Wednesday, July 29, 2009

Prevention and the “Trap of Meaning”

The July 22/29 issue of JAMA contains a very interesting essay by Constantine Lyketsos and Margaret Chisholm titled “The trap of meaning: a public health tragedy”[1] ( The article starts with two obituary quotes:
“Adolf Merckle, the German billionaire whose speculation in volatile Volkswagen stock had pushed his sprawling business empire to the edge of ruin, has committed suicide. . . . "No longer being able to handle the situation . . . he ended his life," the family said.

John Updike, the kaleidoscopically gifted writer . . . died. . . . The cause was cancer.”

They go on to note that the picture of Updike that accompanied the picture showed him with a lighted cigarette, but that the obituary did not suggest that this may have been the cause of his cancer and death. Their point is that, where mental illness and particularly depression are concerned, and especially when these diseases are terminal through suicide, we seek meaning in the objective facts – that Merckle committed suicide because his was disconsolate at the results of his actions, rather than that he was depressed. “Of course, he was depressed,” we might think, “look at what he did and what happened from it.” We like such explanations, as the authors point out “because they have face validity and make sense.” But, on the whole they are wrong, or at least incomplete. For each Adolf Merckle who commits suicide after bringing ruin upon himself, his family and his company, we have many corporate and financial titans who have not. Some may be sad, and some may even be recondite, while others feel unfairly persecuted, entitled, arrogant, and every other possible human response, but most have not committed suicide. What made Merckle different?

Although, I – like Lyketsos and Chisholm – know nothing about the actual medical history of Merckle or Updike, there is a strong possibility that the reason for Merckle’s death was depression, just as there is a there is such a possibility that Updike’s was related to his smoking. When I started the article I thought that the authors were going to talk about how we accept depression but think of smoking as a “behavior”, while they in fact went on the opposite track; this may reflect my increased sensitivity to the issue of depression as terminal disease, which many others may not share.[i] Yes, it is possible or probable that specific life events may trigger the completion of suicide in a person afflicted with depression, but they do not cause it any more that the simple upper respiratory infection leading to pneumonia in a person with chronic lung disease “causes” the death of that long-time smoker. The same trigger, the upper respiratory infections or adverse life events, may inconvenience those of us who are relatively healthy, or in the case of severe viral infections (such as influenza) or serious adverse life events (financial ruin, divorce, death of a loved one) have severe effects upon us, but they do not kill us absent the underlying disease. Depression, a biochemical imbalance in the brain, like chronic lung disease, can be more or less severe, but it is all too frequently fatal.

The most important point that Lyketsos and Chisholm make is that the search for “meaning” in actions such as suicide – that someone killed themselves because they were unhappy because of financial losses, or family losses, other life events – not only is largely wrong, or inadequate, as an explanation, but that it may in fact increase the mortality of the disease. This is because those who suffer from depression, as well as their friends and family, in their search for an explanation, for meaning, for a “cause” in the external events of life, may fail to recognize, deny, or not treat the underlying disease of depression. It is in many ways parallel to high blood pressure: it can be made worse by life circumstances, mild forms may be controlled without drugs, more severe forms usually require drugs, and even those who are treated may still succumb to effects of the disease.

Depression, like many other chronic diseases, is not always successfully treatable. People who clearly recognize their disease, are in therapy, and are on medication may still commit suicide, just as those under treatment for hypertension or heart or lung or kidney disease may succumb. Many people are in denial about their diseases, whether those diseases are of the heart, lung, kidney, or brain. We have talked about many (often defined as “cultural”) beliefs about cause of disease that are not consistent with science and biology. But the type of denial that characterizes depression, couched in the search for “meaning” in life events, is less frequently seen nowadays in conditions seen as more physical. “The trap of meaning,” write Lyketsos and Chisholm, “is a formidable challenge because it feeds off an adaptive human predilection”. That means that people like explanations. The danger is when those explanations are wrong, and blind us to the correct diagnosis and potentially helpful therapy.

[1] Lyketsos CG, Chisholm MR, “The trap of meaning: a public health tragedy”, JAMA Jul22/29,09;302(4);432-3.

[i] In full disclosure, I am definitely not dispassionate about this issue. One of the kindest, smartest and most gentle people I have ever known, as well as someone I loved with all my heart, committed suicide. While those of us who knew him over many years were aware of “episodes” of depression, we obviously did not understand how profound it was. When my son, Matt, took his life at the age of 24, it was at a time when things were going very well in his life, as far as anyone else could see. He was in a strong, loving, committed relationship, about to graduate with a degree from school he loved and where the professors thought him outstanding, had a relatively recently diagnosed chronic physical illness – diabetes – under good control, and had big short and long term plans. He also, not typically but not uncommonly, did not make a suicide gesture, but rather planned it thoroughly and in private, driving to a far off state (where it was easy to buy the gun he used; probably the first time he ever used a gun) and taking enough cash that he could not be tracked by credit cards. He really wanted to do this, and people who were very close to him had no idea. I say all this because yes, if he could do this, then your friend or father or son or wife with depression could, even if they are doing great now.

