nonunion, although it is organized labor that has the lobbying clout to take a stand.

In recent days, labor’s strategy has become clear. Unions are urging their members to flood their representatives with e-mail messages and phone calls in the hope that the House will stand fast and reject the tax. The A.F.L.-C.I.O., a federation of nine million union members, has declared next Wednesday “National Call-In Day” asking workers to call their lawmakers to urge them not to tax health benefits. The International Brotherhood of Teamsters is urging members to tell their representatives that “such a tax is simply a massive middle-class tax hike that this nation’s working families should not be forced to endure.”

Many Democrats fear that enacting the tax will hurt their re-election chances.

“This would really have a negative impact on the Democratic base,” said Representative Joe Courtney, Democrat of Connecticut, who has enlisted 190 House Democrats to sign a letter opposing the tax. “As far as the message goes, it’s a real toughie to defend.”

While union leaders would prefer killing the tax, some say privately that they could live with it if the threshold is lifted to $27,000, say, or $30,000. They argue that many insurance policies above $23,000 are typical of the coverage in high-cost areas like New York or Boston, or policies that cover small businesses or employers with older workers.

According to a union survey, one in four members would be hit by a $23,000 threshold, but only one in 14 if the threshold were raised to $27,000.

White House officials, however, voice concern that raising the threshold that much would lose $50 billion of the $149 billion in revenue that the tax is expected to generate over 10 years.

Those officials and Senate leaders argue, moreover, that unions are wrong to fight the tax, saying that it will hold down health costs and that money employers save on health premiums will ultimately go to higher wages.

Some experts say the tax’s main effect would be to deter insurers from continually raising premiums. “This is a tax on insurance companies, not on workers,” said Erin Shields, an aide to Max Baucus, Democrat of Montana, who is chairman of the Senate Finance Committee and a chief sponsor of the excise tax.

“Health care costs are rising much faster than inflation,” Ms. Shields said. “Imposing this tax will help hold down costs because it will give employers an incentive to find a plan that falls beneath the threshold and will give insurers an incentive to offer the best possible plan below the threshold.”

Ms. Shields defended Mr. Obama, saying the excise tax he backs is far different from Senator McCain’s proposal. Mr. McCain called for eliminating tax breaks for employer-sponsored health benefits, replaced with a tax credit to help consumers obtain health insurance, Ms. Shields said.

She added that the measure Mr. Obama supports would tax only that part of a family policy above the $23,000 threshold — which would be taxed at a 40 percent rate.

But union officials say the tax will cause employers to push higher co-payments and deductibles onto their employees. They argue that a fairer way to generate revenue would be to embrace the House bill, which imposes an income tax surcharge on couples earning more than $1 million.

Neither the House nor the Senate would seem to have much wiggle room on the issue.

Senator Ben Nelson, Democrat of Nebraska, has said he would oppose any bill containing the House’s surtax. His vote was crucial in enabling Senate Democrats to reach the 60 votes needed to pass the health bill over a potential Republican filibuster.

The House bill, meanwhile, passed by only a five-vote margin, and at least three Democrats who voted for it — Mr. Courtney, Phil Hare of Illinois and Carol Shea-Porter of New Hampshire — have said they would oppose a final bill if it contained an excise tax like the Senate version.

Jonathan Gruber, a Massachusetts Institute of Technology economist, predicted the excise tax would raise workers’ wages from 2010 to 2019. “There are many academic studies showing that when health costs rise, wages fall,” he said. “In the mid- and late 1990s, when we got health costs under control, wages rose nicely.” But he added that other factors could have also lifted wages during that period.

Leo W. Gerard, president of the United Steelworkers, scoffed at arguments that by restraining health costs, the tax would lead to higher wages.

“The people who are promoting this tax say companies will make up for this with higher wages,” Mr. Gerard said. “These people who say that have never been at the bargaining table. It doesn’t work that way.”

Robert Gleason, chairman of the Pennsylvania Republican Party, said Mr. Obama had made an about-face that would badly hurt the president and other Democrats. “You remember when the first President Bush said, ‘Read my lips, no new taxes,’ and he raised taxes and he went down to defeat,” he added. “This is the same thing.”

Michael P. James, a 57-year-old steelworker with the Timken Company in Canton, Ohio, campaigned for Mr. Obama and is seething about the tax.

“I don’t think we should be penalized by this bill,” Mr. James said. “The president would be going back on his word. If he goes ahead and passes a bill with the excise tax, I won’t be able to support him again.”

