.
The Sunday New York Times, August 16, 2009, has a plethora of health-reform-related articles and opinion pieces, including an op-ed by President Obama himself (ok, signed by himself), which articulately makes the case for health reform, (“Why we need health care reform”, http://www.nytimes.com/2009/08/16/opinion/16obama.html). It includes a re-statement of his most important, and correct, point: “…what’s truly scary — truly risky — is the prospect of doing nothing.” This point is driven home by the lead editorial, “Lining up for help”, http://www.nytimes.com/2009/08/16/opinion/16sun1.html?ref=opinion , which itself is a commentary on the article from August 13, 2009, “Thousands line up for promise of free health care”, http://www.nytimes.com/2009/08/13/health/13clinic.html?ref=opinion. It describes the efforts of Remote Area Medical, “…which was formed to deliver care to Indians living in remote areas of the Amazon basin…” to deliver care to thousands of people at the Forum in Inglewood in Los Angeles. Not to Indians in the Amazon, not to refugees swarming in from abroad, but to Americans living in one of our great cities.
And Los Angeles, of course, is not alone, not by any means. Barbara Shelly writes in my local Kansas City Star (http://www.kansascity.com/277/story/1381919.html), about the story about thousands of people waiting to be seen in a traveling clinic in Wise, Virginia. She talks about the Southwest Boulevard Family Health Care clinic here in Kansas City, KS, where the medical director, my friend and colleague “Dr. Sharon Lee telephones friendly specialists and pleads with them to treat her uninsured patients with potentially life-threatening conditions.” To not recognize that such situations are not only daily occurrences all over the country, but that the number of people being affected by them grows daily, that President Obama’s assertion that the worst outcome would be to keep our current non-system , is irresponsible, wrong, and when done knowingly for political gain, evil. I addressed this in a recent blog entry, “Health Care Shoutdowns: Liars and Demagogues” (August 11, 2009), and the inflammatory lies continue even as the facts show them to be such.
“In the coming weeks, the cynics and the naysayers will continue to exploit fear and concerns for political gain,” the President writes, but they already are. Sarah Lyall of the Times reports from London (“Health Care in Britain: Expat Goes for a Checkup”, Sarah Lyall, http://www.nytimes.com/2009/08/16/weekinreview/16lyall.html?scp=1&sq=ex-pat&st=cse
on the efforts of Investor’s Business Daily to disparage the health reform movement by comparing it to the British National Health Service, and stating that famed physicist Stephen Hawking, who suffers from amyotrophic lateral sclerosis (ALS, “Lou Gehrig’s Disease”) would not be able to get care if he lived in the UK. Of course, the problem is that Dr. Hawking does live in the UK, and has issued a statement saying that the NHS has kept him alive! (You can look at the link provided by Ms. Lyall, http://www.ibdeditorials.com/IBDArticles.aspx?id=333933006516877, but you won’t find IBD’s assertion there as they have pulled it from their article.)
One of the most irritating lies to me is that of the “death panels” that are called for in the administration and congressional health reform bills. Despite the fact that no such panel was ever called for in the bill, a point explicitly made by senior Republican Senator Charles Grassley when he noted that the end-of-life discussions provision had been dropped by the negotiators because of the misinterpretation of it, the liars and demagogues continue to press the point, led by former vice-presidential candidate and now-former Alaska governor, Sarah Palin: “Palin stands by ‘death panel’ claim”, (Matthew Daly, Associated Press, http://hosted.ap.org/dynamic/stories/U/US_HEALTH_CARE_END_OF_LIFE?SITE=CACRU&SECTION=HOME&TEMPLATE=DEFAULT ). Why I am particularly irritated about this is that it misrepresents a really important health care issue, one that we all need to think about: end-of-life care. It also misrepresents how decisions on limiting access to unproven treatments would be made. I have previously addressed the latter at some length (May 12, 2009, July 5, 2009), and probably will again, but today want to talk about the former.
The legislation under consideration (specifically HR 3200) said that the plan would pay for voluntary consultation with a physician about end-of-life care. We should all be thinking about end-of-life care. If and when we are diagnosed with a terminal disease, or are in extremis at the end of our lives, what do we want done? Treatments that will cure us and have us back to playing tennis? Most of us would say “You betcha!”, but this is not what we are talking about. We are talking about interventions that are done to maintain life, in its literal sense, and are sometimes successful (for a while; no one lives forever) ranging from the seemingly benign administration of nutrition in an atypical way (fluid through a vein, or liquid through a tube in the nose into the stomach or directly into the stomach), to maintaining breathing on a ventilator when there is no hope of ever being able to come off of it, to having electroshocks and chest compressions applied when your heart stops. Contrary to the portrayal on television shows, very few such cardiac resuscitations are done on relatively healthy, relatively young people who go on to survive to live normal lives. The vast, vast majority are done on terminally ill people, most do not survive the intervention, very few survive in a meaningful way – to hospital discharge, and hardly any return to their previous state of pre-hospital function.