This is the tragedy of depression, the risk that it will be written off with “reasonable explanations” or the “trap of meaning”. Recognizing it and treating it may not prevent a terminal outcome, but it is the best we can do, and a whole lot better than pretending it is not there.

Saturday, July 25, 2009

Integrated Health Systems or Thinking Inside the Box?

The health reform debate has generated input from a wide variety of sources, many of whom have usually been content to stay on the sidelines and collect their money. Among these are hospitals and hospital systems; the best known are the integrated hospital systems that have been getting a lot of publicity for controlling costs, like the Mayo Clinic in Minnesota, the Geisinger Clinic in Pennsylvania, the Cleveland Clinic in (duh!) Cleveland, Ohio, and on a smaller scale the Bassett Health System in Cooperstown, NY, which is featured in the July 25, 2009 New York Times article “Hospitals shows a way to save: doctors get salaries, not fees” ( One thing that they allhave in common is that they are integrated health systems, in which the physicians are often salaried and thus not motivated to perform unnecessary tests or procedures, have patients come back more often, or repeat tests because they do not have access to them (in such systems, there are electronic records giving all physicians access to the patients’ records). In such systems, the benefits achieved are not only those of large scale, but of recognizing benefit to the overall system rather than to each component. Thus Bassett, located in a town more famous for the Baseball Hall of Fame (and, IMHO, one of the most beautiful places in the country), “…has opened 13 clinics in schools around the region. The clinics lose money, but Basset is considering opening 14 more.” Because they are good for the health of the community, but also because they may be good for the bottom line of the entire enterprise. Many policy makers are looking at such models, and wondering why these cannot be adopted on a more widespread scale.

Of course, they could be, but it would take the appropriate incentives. Right now, most health care is delivered by doctors in individual practices or small groups, clustered in metropolitan or suburban areas where there are lots of insured people and where the doctors like to live, using individual hospitals that are usually non-profit although increasingly owned by for-profit companies, with each component looking at what is best for its individual bottom line. “Medicine is the last cottage industry,” the Times quotes Jordan J. Cohen, MD, president emeritus of the Association of American Medical Colleges (AAMC), as saying. I have written extensively about the need for more primary care, as well as the more appropriate geographic distribution of physicians, and the challenges faced in trying to recruit students to even enter primary care residency training, not to mention locate in underserved areas.

A large part of this is the huge discrepancy in the amount of money that can be made in primary care compared to subspecialties, and this is not being addressed effectively at this time. Thus, not only do medical students choose specialties that may be more lucrative, but hospitals and hospital systems choose to both recruit patients who are well insured and emphasize care of diseases that are profitable. The health reform debate has definitely focused on trying to find ways to cover the uninsured, but has just begun to look at the latter. Most hospitals, including my own, have developed strong programs in cardiac care, cancer care, and neurosurgery. These are important conditions to treat, but so are pediatrics, psychiatric conditions, obstetrics and many others. What makes those first three so attractive to hospitals is that they – shock – make money! This is entirely due to a reimbursement system that pays a lot for procedures (cardiac care) and tremendous mark-ups for chemotherapy drugs (cancer care). That’s right; the reason a hospital builds a brand-new cancer center to attract patients from St. Elsewhere is because Medicare – and other insurers – pay a big markup on chemotherapy drugs. Sounds a little less noble that way, huh?

Even my hospital, the University of Kansas Hospital, has issued a “White Paper” on Health Reform. Although public, it is not on line and so I’ll have to summarize it. In essence it says: We support health reform. We believe the insured should be covered, both for moral reasons and because we take care of a lot of them and they cost us money. We are not even against a public option, because we can’t figure out any other way that would really cover the uninsured. BUT – don’t base it on Medicare, because Medicare doesn’t pay us enough; if everyone were covered by Medicare, we’d lose money. This is a logical, if self-centered approach, but it is so deeply within-the-box thinking that it can become emblematic of why health reform will never be successful if it tries to satisfy every “player” – including providers such as hospitals and doctors, not to mention pharmaceutical and insurance companies.