David M. Herszenhorn contributed reporting.

http://www.nytimes.com/2010/01/09/business/09union.html

Health-care fix is Medicare for all

Letter to the Editor
The Telegraph (Nashua, NH)
Monday, January 11, 2010

The current health care bills should be rejected. With 45 million people uninsured, 45,000 deaths annually due to lack of insurance, and nearly a million medical bankruptcies a year, a four-year delay in medical reform is unacceptable. Medicare was in place eleven months after passage in 1965.

More disturbing, after spending $1 trillion in the next decade, over 20 million Americans will still be without insurance coverage. Worse, the number of people with skimpy coverage will be rising dramatically. The bills reinforce this with various inadequate coverage levels of 60 to 90 percent of total health care costs.

Taxpayers should be concerned about the 40 percent excise tax on “Cadillac” health plans costing more than $23,000 per family, not indexed for inflation.

The City of Portsmouth paid about $24,500 for a family policy in 2009, and at the current rate of increase each year, would pay $74,079 in 2020. The extra tax per policy would rise quickly from $600 this year to over $20,000 in 2020.

A health policy approaching $100,000 per year is unbelievable and repugnant. Physicians for a National Health Program endorses Medicare For All. When passed, a small tax matched by your employer, provides you with full coverage, without co-payments, deductibles, out-of-pocket costs, or rejection because of preexisting conditions.

Peace of mind for your family, your children and your grandchildren comes from a lifetime program of automatic insurance coverage. We believe that government-involved health care is preferable to Wall Street-run health care. We believe everyone should be covered equally, and any savings should be used to reduce premiums, not to drive up the price of insurance stocks and CEO bonuses.

Every other industrialized country provides health insurance coverage to all of their citizens. Bankruptcies are unheard of, and in most, the citizens never see a bill.

We need to move away from a multitude of plans with a dizzying array of options four years from now, to a single plan which covers everyone now

Thomas Clairmont, MD
Portsmouth, N.H.

http://www.nashuatelegraph.com/opinion/letters/528329-263/health-care-fixis-medicare-for-all.html

It's the financing, stupid!

A second opinion on Gawande’s ‘Cost Conundrum’

By Claudia Chaufan
The Social Medicine Portal, Jan. 7, 2010

I must confess that I was disappointed to see Dr. Atul Gawande’s mantra that more or more expensive care is not necessarily better care go unchallenged even by the otherwise outstanding Amy Goodman’s “Democracy Now.” Unchallenged, that is, when this rather obvious (or at least very reasonable) observation was presented as the critical explanation for why the United States spends more in health care, per person, than any other country in the world, even as it leaves millions uninsured or underinsured, leads thousands to bankruptcy, and allows 45,000 people — 15 times the number murdered in 9/11 — to die for lack of health insurance. Nor was he challenged when he presented his views of Massachusetts as a sound model for health care reform, even as he granted that the program had “failed to control costs.” In fairness to the interviewers, Dr. Steffie Woolhandler’s statement that the center of the Massachusetts program did not hold were shown briefly. Yet to the already confused listener or viewer, the showcase of “opposing expert views” must have felt like the usual “he said, she said” — not awfully enlightening and at best leading to skepticism about both positions.

So back to Dr. Gawande, it appears that he is smart enough to realize that certain forms of payments, like fee for service, lead practitioners to provide more care (which sometimes, but by no means always, may be unnecessary), whereas salaried doctors do not have that incentive (incidentally, salaried doctors are the norm in “socialized medicine”-type systems). And yet, Gawande is not perspicacious enough to ask himself why is it that Canada, Taiwan, France, or Japan, where fee for service reigns supreme, still spend a fraction of even what our cheapest and best run hospitals do. While I am not arguing in favor of fee for service — quite the contrary, I, like many, agree that it at least a very inefficient and administratively burdensome form of payment — I am just pointing out that given this rather banal observation, it is clear that fee for service cannot be the whole story of our high health care costs.

At any rate, had Gawande (or his interviewers) asked this critical question, rather than continuing in the all-too-American exercise of navel-gazing by comparing one (low-cost) American hospital with another (high-cost) American hospital, he might have studied a well-run, or even the best run, American hospital’s costs against the costs of some hospitals in other countries. And he surely would not have failed to see, as it appears he has, that even Switzerland, that comes second after the United States in health care costs (even if Swiss costs are substantially lower, by around 40 percent, than the U.S.’s), and has “private insurers,” bans profit making from the financing of medically necessary care. Right! It’s the financing, stupid!

