The Health Care Story You Should Read Today

Medicare spends three thousand dollars more per person here than the average person earns. wow, that’s impressive.
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What Gawande describes surely constitutes fraud.
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geez, that piece read like the author was on the insurance company payroll. Here’s a hint — any time a writer frames the goal in the health care issue as “universal coverage”, they’re (consciously or unconsciously) shilling for AHIP, BC/BS, Aetna, etc.
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But more to the point, the author uses medicare costs to repeatedly state that McAllen has the highest per capita health care costs in the country while simultaneously talking about disease rates among the entire population. Medicare serves a separate and distinct subset of the population, and you can’t assume that health statistics for the overall population are the same in all demographic categories.
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And even worse, by using the “extreme” case of McAllen as the basis for an article on high health care costs, you wind up ignoring the key issue that concerns most americans — rising insurance rates for those whose medical costs are not covered by the government. The costs of providing care under Medicare are completely irrelevant to the problems associated with the private, for profit health insurance industry.
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In other words, not only is this article largely irrelevant, it is a damaging distraction from the real issues involved in the push for health care reform.

whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
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The central tenet in the “Church of Reagan” creed that represents mainstream Republican thought is that anything that maximizes revenue automatically provides a social good as well. The idea is that the market of individuals seeking to maximize their own situations will foster competition among service providers and lead to optimum results.
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So ingrained is this faith, that people no longer see the need to test it for its truth. Here’s a clue. It’s false. Most Americans are now recognizing that its false and are willing to try out a different theory.
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Personally I’m delighted to be alive and aware during this point in History. I didn’t expect to witness a full 40 year pendulum swing of socioeconomic thought.

There were many moments in “Sicko” that really stuck with me. One was a replay of one of the Nixon tapes, captured here:
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How Kaiser Permanente and Nixon changed healthcare in the US…
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This is a transcript of the 1971 conversation between President Richard Nixon and John D. Ehrlichman that led to the HMO act of 1973:
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John D. Ehrlichman: “On the … on the health business …”
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President Nixon: “Yeah.”
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Ehrlichman: “… we have now narrowed down the vice president’s problems on this thing to one issue and that is whether we should include these health maintenance organizations like Edgar Kaiser’s Permanente thing. The vice president just cannot see it. We tried 15 ways from Friday to explain it to him and then help him to understand it. He finally says, ‘Well, I don’t think they’ll work, but if the President thinks it’s a good idea, I’ll support him a hundred percent.’”
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President Nixon: “Well, what’s … what’s the judgment?”
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Ehrlichman: “Well, everybody else’s judgment very strongly is that we go with it.”
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President Nixon: “All right.”
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Ehrlichman: “And, uh, uh, he’s the one holdout that we have in the whole office.”
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President Nixon: “Say that I … I … I’d tell him I have doubts about it, but I think that it’s, uh, now let me ask you, now you give me your judgment. You know I’m not to keen on any of these damn medical programs.”
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…
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Ehrlichman: “… private enterprise one.”
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President Nixon: “Well, that appeals to me.”
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Ehrlichman: “Edgar Kaiser is running his Permanente deal for profit. And the reason that he can … the reason he can do it … I had Edgar Kaiser come in … talk to me about this and I went into it in some depth. All the incentives are toward less medical care, because …”
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President Nixon: [Unclear.]
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Ehrlichman: “… the less care they give them, the more money they make.”
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President Nixon: “Fine.” [Unclear.]
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Ehrlichman: [Unclear] “… and the incentives run the right way.”
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President Nixon: “Not bad.”

Another moment in “Sicko” that stuck with me was an interview with a group of ex-pat Americans in a French restaurant, where they described their experiences with the French system. One guy noted that when he moved to France, and had to fill in the forms to get in their system, he froze up when he came to the pre-existing conditions part. Until he was told that they wanted to know about any health problems so they could better determine the appropriate health care required. It was to make his health care better, not to deny him coverage.
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And that is the case pretty much everywhere but in the USA. It’s about health care, not about insurance. Really a key distinction.
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Of course another key distinction is the net cost to society is lower “there” and here, and the outcomes are better.

One thing is very clear. No business or individual citizen of this country can afford our current private health care system. We can not continue doing business this way it is simply unsubstainable.