Nonetheless, it may be that we choose to have such interventions at the end of our lives. While many of us would choose not to, might choose palliative care (the kind of care given by hospice) where we get everything we can possibly get to keep us comfortable and pain-free but not vain attempts at treatment, many of us might not. We might choose a “Living Will” that delineates what treatments we want and what treatments we don’t want, or we might not, asking for all treatments. But we should think about it, discuss it with our families and the others whose opinions we care about, including our doctors and other health care providers. We are much better off making those kinds of decisions when we are sentient, and able, than when we are unable to speak or are disoriented or in a coma.
And all of us should have a “Durable Power of Attorney for Health Care” (DPOA-HC), even those of us who are young and healthy, because, unfortunately, accidents happen. The DPOA-HC designates a specific person to make healthcare decisions for us when we are unable to do so for ourselves. This is a particularly wise idea for two reasons. One is that, while the law in most states designates an order of relations to make decisions (beginning with the legal spouse and continuing to adult children and then to adult parents) this can be a problem. The spouse may not, him or herself, be able or willing to make decisions. The children may disagree, and there is no law that says, for example, that the oldest has precedence, or that there is a vote. So it is best to designate one person, although we all hope that all of those we care for will agree. Perhaps the person you want to make the decision is a friend, a pastor, or an unmarried life partner.
The second reason is that it requires you to think about what you would want to happen in a situation where you cannot make your own decisions and to share these thoughts and discuss them with your designee (DPOA) and with others who will be involved. The DPOA is supposed to make decisions based on their understanding of what you would want, even if it is different from what they would want, and the way they understand this is for you to discuss it with them. It is also important to note that the DPOA cannot make decisions for you when you are able to make them for yourself, that it (and the Living Will, or any other “advance directives”) can be revoked by you at any time, and that it only covers health care decisions (not, for example, financial decisions).
All hospitals currently are required to ask patients when admitted if they have advance directives. This makes sense; if you’ve made these decisions, and you’re being admitted to a hospital where you hope good things will happen but they might not, you want them to know about them. Sarah Palin, as governor of Alaska, “signed a proclamation making April 16, 2008, Healthcare Decision Day with the goal to have health care professionals and others participate in a statewide effort to provide clear and consistent information about advance directives”. Most insurance companies pay for consultations with physicians about end-of-life care. Although Medicare does not, most primary care physicians do it anyway. This is altogether a good thing.
The current effort to portray advance directives as something they are not, as something bad, as euthanasia, is not only a scurrilous tactic to oppose health reform legislation, it is a terrible, terrible attack on good health care, on something we should all want to do.
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Wednesday, August 19, 2009
Sunday, August 16, 2009
Should it be a crime to be poor, or, instead, to criminalize poverty?
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Barbara Ehrenreich, in an Op-Ed piece in the NY Times on August 8, 2009, http://www.nytimes.com/2009/08/09/opinion/09ehrenreich.html?pagewanted=1&_r=2&ref=opinion, writes about the restrictive and repressive laws being passed – and enforced – against those who are the least fortunate in a country with a growing number of unfortunates. In “Is it now a crime to be poor?” she begins with the litany of penalties placed upon those who are homeless, including men like Al Szekely, a wheelchair-bound (from a bullet taken in Vietnam) veteran who lives in a homeless shelter. He was arrested –in the shelter – in a police sweep looking for outstanding warrants (don’t they have something better to do? Like arrest bankers or their congressional enablers?)
“It turned out that Mr. Szekely, who is an ordained minister and does not drink, do drugs or curse in front of ladies, did indeed have a warrant — for not appearing in court to face a charge of ‘criminal trespassing’ (for sleeping on a sidewalk in a Washington suburb). So he was dragged out of the shelter and put in jail. ‘Can you imagine?’ asked Eric Sheptock, the homeless advocate (himself a shelter resident) who introduced me to Mr. Szekely. ‘They arrested a homeless man in a shelter for being homeless.’”
Ehrenreich’s story continues, documenting the fact that arrests, for major or minor crimes – create a vicious circle. Employment is hard enough to come by these days, and if you have a criminal record it is nearly impossible. And “For the not-yet-homeless, there are two main paths to criminalization — one involving debt, and the other skin color. Anyone of any color or pre-recession financial status can fall into debt,” and the ways in which people of color are particularly victimized is both appalling and unsurprising. One of the ways in which this occurs is being ticketed – at rates of $250 to $500 – for truancy.