The same is the case with the health care of all other industrialized economies. So even when Europeans, or the Japanese, talk about “private” insurers in health care they rarely, if ever, mean “for-profit” insurers. Private insurers are essentially tightly regulated subsidiaries of government, and if they are ever caught “cherry-picking” they are forced to transfer some of their money to another insurer that covered sicker patients or, as the Swiss do, lower their premiums during subsequent months, unimaginable in the America private health insurance scenario.

Admittedly, some readers might puzzle: “Why would insurers even be in business if not to become filthy rich?” Well, at least one reason is that if they do a good job and attract many members, then they can sell for-profit insurance for the “over and above” services (private hospital rooms, cosmetic surgery, etc.). And note, when Swiss insurers, who prior to 1994 were pretty much like American insurers, failed to meet their part of the social contract (i.e. were becoming filthy rich at the expense of everybody else’s suffering), they got their lesson: price controls and mandated benefits that they had to provide at no profit if they wanted to remain in business.

And had Gawande delved into the politics of health care (and not merely the Pollyannaish version of its history), he surely would not have failed to discover that the coming into being of the National Health Services (NHS) was anything but a “historical accident” (and if it was, then anything can be, and the expression is meaningless). It is surely true that the physical structures, the public hospitals, were “already there” after World War II, a war during which hospitals had been built that provided publicly funded medical care for servicemen. Yet it is equally true, and arguably much more important, that around 1948 there was a confluence of critical political forces, not the least of which was the landslide victory of Labor over the Conservative Party.

How did this unexpected victory happen, despite the popularity won by Conservative British Prime Minister Winston Churchill as a “war leader”? It appears that as “national security” concerns subsided and hunger and unemployment began to take their toll over an impoverished population, Britons concluded that Labor, not Conservatives, would be more inclined and capable to guarantee “bread and butter” issues — what were increasingly seen as basic social rights, such as full employment, income security, public education, and health care. Popular demand for guaranteed basic rights was further strengthened by the success of socialist British Minister of Health Aneurin Bevin to secure the support of the medical establishment: in a masterful move, Bevin decided that offering well paid practitioners who agreed to join the NHS generous salaries would free them “from the necessity to drum up business from rich clients to pay for their basic income” (Glennerster 2007: 51). So if the birth of the NHS was a “historical accident,” it was certainly a very complex one.

So Gawande’s conclusion, given the glaring omission in his theory, is unsurprising: it is U.S. doctors, and their “culture,” that are the source of our high costs – doctors, that is, who respond to a perverse systems of incentives, which according to Gawande, is the way U.S. doctors are paid: more for doing more yet not better.

Now, while doctors may certainly be part of the problem, and while paying more for doing more, even if it is not good and frequently not necessary, is obviously a bad thing, why Gawande chooses to ignore the critical and obvious fact that no other industrialized economy, and many industrializing ones (like Taiwan), leaves over 70 percent of its population (even if Gawande has only counted 50 percent) at the mercy of profit seekers when it comes to financing medically necessary care, is anybody’s guess. (Elsewhere I have laid out, and many other excellent policy analysts, like PNHP doctor Don McCanne, have done so as well, why the only way to eliminate financial barriers to medically necessary care is treating health care as a social right and financing it collectively through a tax-based or social insurance system, incidentally the only way to allow the choices that matter – of doctors and medical establishments, not “health plans” or “preferred providers” lists).

But maybe had Gawande acknowledged the obvious, I suspect that his New Yorker article, where he insists that whether insurance is public or private (we are not told whether the profit motive matters) is not that important after all, would not have never become “required” reading in the White House. Indeed, he even might have been kicked out of the sanctuaries where our health care future is being written (or cooked!), as was the case with many brave doctors (Dr. Margaret Flowers comes to mind), who keep on insisting that our politicians put pe
ople before profits.

http://www.socialmedicine.org/2010/01/07/health-activism/its-the-financing-stupid-a-second-opinion-on-gawandes-cost-conundrum/

It’s the financing, stupid!

A second opinion on Gawande’s ‘Cost Conundrum’

By Claudia Chaufan
The Social Medicine Portal, Jan. 7, 2010

http://www.socialmedicine.org/2010/01/07/health-activism/its-the-financing-stupid-a-second-opinion-on-gawandes-cost-conundrum/

Is Stanford tainted by accepting Pfizer money?