The University of Kansas Hospital is not a bad hospital; by most standards it is a very good hospital, as hospitals go. It has, by dint of major effort over the last decade, risen to the top level of hospitals on most measures of quality of care. It has high patient satisfaction levels. Its census has gone up as most other area hospitals’ have gone down, and not with uninsured people (despite its name, and the fact that it is owned by a “quasi-public” board, it is not funded by state or local government for patient care). However, it does pursue the most profitable “product lines” of cancer, heart disease, and increasingly neurosurgery. It supports physicians who practice in specialties that bring in large dollars. It worries, in a narrow sense, about Medicare reimbursement, but in this way is demonstrating the most “inside the box” thinking.

So, while the integrated health systems of Mayo, Geisinger, and Bassett can work very efficiently, and even satisfy doctors on salaries, taking (perhaps) a loss on primary care but making it back on (to some degree) cost-savings or (to a larger degree) specialist and hospital reimbursement down the most are the dominant players in their market; big organizations in small towns. To make this work in larger communities, to make New York or Los Angeles or Boston or Chicago or Kansas City have health systems that look more like Cooperstown, NY than McAllen, TX (see this blog “Medicare costs: all politics are local”, June 11, 2009) is going require government policies that encourage communities, as well as individual health systems, to provide all the kinds of care needed by people in the community to all the members of the community who need it, rather than trying to cherry-pick people based on insurance status or diseases based on profitable reimbursement policies. As important, it will require incentives (or disincentives) to competition that creates unnecessary excess capacity in a community, but rather replicate the efficiencies that exist in the smaller-community systems in which Mayo, Geisinger, and Bassett are located.

To make this happen can be either simple or complicated. Simple would be learning from both other countries and from our own varied experiences in the United States. We would authorize hospitals and hospital systems to provide specialty services only to the extent that they are needed in the community (because existing services are inadequate in volume or quality) and not because “if we make a prettier cancer center we can steal the patients currently getting perfectly fine care elsewhere to come to us”. We would make hospitals operate within a negotiated global budget, which had separate operating and capital budgets (so they couldn’t scrimp on your operating budget to save money to buy new equipment), so they could allocate their resources to most effectively meeting community needs. We would decrease the incentives to do unnecessary excess procedures, while ensuring that the cost of necessary procedures are covered.

We would decrease (possibly through salary, although it can be done using other strategies, such as a single-payer system) the enormous income differences between specialties so that students enter the specialties that people will need rather than those of financial opportunity. We can have a coordinated system that has control and can encourage of desirable new technologies, use of evidence-based methods and interventions, and control of excess. Contrary to what the University of Kansas Hospital says in its “White Paper”, having EVERYONE in Medicare would be absolutely the BEST solution, as part of an overall health reform plan. Yes, current Medicare reimbursement for some services would have to go up – while others would probably have to decrease – but it would put everyone in the same situation where we had a logical and coordinated basis for payment, and would eliminate the current evils of providing some services rather than others, or marketing to some people rather than others, based upon the reimbursement for one or the insurance status of the other.

Complicated would be the way that we are trying now. Which makes more sense?

Thursday, July 16, 2009

Fetal Monitoring: Why it will continue

The July 7, 2009 edition of Jane Brody’s superb column, “Personal Health”, in the New York Times , “Updating a standard: fetal monitoring” addresses the use of obstetric ultrasound, fetal heart rate monitoring, and other methods of diagnosis of prenatal fetal vulnerability. She notes that while this was hoped to reduce the risk of cerebral palsy and infant death when it was introduced in the 1970s, it was, said Dr. George Macones of the Washington University in St. Louis, a “…technology… rolled out before we knew whether it worked or not.”

Although she notes that fetal monitoring and has been adopted so widely that it is used in more than 85% of deliveries, Brody notes that:

“…experts report that the use of fetal monitoring has produced both negative and positive results, including these:
· Electronic monitoring has led to a significant increase in both Caesarean deliveries and forceps vaginal deliveries.
· Monitoring results are widely used by lawyers to bolster malpractice cases of spurious merit, which has led to soaring costs for malpractice insurance and, in turn, prompted many obstetricians to stop delivering babies.
· Electronic monitoring has not reduced the risk of either cerebral palsy or fetal deaths.”

Pardon me, but which of these are the positives?

I don’t mean to suggest by any means that there is no indication for either prenatal ultrasound or intrapartum fetal monitoring. But it would be nice to have data that it actually achieved the goals – reduction in the rates of cerebral palsy and fetal death – that it was developed and implemented to achieve. Is it possible that it has, but this has not been recognized because, as a result of some unidentified factor or factors, the rates of both would have gone up if not for fetal monitoring? I suppose so, but this is even harder to prove.