The “other” Klein, who is a very very busy boy at his new digs, has been doing excellent reporting on the health care issue. Lots of good text and brilliant graphs, like the one at this post: Health Care Cost Fallacies and described in this paragraph:
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That orange line headed heaven-ward? That’s our deficit. All those other lines dipping down? That’s our deficit if we had the same health care spending per person as France, Germany, Canada, and the UK (all countries, incidentally, with higher life expectancies than our own). You might say, of course, that even radical reform would not bring us down to their health care spending. We could copy France’s system wholesale and still pay more for care. You would be right. But such reforms would bring us much closer than we are now. And to flip Cowen’s second fallacy, the fact that we cannot match the health care spending of other nations does not obviate the savings we are forgoing because we refuse to embrace their successful models.

Thanks for the link. The article was a long one but definitely worth the time. The author gave the best explanation for runaway health care costs that I’ve ever read. One quote from Dr. Dyke really stood out, “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”

wvng: that part of sicko was one where i thought moore got it wrong historically. at the time, believe it or not, hmos were kind of a lefty idea in health care. and if you look at the system today, what’s sending costs out of control is too much wasteful care (that’s where gawande’s story was so revealing). by some estimates, as much as a quarter that is spent on health care goes to unnecessary treatment that could actually be hurting patients, not helping them. finally, kaiser permanente–which is way ahead of the curve on things like coordinating care and electronic record keeping–is a model (like the mayo clinic’s) that is producing better outcomes.

Karen these are just a few of the glaring arguments that this article in and of itself is flawed for the proposal for Universal Healthcare, if we do not first change our practices “universally” across this nation. As I have said many times before, unless we do not first initiate a preventative health care model first, no insurance program will work or become efficient. Sure the universal health record program would be of some benefit that Obama proposes, but is not the root problem with the existing system.
”Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.
There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate.
The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period.
Universal coverage won’t be feasible unless we can control costs. Policymakers have worried that doing so would require rationing, which the public would never go along with.”
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For any program to work you must do the following;
1. Provide education to every Man, Woman and Child on preventative medicine.
2. Promote healthy living first by a sensible diet, and promote a nutritionally sound eating habits.
3. Provide education to Physicians that multiple tests are not always necessary, especially if they first ask themselves are they doing the multiple tests to prevent a potential law suit for malpractice.
4. Pass legislation for a cap on litigation on malpractice cases across the country. (This alone will drive down the cost of medical costs immensely if the cap is set low enough that it is no longer financially viable for lawyers to make millions of dollars off of these cases).
5. Provide “Healthy Living Incentives” to all Americans. Tax breaks or even rebates based on how well your health is rated. Lose weight and get a tax rebate if you remain under a certain BMI, then the tax you pay is reduced so long as you remain in that “healthy range”. If you smoke, provide a tax rebate program. If you continue both poor eating habits and/or smoke after a certain period of time you will be penalized with paying a higher tax rate.
6. Provide community incentives to promote a healthier lifestyle. Create government run community recreation and parks systems that promote health. One thing about socialist countries that I do agree with is their foundation of sports and recreation complexes that everyone can enjoy at little to no cost.
7. Retrain all medical professionals to identify at risk individuals and provide them with in the home counseling. If the medical professional does not become intimate with their patient’s or consumers. If they do not go into the home to see for themselves how they eat and prepare meals, look at the stressors on the main providers then changes will not occur. Currently most insurances do not compensate Nutritionists who provide home health care. This is one of the first critical steps to effect a nutritionally sound diet and meal planning.
8. Educate the next generation. Eliminate the TV commercials that promote unhealthy eating habits and ban them just like we have cigarette commercials. Put a “cap and trade” like tax on alcohol producers, McDonalds and other fast food providers. Give incentives to fruit and vegetable producers, and to families who want to put out a garden every year. Give away free fruit trees to County Extension Offices to distribute to local families. Pay farmers to produce healthy crops instead of beef and pork, penalize those farmers who grow “fat” producing products.
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This is just a simple list I put together this morning. I am sure there are thousands of other great ideas other people can come up with themselves.
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I hope you consider these options Karen when you write your next article to promote a “universal” healthcare program. This is the universal program we need, not a change in the current system of healthcare delivery.