Using a Pfizer Grant, Courses Aim to Avoid Bias

By Duff Wilson
The New York Times
January 11, 2010
Stanford University on Monday will announce plans to develop new continuing education programs for doctors that will be devoid of the drug industry influence that has often permeated such courses.
The work is being done with a $3 million grant — from the drug maker Pfizer.
Dr. Philip Pizzo, dean of the Stanford medical school, says Pfizer will have no say on how the three-year grant will be spent. The university plans to set up unbiased programs of postgraduate education on the Stanford campus rather than the industry-selected topics of the past that have been presented to rooms full of doctors at hotels and resorts.
“It’s a fundamental change,” Dr. Pizzo said Sunday, criticizing the drug industry for poisoning educational programs with marketing messages and doctors for “complicity” in taking speaker fees and expenses-paid trips. He called the grant “a novel rebooting.”
Pfizer, in a statement, said it wanted to help redefine how continuing medical education was financed to ensure the independence and patient benefit of the programs, which most doctors are required to take to maintain their state medical licenses.
“The announcement is self-satirizing,” said Dr. Adriane Fugh-Berman, a Georgetown University medical professor who has researched and written about industry influence in continuing medical education. “Pfizer’s interest in better ways to manipulate physicians is well-known.”
Dr. Fugh-Berman said that Pfizer has major products in two of the four areas that the Stanford press release suggested might be pursued: smoking cessation and heart disease.
Dr. Arnold S. Relman, a former editor of The New England Journal of Medicine, a Harvard professor emeritus, an outspoken critic of industry conflicts and a friend of Dr. Pizzo, said he could not understand the rationale behind the arrangement.
“If it is true — a big, big if — but if it is true that this money is being given without any strings at all and without any obligation on the part of Stanford to please Pfizer, then it’s arguable that it’s O.K.,” Dr. Relman said.
“But it’s just not a good idea for a profession that says it wants to be independent and trusted, a reliable source of information to the profession and the public about drugs, to take money from the drug company under any conditions.”
http://www.nytimes.com/2010/01/11/business/11drug.html?ref=health

This tempering of the contingencies attached to Pfizer’s grant to Stanford’s continuing medical education program (CME) seems like a very small anecdote in the overall picture of health care reform, but it has greater significance than would appear at first blush.
Stanford’s Dean Philip Pizzo has a well deserved reputation for taking principled stands on the ethics of medical education and health care in general. This agreement to accept the Pfizer grant only on the condition that its use in their CME program be exclusively controlled by Stanford, without further input by Pfizer, is another step towards Dr. Pizzo’s goal of a system largely freed from the albatross of ethical compromise.
Are there any reasons that Stanford should not have accepted these funds? The first and most obvious reason is that this expense for Pfizer will be passed on to patients in the form of higher drug prices, already a serious problem that policy makers face.
Also, since Pfizer can deduct this as a business expense, the tax subsidies that we are providing are being turned over to Pfizer, which has control over how to distribute those funds. Do we really believe that a private, investor-owned pharmaceutical corporation has a greater ethical sense and wisdom in determining the use of our taxpayer funds than would our own public stewards? Likely Stanford will make very good use of the funds, but of the options for use of the taxpayer-funded component, is that the best use? It doesn’t seem right to turn that decision over to Pfizer, especially when it appears that the CME programs may still support Pfizer products, but only if Stanford decides so (certainly an ethical problem if and when it comes time to renew the Pfizer grant).
CME programs provide a social good: better health care for everyone. Public funding would prevent such ethical compromises and would help to ensure that CME programs have a mission to improve patient care rather than a mission to advance the pecuniary interests of pharmaceutical and medical-tech firms.
The ethical premise behind the concept of a single payer national health program – an improved Medicare for all – resets the primary mission for our entire health care system from one of private entrepreneurialism to one of service for the benefit of patients.
Dean Pizzo is to be admired for trying to achieve the best under the confines of our current dysfunctional system. You work with what you have, until you have something better.
The greater significance of this anecdote is that the rules under which we operate are wrong, and we need to change them, not just work within their confines as Congress is trying to do. We need a single payer monopsony that belongs to all of us – the people of this nation.

Comment:

Norwegian Health Care

Quinn names state’s public health advocate

A second opinion on Gawande’s ‘Cost Conundrum’

Using a Pfizer Grant, Courses Aim to Avoid Bias

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