What this does demonstrate is how difficult it is to challenge the use of a technology that has become widespread, that makes teleologic sense, and is, in the opinions of most of the experts who use it, a good thing. Once a test or technology has been in widespread use for a long time, it is difficult to subject it to objective assessment. Fetal monitoring is even more difficult than most, involving, as it does, fetuses and newborns. Even though we know that “Electronic monitoring has not reduced the risk of either cerebral palsy or fetal deaths,” to test it would require the use of a comparison group of pregnancies in which babies were randomly assigned to be monitored or not, and outcomes assessed. Who is going to do that when the outcome could be a dead or severely handicapped infant? If “Monitoring results are widely used by lawyers to bolster malpractice cases of spurious merit" imagine the lawsuits that would happen when the first baby who was not monitored died or was born with cerebral palsy. Not to mention how you would feel if it was your baby who was not monitored and had a bad outcome. No one is going to do such a test.

So we will continue to use expensive, and invasive technologies, with some potential risk from excess Caesarean sections (although there are many who believe that these are as safe as vaginal deliveries, and that patient preference for one is an adequate indication; this is another discussion), even though we are not sure that it does anything beneficial.

Thus goes medicine.

Sunday, July 12, 2009

The Primary Care Extension Service


The heath reform bill that will come out of the Senate HELP Committee looks to be seriously flawed, although it will include a public option. The New York Times reports that after “The health committee’s blueprint builds on an incomplete version that was much criticized two weeks ago when the Congressional Budget Office reported that it would cost more than $1 trillion over 10 years and still leave up to 37 million Americans uninsured….Senator Edward M. Kennedy of Massachusetts, the health committee chairman, and Senator Christopher J. Dodd of Connecticut subsequently filled in details of the plan and scaled back subsidies that would help low-income people buy insurance.”

Super. So in response to an inadequate bill that cost too much, they will cut the subsidies to the poorest Americans, likely leading to “coverage” that will be grossly inadequate, rather than cut the subsidies to the insurance industry by creating a single-payer plan that, as I have repeatedly pointed out, would cover everyone and cost much less. The savings would be in part in insurance company profit, but much more in the elimination of the enormous bureaucratic infrastructure that providers must have in place to bill and collect from insurance companies whose corporate goal is to pay as little as possible while avoiding covering those who really need it – the seriously ill. There could be little more inimical to the public’s health than a system run by insurance companies whose goal is not to spend more in the most efficient way possible to get maximal health for the population, but rather to game the system in such a way as to collect maximal premiums while paying out as little as they can get away with, even if that means “rescissions” of coverage – cutting people off when they get sick, as pointed out in the testimony of former CIGNA executive Wendell Potter before the Senate Commerce, Science, and Transportation Committee June 24
While the HELP Committee proposal will include a public plan, it will not significantly save money because the billing and collecting infrastructure will have to remain. In addition, it is likely that the insurance companies will continue to be happy to allow the public sector to cover the highest risk, sickest people – which will make it look less “efficient” and increase the cost.

However, there is at least one VERY good part to the HELP Bill. This is Section 455, p 572, which calls for the establishment of Primary Care Health Extension Services. Obviously based on the enormously successful Cooperative Agricultural Extension Services, run by states usually through their land-grant university, such services would work to enhance the primary care infrastructure in rural areas by consultation and assistance in development of efficient operation, electronic health records, collaborative practice, and other areas which small rural practices usually lack the size to implement. “The Primary Care Extension Program shall provide support and assistance to primary care providers to educate providers about preventive medicine, health promotion, chronic disease management, mental health services, and evidence-based and evidence-informed therapies and techniques, in order to enable providers to incorporate such matters into their practice and to improve community health by working with community-based health connectors…” (referred to in this section as Health Extension Agents’).” The Health Extension Agent “…means any local, community-based health worker who facilitates and provides assistance to primary care practices by implementing quality improvement or system redesign, incorporating the principles of the patient-centered medical home to provide high-quality, effective, efficient, and safe primary care and to provide guidance to patients in culturally and linguistically appropriate ways, and linking practices to diverse health system resources.” This is definitely an idea whose time has come; using the Agricultural Extension model for support of primary care makes perfect sense.

Some such programs have already been piloted in a variety of states, including New Mexico, Oklahoma, and North Carolina, or regions, such as northern California. These programs are discussed in a recent JAMA article by Grumbach and Mold[1], which also contains much of the justification for their use . One model, New Mexico’s Health Extension Rural Offices (HEROs) were explicitly “…developed to improve community health and have close ties with the existing US Department of Agriculture extension service. HEROs are a partnership among the University of New Mexico’s Office for Community Health, New Mexico State University extension offices, County Health Councils, the state’s AHECs, community health centers, the Indian Health Service, community hospitals, rural family medicine residency programs, and a primary care practice– based research network. HEROs are strategically located in underserved rural counties and use county health report cards to guide interventions to address the primary determinants of health and illness.” These county health report cards, available at, provide an excellent model for understanding community health status and the programs that might be developed to address them.