“According to the Los Angeles Bus Riders Union, an advocacy group, 12,000 students were ticketed for truancy in 2008. Why does the Bus Riders Union care? Because it estimates that 80 percent of the “truants,” especially those who are black or Latino, are merely late for school, thanks to the way that over-filled buses whiz by them without stopping. I met people in Los Angeles who told me they keep their children home if there’s the slightest chance of their being late. It’s an ingenious anti-truancy policy that discourages parents from sending their youngsters to school.”
I don’t mean to quote the entire Op-Ed here. Read it. But it pains me to think that there are so many people who are very close to the edge of such poverty, losing their jobs, close to it, who are involved in the anti-health-reform, anti-Obama, movement. One thing that they are not, almost entirely, is minority; they are almost all white. And they feel like victims. They feel – obviously inflamed by purely evil and corrupt parasites on talk radio and TV – that it is the “government” that is responsible for their situation, precariously close to the edge. They see the bailout of the bankers as an example of the government looking out for the wealthy and powerful – and I agree with them. But somehow, bizarrely, they can see the health reform process as again something being done by the government against them. They are wrong. They are acting against their own interests.
There have been times when the government has acted strongly against the interests of most of the American people – the Bush administration almost used that as a playbook: “What is good for the rich and screws regular people? And maybe kills their children overseas? Let’s do that!” The Obama administration is not at all without blame or complicity in this. By bringing in a bunch of Clinton administration veterans (read: “hacks”) to his administration, particularly in the area of treasury and finance, the Obama administration is accurately seen as a friend of the rich and powerful. Well, that is not a change. But they are trying to do something for all of us, to do health reform.
To make sure that all of us are covered, all of the time, whether we are working or we are not, whether we keep the same job or not, whether our employer is big and generous or small and barely surviving, whether we have a pre-existing condition or not or develop a new one, whether we are young or old. I am not a fan of the Obama / Congressional plan to include the evil empire of for-profit insurance companies in the solution, or the vain effort to try to get bipartisan support from a Republican party that is only capable of attack, and of nothing constructive. However, we need even more than the administration and Congressional Democrats are proposing. If people think (often correctly) that the government does not respond to its needs, that the people that they elect to serve and represent them are in the pockets of the big corporations, why in any possible way would they ever be able to imagine that it could be better if those corporations, responsible to no one but their shareholders, are directly in charge?
It is really scary, because it is so reminiscent of the rise of fascism. White working class people being manipulated, using the big lie[1] and racism, to act against their interests by the forces of corporate wealth.
I wrote to my senators, both Republican, both anti-health reform, and both mouthing anti-government slogans, that THEY are the government, and at least they are supposed to listen to me. Not to necessarily do what I want, but at least to listen to me and to the rest of their constituents. Private insurers have no such obligation.
I don’t think, however, that this is mainly about health insurance or health reform. It is a vicious, violent, reactionary, and racist attack by folks who feel threatened. Yes, as Barbara Ehrenreich indicates, those at the lowest rungs of the totem pole – the homeless, the really poor, and racial minorities are the first and most serious victims. But all of us are close to being victims and it is never helped by joining in attacks on the weakest. Attack the strongest. They can take it. Don’t be fooled.
[1] “All this was inspired by the principle - which is quite true in itself - that in the big lie there is always a certain force of credibility; because the broad masses of a nation are always more easily corrupted in the deeper strata of their emotional nature than consciously or voluntarily; and thus in the primitive simplicity of their minds they more readily fall victims to the big lie than the small lie, since they themselves often tell small lies in little matters but would be ashamed to resort to large-scale falsehoods. It would never come into their heads to fabricate colossal untruths, and they would not believe that others could have the impudence to distort the truth so infamously. Even though the facts which prove this to be so may be brought clearly to their minds, they will still doubt and waver and will continue to think that there may be some other explanation. For the grossly impudent lie always leaves traces behind it, even after it has been nailed down, a fact which is known to all expert liars in this world and to all who conspire together in the art of lying. These people know only too well how to use falsehood for the basest purposes. ...” , A. Hitler, Mein Kampf
Barbara Ehrenreich, in an Op-Ed piece in the NY Times on August 8, 2009, http://www.nytimes.com/2009/08/09/opinion/09ehrenreich.html?pagewanted=1&_r=2&ref=opinion, writes about the restrictive and repressive laws being passed – and enforced – against those who are the least fortunate in a country with a growing number of unfortunates. In “Is it now a crime to be poor?” she begins with the litany of penalties placed upon those who are homeless, including men like Al Szekely, a wheelchair-bound (from a bullet taken in Vietnam) veteran who lives in a homeless shelter. He was arrested –in the shelter – in a police sweep looking for outstanding warrants (don’t they have something better to do? Like arrest bankers or their congressional enablers?)