this is closer to my understanding of where HMOs came from. an early proponent was ted kennedy:
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Costs went up, introducing an economic obstacle to individual health insurance. As costs rose, those on the New Left, including then freshman Sen. Ted Kennedy, argued that government ought to pay for everyone’s health care and promoted the idea of a health maintenance organization, a term coined by a left-wing college professor.
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President Nixon appeased the left and proposed the HMO Act, which Congress passed in 1973. The law created new, supposedly cheaper health coverage with millions of dollars to HMOs, which, until then, constituted a small portion of the market. Kaiser Permanente was the only major HMO in the country by 1969 and most of its members were compelled to join through unions.
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http://www.capmag.com/article.asp?ID=2819

Here’s another link, less ideological, that suggests that the main beef that Kennedy and other liberals had with Nixon over HMOs was that he didn’t want to go far enough with them:
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http://books.google.com/books?id=jbVaOwaFCAgC&pg=PA319&lpg=PA319&dq=health+maintenance+organization+act+of+1973+kennedy&source=bl&ots=PPDKrUCZ9s&sig=0hXocopfL2qWojaGkR9Ppdf_S7M&hl=en&ei=rkodSsWTEIvCM_TwsZQP&sa=X&oi=book_result&ct=result&resnum=10

Rusty: I think the approach that people are talking about is doing both universal coverage and cost control at the same time. a lot of health economists (jon gruber at MIT is a leading voice on this) that if you don’t cover people, cost control won’t work, because there will still be too much cost shifting in the system. e.g., the uninsured with get the expensive and inefficient care they now get — a lot of it in emergency rooms — and the costs will be shifted to paying patients. chronic illnesses, the major driver of health care costs, will continue to drain the system of its financial resource.
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then again, universal coverage without changing the way that we reimburse providers–for outcomes, rather than quantity of treatment–would be a fiscal disaster.

another issue: insurance market reform–getting rid of pre-existing condition restrictions, for instance–won’t work unless you get everyone in the system. otherwise, those covered will be disproportionately the sick, and costs will be too high for everyone. several states that have tried to do one without the other have found that out the hard way.

Rusty,
Your list is indeed a good one. Part of the problem comes though from people who would see your suggestions as unnecessary impediments to their freedom. In particular, number 8, controlling what can be advertised on TV specifically runs against standard RW concernes about Free Speech and government interference with the free flow of ideas.
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This suggest to me that there is indeed room to find ‘balance’ against competing interests once we dispense with the notion that government has no business being involved in the discussion in the first place.

Rusty and PD: Also, here’s one idea that someone in the White House suggested to me as a way of bridging the ideological divide for docs who hate comparative effectiveness research and conservatives who say it is the heavy hand of govt getting between you and your physician: Do the research, and don’t require docs to follow it, but make “best practices” a defense in malpractice lawsuits.

Happy to see Rusty offering more serious input. It’s a good reminder that the health care discussion needs to focus on what works, not what’s best promoted or which interest group wins.
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My only overall problem with Rusty’s contribution is the notion that health care reform needs to be an either-or proposition. Making/keeping Americans healthier should undoubtedly be a big – likely the biggest – piece, but I don’t think we can write off attention to the delivery system quite so easily. If Gawande’s article teaches us anything, it’s that there are those in the system attuned primarily to profiteering however good or poor the collective health of the populace may be. Health care providers should be compensated well, but we need safeguards against the potential for “Dr. AIGs” gaming the system for short-term gain.

Rusty,
I agree (almost) completely . . . this post, combined with your welcome post on the Memorial Day thread, sets a benchmark for right-leaning posters around Swampland. Now just get spob and textee on board, and you may actually end up persuading some of us lefty loons to your cause!

KT, I think there is a distinction between a discussion of the “why” of HMOs in theory, and that particular conversation with Nixon and Erlichman that noted: “All the incentives are toward less medical care, because … the less care they give them, the more money they make.”
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The correct incentives for a health care system should always be toward the appropriate medical care.
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Ditto on rusty’s list – really good job. I like the tax incentives promoting healthy behavior. The French system is notably good a prevention, I understand, one of the reasons they are doing so well in any cost:benefit analysis.

wvng: agree, but i think that little snippet of conversation doesn’t accurately describe anyone’s motivations (including nixon’s) in what was a big national debate at the time.

wvng: should clarify. meant it doesn’t FULLY describe their motivations. yes, kaiser thought they had a good business model, but they also believed they had a better care model–including one that emphasized preventive care–than what existed at the time with fee for service medicine. and nixon was actually pretty progressive on this issue, taking on the AMA, something that many of his predecessors (notably truman — but even woodrow wilson was called a socialist by the AMA) had tried and failed to do. my whole problem with moore’s movie was that it distorted what was a very complex history. and he knew that anything that evoked nixon would get boos and hisses from his audiences.