In addition, the HEROs programs emphasize the use of these health extensions to develop primary care workforce education pipeline programs.The 4-H program, a large part of most cooperative agricultural extension programs, is a great model for health careers pipeline programs. To physicians and other health care providers in underserved rural (as well as urban) areas, we are going to need to both create and maintain interest among young people in these areas, convince them that they can become health professionals, and develop strong programs for academic and social support that they will need to be successful. Along with the support for rural practices, the “county” (or multi-county) Health Extension agents can harness the enthusiasm of rural youth, their knowledge of genetics based on livestock breeding, and their interest in serving their communities. The communities themselves will certainly be enthusiastic supporters of such efforts.

Whatever the other limitations of the HELP committee bill may be, its recognition of an support for the patient-centered primary care medical home, and the development of primary care extension services to facilitate them, along with enhanced educational pipeline programs for health careers, are extremely important and creative advances in enhancing the health of the public.

[1] Grumbach K, Mold JW, “A health care cooperative extension service: transforming primary care and community health”, JAMA 2009;301(24):2589-91.

Wednesday, July 8, 2009

Proposals to Tax Health Benefits and Institute Individual Mandates

The July 2, 2009 issue of the New England Journal of Medicine includes a larger-than-usual number of ”Perspectives” articles. Two directly relate to current health-reform efforts. Jonathan Gruber, of MIT, in “A win-win approach to financing health care reform”,, argues that the cost can be met by eliminating (or reducing) the tax subsidy on employee health benefits. He notes that the loss to the federal government in taxes that occurs because employees do not pay tax on employer contributions to health insurance as they would on regular income amounts to $250 billion a year. He cites 3 flaws: that we could use the money, to expand health care access, among other things, that this is a regressive tax break with greater benefit going to those in higher income brackets (and therefore usually higher tax brackets, as well as often more expensive coverage), and that it undervalues the cost of health care compared to other goods, encouraging over-utilization. This last depends on what you mean by “over-utilization” , but, as I noted on July 5, most identified “over-utilizations” (e.g., going to the doctor for a cold) are not big cost-drivers. The high costs are for services that, for the recipient anyway, seem very important. The waste in these costs is when untested or inadequately evaluated or even evaluated-and-found-to-be-ineffective therapies are applied. (This involves comparative-effectiveness research, and is the subject of two other “Perspectives” in this issue,,, and has been addressed by me previously, on May 12, 2009). The other two make some sense.

Gruber then identifies 4 “counterarguments”, and goes on to counter them. Of these, the first is technical (how it could be done administratively) but the others are important. The first (or second, I guess) is that high-risk groups who now can get group insurance would have more difficulty. He states that this would be eliminated with a new form of health coverage for all. It would be, but this would have to be a conscious effort. Too often in legislation a protection is lost with a “plan” to provide it in another way that is never, in fact, implemented. His next “counterargument” is that it would be in effect a tax increase. Yes, he says, but this could be done in a manner that exempts lower-income workers from the tax, and is thus a more progressive tax. Not a bad idea, but again, it would have to specifically include this plan. His final “counterargument” is that it would be unfair to those living in regions with a higher cost of health care (thus higher premiums to be taxed) or those with an older workforce. He suggests a simple adjustment factor.

The cost of the tax break on employer-paid health insurance benefits is important. It is one of the components of the costs currently borne by government (along with Medicare, Medicaid, coverage for federal, state and local government employees, and VA) that collectively account for more than half of all health spending, and would be enough to cover everyone under a single-payer system. And that is how it should be used. To eliminate while continuing a plan that is based on employer-purchased (from a for-profit company) insurance absolutely does run the risks that Gruber has tried to address.

In another perspective, Linda J. Blumberg and John Holahan, from the Urban Institute, advocate for individual mandates; this is the method adopted in Massachusetts, which requires everyone to buy a health insurance policy and (presumably) subsidizes the cost for the poor. Their piece, “The individual mandate – an affordable and fair approach to achieving universal coverage”,, starts by criticizing the practices of insurance companies, which of course are encouraged by the entire process of health insurance underwriting and financial incentives:

“Health insurers engage in many practices that make it difficult for people with health problems to obtain and maintain their coverage; they do so for the express purpose of protecting themselves from the potentially enormous financial consequences of adverse selection. Adverse selection entails the disproportionate enrollment in insurance plans of people with higher-than-average health risk. There is a natural tendency for such selection to occur, because people prefer to pay for coverage only when they think they will need health care services. Insurance pools cannot be stable over time, nor can insurers remain financially viable, if people enroll only when their costs are expected to be high. Consequently, insurers create, and regulators permit, structured barriers against such behavior, including such policies as exclusion periods for coverage of preexisting conditions, benefit riders that permanently exclude particular types of care, higher premium rates or cost-sharing requirements for people with health problems, and outright denials of coverage.”

