We are moving in the wrong direction: the health care crisis and American hubris

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The passion for democracy and liberation from tyranny continues to spread across the Middle East, with major actions (and reactions from dictators) taking place in Bahrain, Yemen, Libya and even Iran. While decades of US foreign policy has focused on supporting these dictators while talking democracy, the people in these countries are looking at the US as a model, not of foreign policy, but of democracy. They may have economic interests, but -- in Libya, for sure, they are willing to die for freedom. Finally, our President, from whom we (and they) had expected great things, is speaking on behalf of freedom.

However, as I wrote last week, things are moving in the wrong direction in the US itself, where right-wing zealots funded by billionaires have taken over not just Congress but the legislatures of many states. Wisconsin is the prime example of an attempt, which may yet be successful, to strip the basic rights of labor unions to organize and fight for their members, a class war thinly veiled by statements of fiscal responsibility negated by the fact that the unions have already agreed to the financial cuts. On NPR’s Morning Edition on Feb 21, 2011 Steve Inskeep,the host interviewing Senate President Scott Fitzgerald, who is carrying the water for Gov. Scott Walker’s bill, could barely contain his irritation as Sen. Fitzgerald kept dodging the questions, reiterating boilerplate talking points rather than answering.

And we are not doing so well. In Empire at the End of Decadence (NY Times, Feb 18, 2011), Charles Blow provides a stunning graphic chart comparing the United States to other countries in the developed world across a variety of areas on which we do, or should, pride ourselves. We don’t come out very well. Among the International Monetary Fund’s (IMF) 33 advanced countries, we are not in the best in any of the 9 areas. We are dead last in prison population per 100,000 (745, more than twice 2nd place Israel’s 325), and tied for worst, with Korea, with 16% of people indicating that they had not enough money for food in the last year. In the only direct health measure, life expectancy at birth, we are, at 78.24 years, ahead of only 5 of the other 32 countries; Slovakia at 75.62, is the lowest, and Taiwan is jus t behind us at 78.15 (the other 3 are Slovenia, Cyprus, and the Czech Republic).

While Republicans rant about individual mandates and repealing “Obamacare”, the health insurance crisis is not over. In the New York Times, Feb 20, 2011, Donna Dubinsky wrote “Money won’t buy you health insurance”. This “co-founder of Palm Computer and Handspring, is the chief executive of a computer software company” describes the difficulty that she had in obtaining insurance on the private market despite being quite well-to-do when neither she nor her husband worked for a large company any more. After being denied coverage at all because of “pre-existing conditions” (“For me, it was a corn on my toe for which my podiatrist had recommended an in-office procedure. My daughter was denied because she takes regular medication for a common teenage issue. My husband was denied because his ophthalmologist had identified a slow-growing cataract,” she finally found a company that would insure them at a high rate with a high deductible, and the rates have continued to rise although they pay (because of the deductible) most of the bills themselves.

The point is not that she is in tough straits. I am sure Ms. Dubinsky would agree that there are a lot of people who we should have a lot more sympathy for than her; people who are homeless and jobless and hungry, and millions more who are on the verge of becoming so. And yet there are many who continue to see the uninsured as “other”, the “them”, rather than the “me and my neighbors”, despite the fact that many of their neighbors, and relative, and friends, must be in this boat. Ms. Dubinsky’s article points out, if there were any more evidence needed, that insurance companies are greedy and absolutely not to be trusted with the health care of the American people. The Affordable Care Act, (ACA) mandates individuals to purchase health insurance, ostensibly the objection of the Republican right (who are presumably either well insured or healthy and optimists), which was the only way the insurance companies would buy in: they basically said “We can only allow no underwriting (denying insurance to people they assess as too high a risk) this if you make everyone buy insurance.”

Should you even think for a moment that for-profit insurance companies are anything but self-serving, it is worth looking at Jacob S. Hacker and Carl DeTorres’ scorecard, The Health of Reform (NY Times, Feb 17.2011). They grade the ACA in Rollout, Reaction, and Results and give the overall program so far a “B”. The reaction of the insurance companies gets a “C”: “Eager to have millions of new private customers, the big private plans and their lobby are against repeal. Still, they spent tens of millions of dollars supporting the anti-reform candidates in the elections and are fighting key consumer protections and cost controls”.