Having lived in Germany for 5 years last decade, I can vouch for a number of items on Rusty’s list and add the following:
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7. Doctors, risk and employment. And excellent feature of the German health system was that health policy was backed up with employment policy. If you got sick, your Doctor gave you a note to take to your employer allowing you to stay home and recover, with pay. If you were expecting a child, the mother could take at least 12 weeks of leave, and, more recently, the father could take up to 4 weeks.
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3+4. Malpractice and litigation. While Germany and other European countries limit damages, they also have systems which emphasize care rather than profit. As long as insurance companies are getting rich by denying care, litigation is the only recourse we have as health service consumers. Two sides of the same coin. We can’t fix one without the other.

Thank you for your reponses Karen. But responding back to your two posts, in particular to this one below;
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Karen Tumulty Says:
Wednesday, May 27, 2009 at 10:32 am
Rusty and PD: Also, here’s one idea that someone in the White House suggested to me as a way of bridging the ideological divide for docs who hate comparative effectiveness research and conservatives who say it is the heavy hand of govt getting between you and your physician: Do the research, and don’t require docs to follow it, but make “best practices” a defense in malpractice lawsuits.”
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The statement that “conservatives who say it is the heavy hand of governemtn” I believe is a little shallow and condesending. The conservatives I know are not against reform. The reform they are looking at, and which makes the most fesible sense in cost effectiveness is changing behaviors. Yes this will take a rather long time to do because we are asking people to change behavior. But, in the long run if this is not done it will bankrupt any system put into place.
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I agree that those without any health insurance at all are utilizing our ERs as basic medical care facilities instead of cheaper clinics and the like. Why can’t we have clinics funded by Government money paid by the tax payers? What is wrong with providing that service, rather than initiating a whole new insurance program that will eventually destroy the entire system? People will recieve basic medical care, and the rest of us who are out there will continue with the type of care we have come to not only expect, but enjoy.
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I do believe that the majority of people who are un-insured or under insured are illegals in our country. The rest, if they choose to do so could apply for government insurance programs that already exist, and those that fall just above the limits should be given the opportunity for a different insurance program based on their range of income that does not already exist. That in my mind would solve alot of the concerns you have expressed.
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Change for the sake of change is not always the best fix for the problem. This is where I disagree with most liberals. They want to “throw the baby out with the bath water” before looking at it all comprehensively, throughly to come up with a better solution. I predict this issue will become as divisive as abortion soon, once the vast majority see what impacts a universal healthcare program will have on the majority of people in this country with adequate health insurance.
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There is what 40 million or so un/under insured? While there are well over what 200 million citizens in the US? So what you are saying is 20% of the population is causing 90% of the problems, right?
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Just pass legislation to assist the 20% as a temporary fix, and then address the more serious long term problems.

A “for profit” health care system is immoral. As long as you have insurance companies and medical corporations skimming money off the top nothing will change. The folks in Washington – the politicians and those who guide our “discourse” like to talk about “political viability” when they talk about a “single payer” system. It would be beneficial to all if all options were on the table and we can speak the truth. That is we need to admit that the corporate medical lobby (insurers, pharmaceutical companies, etc) OWN our politicians. Bribery is legal in DC and it’s the issue that dare not be spoken in our discourse.

Bill Moyers had an excellent and informative show on the topic this past week. It was refreshing to see a point of view that is surprisingly absent in our so-called “liberal” media.

http://www.pbs.org/moyers/journal/05222009/profile.html

rusty: what do you think about making “best practices” (based on comparative effectiveness research) a defense in malpractice lawsuits? e.g., dr could say he didn’t (order that last MRI/prescribe the more expensive drug/do surgery as a first resort) because the research did not suggest it was warranted. seems like a win-win to me.