So insurance companies do a whole lot of awful things, but it the fault of those people who will not buy insurance until they are sick. Maybe this is a part, but it is also because they are trying to make as much money as possible, as opposed to provide needed health care for people. Blumberg and Holahan state that, by requiring everyone to buy insurance (with subsidies for the poor) all this need for adverse practices will disappear. They go on and on, talking about (let us remember Gruber, above) how this will – if it is enforced – work. Complexly. As they note,
The cost of subsidies will be relatively high, but most subsidies will go to benefit the poorest and sickest — those who are most likely to enroll on a voluntary basis. Thus, a mandate will tend to bring healthier people and those with higher incomes into the system at a relatively low incremental cost, as compared with a voluntary approach — and with the added benefit of government financing redirected from the programs that currently cover uncompensated care.”
Or – we could just have a single payer system.

Blumberg and Holahan say “Enforcement is the final issue.” They suggest that, like Massachusetts, the federal government enact a penalty – “equal to half the lowest available premium” – for people who don’t buy coverage. And, to show that they are not hard-hearted, they “…believe that those who do not enroll in a qualified plan should receive care when it is sought (as if they were enrolled) but should then have to pay back-premiums for the calendar year, plus a penalty, possibly as much as 25%.” Sweet. And what if they can’t? After all, it’s worked in Massachusetts – oh yeah, it doesn’t. Lots of people are not getting coverage, those that do can’t get an appointment to see a doctor, and those that get penalized are paying penalties far in excess of much more serious crimes – if they are individuals. Of course, if they are companies, the penalty is a fraction of the cost of actually buying employees health insurance.

Why are all these people coming up with such stuff? Why do they torture themselves – and us – by complex mathematical calculations and mandates and penalties? The answer is in their last sentence: “In our view, an enforceable individual mandate, with adequate subsidies and benefits, as well as a choice of plans, is the most politically feasible route to universal coverage in the United States today.” That is, they don’t think a rational, cost-effective plan that will cover everybody and save money – a single-payer plan – can get enacted. Now if there were only some leadership, we might actually be able to do something rational.


Sunday, July 5, 2009

European vs. US Health Systems: Which one has the real drawbacks?

An Associated Press story that appeared in the New York Times on Independence Day, July 4, 2009 titled “Europe's Free, State-Run Health Care Has Drawbacks”, tries to be a cautionary piece about going too far with health reform. It starts:
“As PresidentBarack Obama pushes to overhaul the American health care system, the role of government is at the heart of the debate. In Europe, free, state-run health care is a given.
The concept has been enshrined in Europe for generations. Health systems are built so inclusive that even illegal immigrants are entitled to free treatment beyond just emergency care. Europeans have some of the world's best hospitals
and have made great strides in fighting problems like obesity and heart disease.”

Sounds pretty good to me. No problems yet. Then the warning:
“But the system is far from perfect.” We knew it. Let’s hear about those problems:
In Britain, France, Switzerland and elsewhere, public health systems have become political punching bags for opposition parties, costs have skyrocketed and in some cases, patients have needlessly suffered and died.”

Excuse me? These are supposed to be problems with Europe? These are also problems in the United States, the main differences being 1) scope – how bad and extensive these problems are (worse in the US than in Europe), and 2) intent – who are we trying to cover (them: everyone; us: some people. Certainly including the policymakers).

Let’s deal with these one at a time:

“Public health systems have become political punching bags for opposition parties…” Of course. Everything is. But in Europe, even those criticisms address the edges of the system; no significant political group in any of those countries is suggesting the abandonment of government-guaranteed to coverage and access to care. In the US, in contrast, the opposition (Republicans) has taken essentially no position except to say “no”. The Republican position on health reform reminds one of nothing so much as a 2-year old who can only utter that one syllable but is completely incapable of coming up with a positive suggestion. Of course, they have limited options since the administration and the Democratic leadership of the Senate have committed themselves to building the sacred for-profit insurance industry into their own health reform proposals. They can still oppose the public option (remember, there is nothing that they are actually for) and repeat the party-talking-points of “government run health care” and “government bureaucrats getting between you and your doctor” so often that they should be paid by the “Daily Show” for supplying Jon Stewart with some of his funniest clips. But as I discussed in my letter to Senator Brownback (June 24, 2009), this is nonsense. There is no way that government bureaucrats could hold a candle to insurance company bureaucrats, and at least in theory they are working for the public and have as their mission the funding of health care, not making profit. And no one is proposing government-run health care (although, despite occasional horrors like the VA urologist in Philadelphia, the VA and the military hold up pretty well to the private sector!), but rather government-financed health care. And government is pretty efficient about paying -- you know anyone who has complained about not getting their Social Security check lately? And – sadly to my mind – there will continue to be a grossly-subsidized “private option” that will be allowed to profitably skim the healthy people and leave the old and sick to the public sector.