Paul Krugman is generally a supporter of the ACA health plan, believing that it actually will be a major step to addressing our fiscal problems. “What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue. “He continues (Willie Sutton Wept, NY Times, Feb 18, 2011),
“What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue….What would real action on health look like? Well, it might include things like giving an independent commission the power to ensure that Medicare only pays for procedures with real medical value; rewarding health care providers for delivering quality care rather than simply paying a fixed sum for every procedure; limiting the tax deductibility of private insurance plans; and so on. And what do these things have in common? They’re all in last year’s health reform bill. That’s why I say that Mr. Obama gets too little credit. He has done more to rein in long-run deficits than any previous president. And if his opponents were serious about those deficits, they’d be backing his actions and calling for more; instead, they’ve been screaming about death panels.”
So, while the President’s plan might be criticized for being a giveaway to insurance companies, the right is attacking it for all the things it actually does well!

Dubinsky ends her article “If members of Congress feel so strongly about undoing this important legislation, perhaps we should stop providing them with health insurance. Let’s credit their pay for the amount that has been paid by the taxpayers, and let them try to buy health insurance in the individual market. My bet is that they all would be denied. Health insurance reform might suddenly not seem to them like such a bad idea.”

Maybe, but some folks have no shame. It is not a bad idea, it is, as Krugman demonstrates, a pretty good idea from an economic as well as health standpoint. And Blow may be right when he says that, rather than confront the realities of developing a population with the health and education to compete in a global economy, too many people “…would prefer to continue to bathe in platitudes about America’s greatness, to view our eroding empire through the gauzy vapors of past grandeur.”

That is not a conceit that we can afford.

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Universal Health Insurance or Universal Quality Health Care?

Jonathan Gruber, an MIT economist, has a piece in the January 29 issue of the New England Journal of Medicine entitled “Universal Health Insurance Coverage or Economic Relief – A False Choice”.[1] He clearly delineates the case for proceeding with health reform even in – perhaps especially in – these difficult economic times. He argues that rather than “Universal coverage…” being “…a luxury that we must do without in order to make way for other programs that will stimulate the economy”, that it is not only necessary for people’s health, but will in itself stimulate the economy. He suggests that “broad subsidies that make affordable health insurance available to lower-income families would improve not only the health of these families but the health of our economy, by freeing up funds that the families could spend on other consumer goods.”

Other ways it would stimulate the economy include elimination of “job lock”, the common (he states as much as 25%) circumstance in which people are afraid to leave their jobs, even for new and exciting opportunities (and “the most productive positions”), for fear of losing their health insurance, especially when they have pre-existing conditions. He notes that universal health insurance, if it required electronic health records and other methods of information sharing, would also be a great economic stimulus to the information technology industry. He cites the “white paper” issued by Sen. Baucus (D-MT), calling for dramatic investment in primary and preventive care, and the creation of the “patient centered medical home”, both things I have written about and strongly supported in previous posts. Finally, he discusses how having universal health coverage will allow us to focus on controlling spiraling health care costs: “I have witnessed this effect firsthand in Massachusetts, where for years our advocacy community focused exclusively on expanding coverage for medical expenditures and therefore opposed most initiatives that might have put that goals at risk, even those that might have meant controlling costs. Since Massachusetts passed its universal-coverage plan, this powerful advocacy community has shifted its attention to controlling costs as a means of preserving the program’s affordability to the state.”

These are all important points, and Dr. Gruber’s case for moving ahead with health reform as expeditiously as possible is on target. However, his position is inadequate, incomplete, and likely doomed to not achieve the goals he articulates because of several major misconceptions or issues insufficiently thought through. While his endorsing primary care and prevention is great, he goes on to state that “Such an approach would shift the focus of the health care system from specialists to preventive care practitioners with much lower barriers to entry, such as those for nurse practitioners and registered nurses.” This is a deeply flawed concept on several levels.