I’m enjoying rusty’s substantive contributions today. Would it be shallow and condescending to offer an attaboy?
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I also think rusty errs in describing our “system.” We don’t have a system. That is why countries seeking to start their own national health care system don’t look to us, they look to practically anyone but us to get viable ideas. And they manage to come up with models that both fit their national character and work. See T R Reid’s excellent Sick Around the World.
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As for “Yes this will take a rather long time to do because we are asking people to change behavior. But, in the long run if this is not done it will bankrupt any system put into place.” True, but a quick look at the following piece Health Care Cost Fallacies illustrates what President Obama keeps repeating – we can’t get our escalating budget problems under control without dealing with the health care issue comprehensively. Other countries have managed to do just that (see TR Reid again).

Best practices I have found Karen are viable when used with caution. You are really saying “most everyone is the same, and the same symptoms one person has is “probably” the same as the other person’s symptoms as well. That fallicy is also why we see people die unexpectedly and without reason. I think you are setting a lethal standard when you take away the Physicians ability to independently diagnose his or her patients. That is my only disagreement with your “best practice” theory.
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When best practices are used like all generalities, then and only then will it be not only practical, but safe for each individual.
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So far as using it for litigation, I have no problem with that at all for a defense, and would highly support such. The problem is in our judical system, “anyone can sue anyone for any reason” is still the norm. The cost of defending yourself is the real problem against malpractice cases. Putting caps on the awards given in my mind is a much better approach to it all so far as ligation is concerned. Not that I wish for my attorney friends and neighbors to lose out on income. I just wish for a day that we can go back to practicing medicine as we were trained rather than looking at it all through the eyes of an attorney first for the potential risks involved to the patient versus the benefit of a potential positive outcome and successful recovery.

rusty, question. Have you seen TR Reid’s Sick Around the World? If so, which of the five models described there seem most appropriate to your sensibilities? The latest to the game were the Swiss:
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Reid’s last stop is Switzerland, a country which, like Taiwan, set out to reform a system that did not cover all its citizens. In 1994, a national referendum approved a law called LAMal (“the sickness”), which set up a universal health care system that, among other things, restricted insurance companies from making a profit on basic medical care. The Swiss example shows health care reform is possible, even in a highly capitalist country with powerful insurance and pharmaceutical companies.
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Today, Swiss politicians from the right and left enthusiastically support universal health care. “Everybody has a right to health care,” says Pascal Couchepin, the current president of Switzerland. “It is a profound need for people to be sure that if they are struck by destiny … they can have a good health system.”

Staying out of this because the exchange between Rustydog and KT is so valuable, but thanks very much for the link to this piece, KT (there’s plenty to question about the writer’s assumptions, methodology and conclusions, but I’ll leave that alone for the time being, because it’s so worth commenters’ time to read for themselves).

Karen (or anyone else)-

Would you please comment on plukasiak’s assertion in his comment at 7:27 am that Gawande’s article is “largely irrelevant” and “a damaging distraction from the the real issues…”?

I read the entire article and thought it well researched and informative. I found myself agreeing with the author’s statement that we “need to fund research that compares the effectiveness of different systems of care–to reduce our uncertainty about which systems work best for communties. These are empirical, not ideological, questions.”

Are plukasiak’s objection’s valid or are they “ideological”? I’m not an expert on any of this, but I thought the article was useful.

I’ve made this point before but I think it bears repeating. One of the reasons that malpractice insurance is such a big problem is because the subject of illness is prone to irrational thinking. The fact of the matter is that in spite of all the advances we’ve made in the last 100 years, there’s still a ton of circumstances that Doctors are powerless to control. The tendency of patients to want someone to blame when things go awry is also almost universal.
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Add to that the significant difficulty in doing proper double-blind research which may include withholding treatment from the control, group and the basic problem of random factors and you have a recipe for wishful thinking that places the caregivers on the short end of the stick.
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Real malpractice is a real problem but real ambulance chasing is also a real problem. It’s part of the equation that we can’t leave hanging while working on reform.

SZ-

I think I just set you up with a slow, fat pitch for you to knock out of the ballpark.

We are moving backwards if we believe that universal health insurance will solve the health care problem.