“It turned out that Mr. Szekely, who is an ordained minister and does not drink, do drugs or curse in front of ladies, did indeed have a warrant — for not appearing in court to face a charge of ‘criminal trespassing’ (for sleeping on a sidewalk in a Washington suburb). So he was dragged out of the shelter and put in jail. ‘Can you imagine?’ asked Eric Sheptock, the homeless advocate (himself a shelter resident) who introduced me to Mr. Szekely. ‘They arrested a homeless man in a shelter for being homeless.’”
Ehrenreich’s story continues, documenting the fact that arrests, for major or minor crimes – create a vicious circle. Employment is hard enough to come by these days, and if you have a criminal record it is nearly impossible. And “For the not-yet-homeless, there are two main paths to criminalization — one involving debt, and the other skin color. Anyone of any color or pre-recession financial status can fall into debt,” and the ways in which people of color are particularly victimized is both appalling and unsurprising. One of the ways in which this occurs is being ticketed – at rates of $250 to $500 – for truancy.
“According to the Los Angeles Bus Riders Union, an advocacy group, 12,000 students were ticketed for truancy in 2008. Why does the Bus Riders Union care? Because it estimates that 80 percent of the “truants,” especially those who are black or Latino, are merely late for school, thanks to the way that over-filled buses whiz by them without stopping. I met people in Los Angeles who told me they keep their children home if there’s the slightest chance of their being late. It’s an ingenious anti-truancy policy that discourages parents from sending their youngsters to school.”
I don’t mean to quote the entire Op-Ed here. Read it. But it pains me to think that there are so many people who are very close to the edge of such poverty, losing their jobs, close to it, who are involved in the anti-health-reform, anti-Obama, movement. One thing that they are not, almost entirely, is minority; they are almost all white. And they feel like victims. They feel – obviously inflamed by purely evil and corrupt parasites on talk radio and TV – that it is the “government” that is responsible for their situation, precariously close to the edge. They see the bailout of the bankers as an example of the government looking out for the wealthy and powerful – and I agree with them. But somehow, bizarrely, they can see the health reform process as again something being done by the government against them. They are wrong. They are acting against their own interests.
There have been times when the government has acted strongly against the interests of most of the American people – the Bush administration almost used that as a playbook: “What is good for the rich and screws regular people? And maybe kills their children overseas? Let’s do that!” The Obama administration is not at all without blame or complicity in this. By bringing in a bunch of Clinton administration veterans (read: “hacks”) to his administration, particularly in the area of treasury and finance, the Obama administration is accurately seen as a friend of the rich and powerful. Well, that is not a change. But they are trying to do something for all of us, to do health reform.
To make sure that all of us are covered, all of the time, whether we are working or we are not, whether we keep the same job or not, whether our employer is big and generous or small and barely surviving, whether we have a pre-existing condition or not or develop a new one, whether we are young or old. I am not a fan of the Obama / Congressional plan to include the evil empire of for-profit insurance companies in the solution, or the vain effort to try to get bipartisan support from a Republican party that is only capable of attack, and of nothing constructive. However, we need even more than the administration and Congressional Democrats are proposing. If people think (often correctly) that the government does not respond to its needs, that the people that they elect to serve and represent them are in the pockets of the big corporations, why in any possible way would they ever be able to imagine that it could be better if those corporations, responsible to no one but their shareholders, are directly in charge?
It is really scary, because it is so reminiscent of the rise of fascism. White working class people being manipulated, using the big lie[1] and racism, to act against their interests by the forces of corporate wealth.
I wrote to my senators, both Republican, both anti-health reform, and both mouthing anti-government slogans, that THEY are the government, and at least they are supposed to listen to me. Not to necessarily do what I want, but at least to listen to me and to the rest of their constituents. Private insurers have no such obligation.
I don’t think, however, that this is mainly about health insurance or health reform. It is a vicious, violent, reactionary, and racist attack by folks who feel threatened. Yes, as Barbara Ehrenreich indicates, those at the lowest rungs of the totem pole – the homeless, the really poor, and racial minorities are the first and most serious victims. But all of us are close to being victims and it is never helped by joining in attacks on the weakest. Attack the strongest. They can take it. Don’t be fooled.