“Costs have skyrocketed”. Yes. Costs have skyrocketed around the world, largely as a result of the increased availability of high-cost technological interventions. But nowhere have they increased anywhere near as much as in the US. The article states: “The U.S. already spends the most worldwide on health care. According to the Organization for Economic Co-operation and Development, the U.S. spent $7,290 per person in 2007, while Britain spent $2,992 and France spent $3,601.” Doing the arithmetic, the US spent, per capita, twice as much as France and two-and-a-half times as much as Britain. Which system has a problem with cost control? And, of course, something that cannot possibly be repeated too often, as it is the core, most important point of the discussion, those countries cover everyone and in the US we only cover some people – and every year that is both a decreasing percent and worse coverage for those who are left in. And per the World Health Organization (WHO), they have far better health outcomes than does the US,

“In some cases, patients have needlessly suffered and died.” A particular, and very serious example is given: “More serious problems in Britain's health care were reported last month, when cancer researchers announced that as many as 15,000 people over age 75 were dying prematurely from cancer every year. Experts said those deaths could have been avoided if those patients had been diagnosed and treated earlier.” This is indeed serious, but the issue at fault is not that the government controls health care, but rather that it would have cost more money. See above – Britain spends less than half of what the US spends per capita on health care. If they are to not have such health care deficiencies for their population, they are going to need to spend more, if nowhere near the amount the US spends. People need to understand the difference between how much is spent on health care (probably too little there, too much here) and how those funds are distributed (very inequitably here, much more equitably there). And, of course, there is no comparison to the US and no context. The BBC article presenting this news,, indicates that the calculations were done assuming the outcomes of Western Europe for those 75-84 and those of the US for people 85 and older. Note that this population of Americans are covered by a single-payer health care system: Medicare. By contrast, the Institutes of Medicine (IOM) of the National Academy of Sciences in the US, estimated in 2004 that there were 18,000 excess deaths in this country in people 18-64 (a group with a far lower death rate than those 75 and over) as a result of lack of insurance

Data from Britain and other European countries are population based, looking at the impact on all people. Too often, reports of “excellent” health outcomes in the US are severely skewed by looking only at the people who have had access to and received treatment. By excluding those who never get care, we grossly underestimate the horrible results of having a huge population without access.

Of course, this population does not, and will never, include those who make critical comments of systems that cover everyone. These comments are often specious and, even when true, are largely irrelevant. An excellent example is that from Dr. Alphonse Crespo, an orthopedic surgeon and research director at Switzerland's Institut Constant de Rebecque, quoted in the AP article: ''The minute you make health insurance mandatory, people start overusing it…If I have a cold, I might go see a doctor because I am already paying a health insurance premium.” This true, but scurrilous, assertion is flawed on two major counts. The classic RAND corporation study of health insurance done in the 1970s and published in 1982 demonstrated conclusively that people who have higher out-of-pocket costs, such as copayments do access care less often for minor problems, like colds, than those who do not. But they also access care far less often for major problems, like cardiac disease, diabetes and hypertension, which is much more significant, and has much more serious negative effects upon both cost and health, when these people end up receiving care at late stages of their diseases Lots of people, even those who know or should know that there is no effective treatment, go see doctors when their symptoms are bad enough, but all of them together do not account for a significant part of health care costs. These costs are driven by those with conditions most people who agree do need treatment. It is worthy repeating what Dr. Robert Ferrer noted in this blog on May 8, 2009:

The healthiest half of Americans accounts for only 3% of health care expenditures. Conversely, the sickest 5% account for 55% of expenditures and the sickest 10% for 70% of expenditures. So most health spending isn't folks with a cold or twisted ankle who run to the doctor. Most health spending is NICU babies and 20 year-olds with massive trauma from car accidents and cancer patients and old folks with congestive heart failure and 5 hospitalizations in the last year.”

Whatever the problems being confronted by European health systems, largely driven by underfunding and the rising cost of high-technology care, they pale compared to those in the US. For starters, and for finishers, they cover everybody. Until the US has a health care system that does, and does so equitably, it is not even on the same page. If we are to take the real lesson from this AP article, it is in the quote from Princeton health economist Uwe Reinhardt: ''These countries are in some way an inspiration for our reforms…All of these countries somehow manage to assess risk and compensate for it ... we could learn from that”

Yes. But the question is: Will we?