I enjoyed the link very much and discovered that Gawande has many other articles I want to look at, including human rights issues. He is a brilliant person, Rhodes scholar, Harvard professor. How he finds time to do this writing is beyond me. Travel and meandering around McAllen, Texas? I am in awe.
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The most important point he makes, to me, is the apparent innocent ignorance of health care providers of what the status quo is accross the spectrum regionaly and institutionally. Nobody really knows and he doesn’t draw firm conclusions so much as pointing out that cogent fact.
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I have enjoyed as well reading this thread, including rusty’s contribution, and I know it is his field of vocation. But, to rusty, ever the conservative voice on the Swamp, I point out the most distressing and depressing conversation Gawande had was with Dr. Gelman, the CEO of a hospital, and host of the unrelenting conservative radio program. Gelman had all the answers, those he didn’t know were unimportant, government was the culprit, and he just wasn’t inclined to discuss the issue. How typical.

I did not read your article you cite by TR Reid until now, wvng. But, his search for the “better” system is intriguing to say the least.
I do offer this up as a possible concern by utilizing smaller countries as model programs like Taiwan and Switzerland. They are much smaller countries and do not have the populations to support as we have in the United States, and their healthcare is more geared towards prevention than cure from my experiences by seeing both systems in action from their transition from a private system to a government supported system. Also I do not believe either country has the immigrant issue as well, especially illegal immigrants in their countries illegally to contend with.
This leads me again back to my original comment that if you first do not have in place a prevention model, then any insurance system or model will not succeed. Many countries which did not have this in place first, failed miserably. Case in point, England, and to a lesser degree Canada. Both much larger countries than the two you cite, but similar systems prior to going “universal” as ours is currently.
I just hope people consider that we do have a good system in place. Yes it does need reform, I will not argue that point. However, with a private system or a system that supports private as well as public funded we shall continue to see the great medical advances we have enjoyed for the past 100 years. If we totally shut out private enterprise in our medical delivery, I fear that the research by private companies will eventually dry up and we will no longer see these tremendously important advances in medical care. I do not care what country it is, the United States of America leads in all aspects of medical research and development today and for the past at least 50 years or more. I do not want to see us lose that position.

rusty: on that score of the various systems around the world, i found gawande’s earlier piece on how they each developed to be very interesting:
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http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande?currentPage=all
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Worth reading the whole thing, but here’s his conclusion about what this says for us:
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//We cannot swap out our old system for a new one that will accomplish all this. But we can build a new system on the old one. On the start date for our new health-care system—on, say, January 1, 2011—there need be no noticeable change for the vast majority of Americans who have dependable coverage and decent health care. But we can construct a kind of lifeboat alongside it for those who have been left out or dumped out, a rescue program for people like Starla Darling.
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In designing this program, we’ll inevitably want to build on the institutions we already have. That precept sounds as if it would severely limit our choices. But our health-care system has been a hodgepodge for so long that we actually have experience with all kinds of systems. The truth is that American health care has been more flotilla than ship. Our veterans’ health-care system is a program of twelve hundred government-run hospitals and other medical facilities all across the country (just like Britain’s). We could open it up to other people. We could give people a chance to join Medicare, our government insurance program (much like Canada’s). Or we could provide people with coverage through the benefits program that federal workers already have, a system of private-insurance choices (like Switzerland’s).
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These are all established programs, each with advantages and disadvantages. The veterans’ system has low costs, one of the nation’s best information-technology systems for health care, and quality of care that (despite what you’ve heard) has, in recent years, come to exceed the private sector’s on numerous measures. But it has a tightly limited choice of clinicians—you can’t go to see any doctor you want, and the nearest facility may be far away from where you live. Medicare allows you to go to almost any private doctor or hospital you like, and has been enormously popular among its beneficiaries, but it costs about a third more per person and has had a hard time getting doctors and hospitals to improve the quality and safety of their care. Federal workers are entitled to a range of subsidized private-insurance choices, but insurance companies have done even less than Medicare to contain costs and most have done little to improve health care (although there are some striking exceptions). //

To formerlyjames. I agree with you on Dr Gelman. However he is no longer a Physician in my opinion and has transferred to the business arena of Medicine as a CEO. You must take his comments as such, that of a businessman, not a physician.