[1] “All this was inspired by the principle - which is quite true in itself - that in the big lie there is always a certain force of credibility; because the broad masses of a nation are always more easily corrupted in the deeper strata of their emotional nature than consciously or voluntarily; and thus in the primitive simplicity of their minds they more readily fall victims to the big lie than the small lie, since they themselves often tell small lies in little matters but would be ashamed to resort to large-scale falsehoods. It would never come into their heads to fabricate colossal untruths, and they would not believe that others could have the impudence to distort the truth so infamously. Even though the facts which prove this to be so may be brought clearly to their minds, they will still doubt and waver and will continue to think that there may be some other explanation. For the grossly impudent lie always leaves traces behind it, even after it has been nailed down, a fact which is known to all expert liars in this world and to all who conspire together in the art of lying. These people know only too well how to use falsehood for the basest purposes. ...” , A. Hitler, Mein Kampf
Tuesday, August 11, 2009
Health Care Shoutdowns: Liars and Demagogues
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One of the striking new developments in the health reform debate is the occurrence of “shoutdowns”, where opponents of health reform, in events that obviously orchestrated, show up at appearances by Democratic Congressmen to scream against health reform (addressed by two recent articles in the NY Times, August 8, 2009, “Beyond Beltway, Health Debate turns hostile”, http://www.nytimes.com/2009/08/08/us/politics/08townhall.html?ref=weekinreview, and “Where have you gone, Joe the Citizen?” http://www.nytimes.com/2009/08/09/weekinreview/09stolberg.html?ref=politics).
According to these articles, many of the demonstrations are organized by Freedom Works, Tea Party Patriots, Sean Hannity and other well-funded right-wing groups. While freedom of speech is a good thing, preventing others from speaking, and preventing the events from occurring, is more suggestive of Brown Shirts than Americans. The conservative radio commentators, such as Hannity, O’Reilly, and Limbaugh, the right wing think tanks and activist groups, and the reactionary billionaire individuals and corporations that fund them, are bankrupt when it comes to health reform ideas, but are clear what they do not want. Coverage for all. A public option. A single payer system. Anything that will limit the profits of the insurance and pharmaceutical industries. But how do they get regular people out to yell and scream?
Well, some of them are ideologues themselves. Some of them have drunk the Kool-Aid of “no government” (except when it benefits me), or no socialism. There are always, in every country, multiple groups arrayed across the political spectrum. But the other way to get these folks out is to lie to them, to make them believe that health reform will take away their health care, limit access to their doctor, take away their current government benefits (“Keep the government’s hands off my Medicare!” is a nonsense chant heard all too often, and not nonsense to the chanter.) Misinformation is everywhere. A member of my family received an email containing the following nonsense: “…you will see that after 65 all Health Care will be limited and the people (SEC. to be specificied) will make our health care choices for us. Also the community service people will be in on the act to deny and/or approve (this is ACORN) OBAMA and his crew are denying what this plan is and they keep saying you get to choose, however, if you persist in reading you see that in 2013 all other plans are frozen out and only the public plan remains. Then the government wants access to your bank account so that after you are dead they(the government) can and will seize assets.”
What? Are these paranoid nuts, or just liars?
CJ Janovy, editor of the Kansas City Pitch, recently attended an “event” of this sort in a KC suburb which she describes on her blog, “Saturday morning's protest: Coffee and crabbiness with Cleaver in Lee's Summit”, http://blogs.pitch.com/plog/2009/08/saturday_mornings_protest_coffee_and_crabbiness_with_emanuel_cleaver_in_lees_summit.php : “Most ridiculous thing anyone said -- and more than one person said it ‘I'd rather have no health insurance than government health insurance.’” *
More disturbing yet are the threats of violence, so far only involving fistfights. However, as reported by Rachel Weiner in the Huffington Post, http://www.huffingtonpost.com/2009/08/10/gabrielle-giffords-town-h_n_255656.html, “…one visitor dropped a gun at the meet n' greet held in a Douglas Safeway,” by Congresswoman Gabrielle Giffords (D., AZ); and these opponents were not only unhappy with the Congresswoman, but with the fact that trade unionists were present to support her. “One of the callers to the Service Employees International Union said, "I suggest you tell your people to calm down, act like American citizens, and stop trying to repress people's First Amendment rights... That, or you all are gonna come up against the Second Amendment."