First, there is a major qualitative distinction between the skill set and practice role of registered nurses and nurse practitioners. Glossing over this is the most obvious indication of a fantastic lack of understanding of medical care and health care delivery. As documented by my guest author Robert Bowman in the January 15 entry “Ten Biggest Myths Regarding Primary Care in the Future”, nurse practitioners do not provide enough “standard primary care years” of practice to meet our needs, and without a more comprehensive approach to addressing the primary care/subspecialist imbalance, NPs (and physicians’ assistants) are likely to continue to move from primary care into higher-paying positions in subspecialty care. This leads to the third flaw, the idea that we can increase the number of practitioners in the primary care / preventive specialties without limiting the production of subspecialists. These “partialists” are paid an enormous amount for caring for “pieces” of people and are paid especially well for providing procedures, many of which involve mainly psychomotor rather than cognitive skill. Not every procedure is “brain surgery”; many are routine activities that could easily be done by technicians trained at a community college level (as are X-ray and laboratory technicians). However, they are so highly reimbursed that there is great pressure to 1) keep the entry level high (physician subspecialist), and 2) increase the volume of these procedures – many studies have demonstrated that in the weird inverted “market” of medical care, it is the availability of subspecialists and technology that drive demand rather than vice versa. Only by dramatically decreasing the financial incentives to enter subspecialties while increasing incentives to enter primary care can we reach the proper ratio of primary care to subspecialty care providers. (If our goal is to have 50% primary care providers, while we currently have 30% or less, we will need to have a much greater than 50% primary care provider output or it will be more than 30 years before we achieve this goal.)

Finally, Gruber’s flip comment plays directly into the idea, entrenched in the medical profession and medical trainees, that subspecialties, because they earn so much more, require greater skill and intelligence and thus merit higher “barriers to entry” than primary care. This is absolutely not so. In addition to the issue of high reimbursement for relatively simple psychomotor procedures noted above, “partialists” only care for one aspect of a person’s health. Thus, an individual’s care is not only spreading among many providers, increasing fragmentation, but dramatically increases cost by multiple subspecialist referrals for conditions (“I’m a cardiologist; I do hearts. If your knee hurts, see an orthopedist”). The specialty of primary care (I am aghast that Gruber is inane enough to contrast “primary care provider” and “specialist”) provides care for the whole person. Rather than managing a single condition or organ system, the primary care provider manages many chronic diseases, sometimes with help from consultants whose recommendations s/he has to coordinate and rationalize in his/her role as the primary consultant to the patient. S/he also cares for acute problems. And provides preventive care, counseling and screening. And understands the impact of the family and community of each person, and on their health and their ability to address their health needs. And “asks for trouble”, even when the patient doesn’t complain of a problem (“Are you feeling safe at home?). And, most importantly, recognizes that the role of primary consultant to the patient means working hard to understand the patient’s world-view, to speak their language, and realize that “knowing the right answer” is absolutely meaningless unless it can be translated into health benefit for the patient. This is a skill set that is exceedingly complex, difficult to develop and maintain, and requires the highest level of cognitive and interpersonal skills, and requires constantl improvement over time. In Gruber’s Massachusetts, health reform has been stymied by the insufficient number of primary care providers to care for all the newly-insured despite a wealth of subspecialist / partialists. His comments implying the simplicity of primary care do nothing to advance the quality of health care to our population, which is after all the goal of health reform -- not coverage but access to high quality care for all.

Beyond these issues with primary care, Gruber’s analysis is fatally flawed in its assumption that expanding insurance coverage – with the government paying for it – is the solution to universal coverage. He only tangentially addresses the issue once, saying “Other countries, such as the Netherlands and Switzerland, have demonstrated that it is possible to have both universal coverage (even coverage provided through private insurance companies) and much lower health care spending.” As clearly noted in T.R. Reid’s “Frontline” piece “Sick around the world”,[2] Switzerland’s insurance companies are – and were even before universal coverage – not for profit. This makes a tremendous difference.

To suggest that we should have universal coverage paid for by the government through for-profit insurance companies, is exactly equivalent to giving enormous government bailouts to the financial sector that they can use to pay stockholder dividends and executive bonuses! (Whoops, we did that!) It is absolutely wrong and misguided. It is morally and logically bankrupt, and, ultimately, financially bankrupting.

[1] Gruber J, “Universal Health Insurance Coverage or Economic Relief – A False Choice”. NEJM 29Jan,2009;360(5):437-9.
[2] http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/