Wednesday, July 1, 2009

Stonewall: 40 years Later

This Sunday was the 40th anniversary of the “Stonewall riots” that occurred in Greenwich Village in New York City in 1969. Gay bar patrons suddenly, unexpectedly, fought back against the police harassment that had become routine. The 48 hours of that weekend are credited with beginning the gay rights movement. There has been a great deal of coverage of this anniversary in the press; President Obama has invited gay leaders to the White House for a commemoration. Of course, this coverage has far exceeded the coverage that occurred that weekend and the days following the actual events. With the exception of the Village Voice, the story was buried in the interior of the city’s, and nation’s, papers. In an op-ed piece in the New York Times on June 25, 2009 (, reporter Lucian Truscott IV describes his coverage as a summer intern for the Voice who, as “perhaps the unlikeliest person in the world to cover the Stonewall riots for The Village Voice…” having “… graduated from West Point only three weeks earlier and was spending my summer leave in New York before reporting for duty at Fort Benning” and says that the raids, by the NYPD Morals Unit (!!), was not a generalized crackdown against gay bars, but against Mafia-run bars. Of course, all the gay bars were mob-run.

The brave young men who decided to stand up against this harassment were not the established “leaders” of the gay community in Greenwich Village (Truscott says “I was there on the Saturday and Sunday nights when the Village’s established gay community, having heard about the incidents of Friday night, rushed back from vacation rentals on Fire Island and elsewhere. Although several older activists participated in the riots, most stood on the edges and watched.”) It is rarely the established leaders who create the breakthroughs in any movement, for they have too much to lose. In the film “Milk”, which portrays a period in San Francisco some years after Stonewall, the activism of Harvey Milk and his friends and followers are seen as threatening to gay leaders, who do not initially support him.

Nor were these rioters the “gay contingent” of the young radical college students of the day. Rather, they were young men, largely working-class, many of them living on the streets or in slums, who had come to the Village from the whole of Greater New York. In many cases, they had been turned out of their houses by their families; in virtually all cases they were seeking a place where they could openly be themselves. The police were shocked, the gay leaders were shocked, the community was shocked, and the mainstream media closed their eyes.

And for many those eyes, and the eyes of our government, are still closed. Forty years later, while there have been many great advances in the rights of gays (no longer is the practice of gay sex punishable by castration in many state!), we are still not yet at the only place it is fair, reasonable, or moral to be.

More than 75% of our people support the rights of gays to serve in the military but we still have “Don’t ask, don’t tell” (and it would be wrong if it were only 10%!). In May 2009, Dan Choi, an Army officer and West Point graduate who was an Arabic translator was dismissed from the Army after opening identifying himself as gay. Comedian Jon Stewart famously commented: “So it was okay to waterboard a guy 80 times but God forbid the guy who could understand what that prick was saying has a boyfriend? Waterboarding may make a prisoner talk, but it ain't gonna make him talk English."

But Choi was not the first. Military Arabic translator Alistair Gamble discussed his firing in a New York Times Op-Ed piece on November 29, 2002, and Stephen Benjamin described his in another Times Op-Ed on June 8, 2007. Times reporter Nathaniel Frank has followed the story, with two long articles, one describing the firing of nine translators on November 28, 2003, and another followup after Choi’s dismissal on March 18, 2009.

Six states have legalized gay marriage, but the federal Defense of Marriage Act (DOMA), first enacted under President Clinton, is still in effect defining marriage as between a man and a woman, and the Obama administration’s Justice Department has filed a brief supporting it. Not all politicians who are supporters of DOMA and opponents of gay rights are nauseating hypocrites like Nevada Senator John Ensign and South Carolina Governor Mark Sanford, but these two, like many others, demonstrate that if heterosexual marriage needs protection it is not from loving gay couples who wish, against all rules, to demonstrate their commitment to each other through marriage. Let me be clear – what makes Ensign and Sanford and their ilk slime is not their extramarital affairs, which from my point of view is an issue between them and their families, but their vicious hypocrisy in preaching “family” and opposing gay marriage while carrying on in ways that clearly demonstrate that they are driven only by their own phallic narcissism.

We have a long way to go before gay people in the United States have been granted their full civil rights, but make no mistake – there is only one OK, moral and acceptable outcome. That is full, non-contingent, civil rights for all people. Including gay people.

Sure there are a lot of people who don’t approve of, don’t like, or are scared of gayness and gay people. There are also racists, religious bigots, and misogynists. That doesn’t make it OK, or supportable in any way by our society. Forty years after Stonewall we must finally put to rest the unconscionable laws and policies that discriminate against people because of their sexual orientation.

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