OK. So I’m upset. Like a lot of pointy-headed intellectuals, I would rather argue the issues than shoot them out in the middle of the street like a hero in one of my beloved Marty Robbins songs (although Rep. Gifford might end up needing the services of the Arizona “Ranger with a big iron on his hip” http://www.cowboylyrics.com/lyrics/robbins-marty/big-iron-11880.html [1]). I do believe that supporters of health reform need to start turning out in massive numbers. But people who want to read more about this, including incisive commentary, have a lot to choose from. In addition to the sources cited above, there is an excellent piece from Robin Wells in the Huffington Post August 8, 2008, recommended by Paul Krugman, http://www.huffingtonpost.com/robin-wells/what-obama-needs-to-learn_b_254714.html, who notes that “Our uniquely noxious blend of racism, right wing politics, and moneyed interests exploiting racial fears and economic insecurity have hollowed out the core of moderation in American politics. In an unbroken line from Goldwater to Limbaugh and Palin, the Republican party has committed itself to scorched-earth tactics that have shredded the economic, political, and moral fabric of this country.”
What I can do is to address some of the concerns that people, such as my relative who sent me the anonymous email quoted above, may have after this right wing onslaught. The ones making these assertions, from Palin to Limbaugh to Hannity to O’Reilly to Mitch McConnell to John Boehner to Freedom Works are evil liars, but regular folks hearing these lies may legitimately be worried. OK, here goes:
No, the plans being put forward by the Democrats, President and Congress alike, are not going to euthanize your grandmother. They are not going to leave you naked, without health insurance. They are not going to cost you a lot more – in fact they are likely to cost you less, unless you are very wealthy. (Note: this descriptor, “very wealthy”, generally applies to the folks mentioned above and the owners of the big insurance companies and their lobbyists, but not to the folks actually showing up and yelling.)
These plans are not what I have been advocating for, a single-payer system where one payer would cover everyone, and save lots of money at the outside by elimination of not only insurance company profits but the massive inefficient billing and collecting infrastructure (see previous blog entries), but it is to the extent that they would come a little closer that is (to put it mildly) agitating the right.
No one will lose their Medicare. Indeed, much of the “public option” being discussed would be expanding Medicare, the most popular, and one of the most successful, government programs ever implemented, to more people. HR 676, the single-payer bill sponsored by Rep. John Conyers and cosponsored by nearly 100 house members, is in fact called the “Improved and Expanded Medicare for All” bill. HR 3200, the current house bill, is not single-payer but does expand Medicare. The costs will be higher than I would like, not because of any “government involvement” but specifically because of the retention of private health insurance, which will necessitate maintaining the huge and costly billing and collecting infrastructure. However, currently direct government funds account for nearly 40% of our health care spending (Medicare, Medicaid, insurance for government employees and retirees at all levels) and when the taxes not paid on employer-sponsored insurance are added in, it is almost 60%. That 60% of OUR healthcare spending, which leaves 47 million people uninsured and tens of millions of more poorly insured, is more than that spent, per capita, to cover everyone in any other industrialized country. Yes, multimillionaires might spend about $10,000 more per year under HR 3200. What is wrong with that? Regular people would not.
And no one is going to euthanize your grandmother. In fact, your grandmother, your mother, you, and your children will get better care. This is a “red herring”, a complete distortion of a discussion about efforts to control costs by not doing procedures that do not benefit people but still have the potential to harm them. This makes perfect sense, and is the way it should be, and is the way I want it to be, and is almost certainly the way everyone would want it to be for themselves and their families, but is not the way that it is now. The reimbursement system that we currently have rewards doing procedures, even procedures that are not proven to benefit anyone, that will definitely not benefit the patient affected, may do them harm, and often are expressly against a patient’s wishes (e.g., your grandmother who has expressed her desire to not have any interventions except those that increase her comfort). I have discussed this at length in various columns, including Feb 13, 2009, Jun 22, 2009 and especially “Clinical Guidelines and Technology Assessment”, May 12, 2009 http://medicinesocialjustice.blogspot.com/2009/05/clinical-guidelines-and-technology.html.)
The people who are stirring up the pot are liars and demagogues, looking out, at bottom, for the financial interest of the billionaires and insurance companies that fund them. Regular people should not believe them. We are better than that. We need to support a health reform program that covers everyone. And reject these scare tactics. And be vocal about it. And make sure that we don't allow Brown Shirts to set the tone of the debate.
[1] As best as I can find, copyright Elvis Presley Music, Inc., Unichappell Music Inc.
* I had an idea for a bumper sticker that was made for these people: "We don't need to provide health coverage to everyone. If you think it's wrong, we can leave YOU out!". Of course, the problem would be that they would turn it down when healthy and then coming asking for it when they got sick and needed it. We would have to make them sign waivers that they would never ask for it. Maybe their billionaire friends in the health insurance industry would take care of them.
.