Karen;
“In designing this program, we’ll inevitably want to build on the institutions we already have”.
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On this note from which you cite Karen, I have no opposition. Let us begin the transformation!

moderatelyinterested Says:
Wednesday, May 27, 2009 at 1:26 pm
Karen (or anyone else)-
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“In other words, not only is this article largely irrelevant, it is a damaging distraction from the real issues involved in the push for health care reform”.
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moderately: As soon as I read the last statement from plukasiak, I immediately threw it out as any logical point of discussion on this topic.
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Enough said.

rusty, when you have two hours clear, try watching the Sick Around the World video. It’s available on-line at the link. One question Reid asked in each country was: “How many people in your country go bankrupt due to medical bills.” The answer everywhere was “no one.” The answer, from a quintessentially Swiss fellow was something along the line of ‘No one, it would be unthinkable.’
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In the USA (“we’re number one, we’re ….), not so much: Medical Bills Leading Cause of Bankruptcy, Harvard Study Finds
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Illness and medical bills caused half of the 1,458,000 personal bankruptcies in 2001, according to a study published by the journal Health Affairs.
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The study estimates that medical bankruptcies affect about 2 million Americans annually — counting debtors and their dependents, including about 700,000 children.
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Surprisingly, most of those bankrupted by illness had health insurance. More than three-quarters were insured at the start of the bankrupting illness. However, 38 percent had lost coverage at least temporarily by the time they filed for bankruptcy.
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Most of the medical bankruptcy filers were middle class; 56 percent owned a home and the same number had attended college. In many cases, illness forced breadwinners to take time off from work — losing income and job-based health insurance precisely when families needed it most.
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Families in bankruptcy suffered many privations — 30 percent had a utility cut off and 61 percent went without needed medical care.
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Tis was the core point of Sicko – hundreds of thousands of responsible members of society who have insurance, and think they have good insurance, go bankrupt from medical bills every year.
The consequences of this to our society are profound.

I do not need to watch “Sicko” which I think the majority of that video was full of crap, but I do agree with the bankruptcy point and no American should lose everything they have worked so hard to acheive in life due to a castastrophic illness. I have always felt that we need to take care of our own in these cases, and stop spending money on needless programs that are ineffective, wasteful, and basically deemed “pork”. Once we can get our elected representatives to agree on that, then I think we can afford to “take care of our own”. Perhaps we can start off with shutting down our bases in Korea, and let the Chinese deal with North Korea on their own. I for one would love that option. Think about how many millions of Americans could receive free health care at local clinics with all of that money.
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So I think we are totally in agreement on that point, wvng.

moderatelyinterested:
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I think I just set you up with a slow, fat pitch for you to knock out of the ballpark.
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As I mentioned in a prior post, I think it’s much better for the discussion if I were not to unintentionally monopolize the thread, but thank you so much for your interest.

Are plukasiak’s objection’s valid or are they “ideological”? I’m not an expert on any of this, but I thought the article was useful.
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a couple of points…
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McAllen is “the worst in the nation”. Basing a discussion of solutions based on the worst that is happening, rather than what typically happens, is a recipe for demagoguery. (for example, look at how “the worst” has influenced the discussion of welfare reform, public housing reform, education reform, etc….).
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Gawande’s “solution” is based on “socialization” at the providers end of the health care equation. Its about “doctors on salary” (Kaiser and Mayo– removing the incentive to work harder/treat more patients) or “collective compensation” (Grand Junction, where all doctors get the same fees regardless of who is paying, which means that all fees are collectivized and then redistributed based on patient count.)
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Does this sound feasible to you as a path toward reform?
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Obviously, there are savings to be achieved through more “efficient” treatment. But the idea that more tests are always bad is just silly. This is especially true with regard to the woman who had chest pain — the question here is whether we do the tests for the small percentage of 40 year old women whose lives will be saved by more tests when they present with chest pains that don’t show up as a heart attack with an EKG, or whether we write off those women — allowing their heart disease to progress to the point where they require major invasive surgery and/or die.
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Gawande gives us the worst case scenario in which a woman who presents with chest pains is automatically given a whole battery of tests — that is not the norm, and by representing it as “the problem” Gawande does, in fact, distract from the real issues.

rusty, “Sick Around the World” is not Sicko. It’s a Frontline special.