One of the striking new developments in the health reform debate is the occurrence of “shoutdowns”, where opponents of health reform, in events that obviously orchestrated, show up at appearances by Democratic Congressmen to scream against health reform (addressed by two recent articles in the NY Times, August 8, 2009, “Beyond Beltway, Health Debate turns hostile”, http://www.nytimes.com/2009/08/08/us/politics/08townhall.html?ref=weekinreview, and “Where have you gone, Joe the Citizen?” http://www.nytimes.com/2009/08/09/weekinreview/09stolberg.html?ref=politics).
According to these articles, many of the demonstrations are organized by Freedom Works, Tea Party Patriots, Sean Hannity and other well-funded right-wing groups. While freedom of speech is a good thing, preventing others from speaking, and preventing the events from occurring, is more suggestive of Brown Shirts than Americans. The conservative radio commentators, such as Hannity, O’Reilly, and Limbaugh, the right wing think tanks and activist groups, and the reactionary billionaire individuals and corporations that fund them, are bankrupt when it comes to health reform ideas, but are clear what they do not want. Coverage for all. A public option. A single payer system. Anything that will limit the profits of the insurance and pharmaceutical industries. But how do they get regular people out to yell and scream?
Well, some of them are ideologues themselves. Some of them have drunk the Kool-Aid of “no government” (except when it benefits me), or no socialism. There are always, in every country, multiple groups arrayed across the political spectrum. But the other way to get these folks out is to lie to them, to make them believe that health reform will take away their health care, limit access to their doctor, take away their current government benefits (“Keep the government’s hands off my Medicare!” is a nonsense chant heard all too often, and not nonsense to the chanter.) Misinformation is everywhere. A member of my family received an email containing the following nonsense: “…you will see that after 65 all Health Care will be limited and the people (SEC. to be specificied) will make our health care choices for us. Also the community service people will be in on the act to deny and/or approve (this is ACORN) OBAMA and his crew are denying what this plan is and they keep saying you get to choose, however, if you persist in reading you see that in 2013 all other plans are frozen out and only the public plan remains. Then the government wants access to your bank account so that after you are dead they(the government) can and will seize assets.”
What? Are these paranoid nuts, or just liars?
CJ Janovy, editor of the Kansas City Pitch, recently attended an “event” of this sort in a KC suburb which she describes on her blog, “Saturday morning's protest: Coffee and crabbiness with Cleaver in Lee's Summit”, http://blogs.pitch.com/plog/2009/08/saturday_mornings_protest_coffee_and_crabbiness_with_emanuel_cleaver_in_lees_summit.php : “Most ridiculous thing anyone said -- and more than one person said it ‘I'd rather have no health insurance than government health insurance.’” *
More disturbing yet are the threats of violence, so far only involving fistfights. However, as reported by Rachel Weiner in the Huffington Post, http://www.huffingtonpost.com/2009/08/10/gabrielle-giffords-town-h_n_255656.html, “…one visitor dropped a gun at the meet n' greet held in a Douglas Safeway,” by Congresswoman Gabrielle Giffords (D., AZ); and these opponents were not only unhappy with the Congresswoman, but with the fact that trade unionists were present to support her. “One of the callers to the Service Employees International Union said, "I suggest you tell your people to calm down, act like American citizens, and stop trying to repress people's First Amendment rights... That, or you all are gonna come up against the Second Amendment."
OK. So I’m upset. Like a lot of pointy-headed intellectuals, I would rather argue the issues than shoot them out in the middle of the street like a hero in one of my beloved Marty Robbins songs (although Rep. Gifford might end up needing the services of the Arizona “Ranger with a big iron on his hip” http://www.cowboylyrics.com/lyrics/robbins-marty/big-iron-11880.html [1]). I do believe that supporters of health reform need to start turning out in massive numbers. But people who want to read more about this, including incisive commentary, have a lot to choose from. In addition to the sources cited above, there is an excellent piece from Robin Wells in the Huffington Post August 8, 2008, recommended by Paul Krugman, http://www.huffingtonpost.com/robin-wells/what-obama-needs-to-learn_b_254714.html, who notes that “Our uniquely noxious blend of racism, right wing politics, and moneyed interests exploiting racial fears and economic insecurity have hollowed out the core of moderation in American politics. In an unbroken line from Goldwater to Limbaugh and Palin, the Republican party has committed itself to scorched-earth tactics that have shredded the economic, political, and moral fabric of this country.”
What I can do is to address some of the concerns that people, such as my relative who sent me the anonymous email quoted above, may have after this right wing onslaught. The ones making these assertions, from Palin to Limbaugh to Hannity to O’Reilly to Mitch McConnell to John Boehner to Freedom Works are evil liars, but regular folks hearing these lies may legitimately be worried. OK, here goes:
No, the plans being put forward by the Democrats, President and Congress alike, are not going to euthanize your grandmother. They are not going to leave you naked, without health insurance. They are not going to cost you a lot more – in fact they are likely to cost you less, unless you are very wealthy. (Note: this descriptor, “very wealthy”, generally applies to the folks mentioned above and the owners of the big insurance companies and their lobbyists, but not to the folks actually showing up and yelling.)
These plans are not what I have been advocating for, a single-payer system where one payer would cover everyone, and save lots of money at the outside by elimination of not only insurance company profits but the massive inefficient billing and collecting infrastructure (see previous blog entries), but it is to the extent that they would come a little closer that is (to put it mildly) agitating the right.
No one will lose their Medicare. Indeed, much of the “public option” being discussed would be expanding Medicare, the most popular, and one of the most successful, government programs ever implemented, to more people. HR 676, the single-payer bill sponsored by Rep. John Conyers and cosponsored by nearly 100 house members, is in fact called the “Improved and Expanded Medicare for All” bill. HR 3200, the current house bill, is not single-payer but does expand Medicare. The costs will be higher than I would like, not because of any “government involvement” but specifically because of the retention of private health insurance, which will necessitate maintaining the huge and costly billing and collecting infrastructure. However, currently direct government funds account for nearly 40% of our health care spending (Medicare, Medicaid, insurance for government employees and retirees at all levels) and when the taxes not paid on employer-sponsored insurance are added in, it is almost 60%. That 60% of OUR healthcare spending, which leaves 47 million people uninsured and tens of millions of more poorly insured, is more than that spent, per capita, to cover everyone in any other industrialized country. Yes, multimillionaires might spend about $10,000 more per year under HR 3200. What is wrong with that? Regular people would not.
And no one is going to euthanize your grandmother. In fact, your grandmother, your mother, you, and your children will get better care. This is a “red herring”, a complete distortion of a discussion about efforts to control costs by not doing procedures that do not benefit people but still have the potential to harm them. This makes perfect sense, and is the way it should be, and is the way I want it to be, and is almost certainly the way everyone would want it to be for themselves and their families, but is not the way that it is now. The reimbursement system that we currently have rewards doing procedures, even procedures that are not proven to benefit anyone, that will definitely not benefit the patient affected, may do them harm, and often are expressly against a patient’s wishes (e.g., your grandmother who has expressed her desire to not have any interventions except those that increase her comfort). I have discussed this at length in various columns, including Feb 13, 2009, Jun 22, 2009 and especially “Clinical Guidelines and Technology Assessment”, May 12, 2009 http://medicinesocialjustice.blogspot.com/2009/05/clinical-guidelines-and-technology.html.)
The people who are stirring up the pot are liars and demagogues, looking out, at bottom, for the financial interest of the billionaires and insurance companies that fund them. Regular people should not believe them. We are better than that. We need to support a health reform program that covers everyone. And reject these scare tactics. And be vocal about it. And make sure that we don't allow Brown Shirts to set the tone of the debate.
[1] As best as I can find, copyright Elvis Presley Music, Inc., Unichappell Music Inc.
* I had an idea for a bumper sticker that was made for these people: "We don't need to provide health coverage to everyone. If you think it's wrong, we can leave YOU out!". Of course, the problem would be that they would turn it down when healthy and then coming asking for it when they got sick and needed it. We would have to make them sign waivers that they would never ask for it. Maybe their billionaire friends in the health insurance industry would take care of them.
.
Thursday, August 6, 2009
Doctors, their Patients, and Health Reform
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Recently, some of us in the medical profession have seen proposals from medical societies for letters that physicians can send to their patients, asking them to weigh in (with the opinion of the physician, or at least of the medical society, on health reform proposals. I suspect that many of the rest of us, as patients will receive them. The idea that physicians can multiply their level of influence on the policy debate is an interesting and not uncontroversial one; however here I will focus primarily on the content that those letters might take. Any position or letter taken by any large group, such as a medical society, will obviously have members who disagree in part or in whole with its content, but the fact that the medical society is weighing in may be quite influential.
The most important issue is the health of the American people, a very important component of which is access to health care. This means financial access without unreasonable barriers, geographic access, access to a primary care medical home, and access to proven, evidence-based diagnostic and treatment methods. It is also critically important that the cost of "health care" be controlled; I put it in quotes because a large part of that cost is in administrative costs. These costs, which are "waste" in the sense that they do not deliver health care to anyone, include, and are driven by, the enormous profits health insurance companies make, but are far more than that. They are in the huge billing and collecting infrastructures that the insurance companies (to try to not pay) and all providers (to try to get paid) have to have in place. Zero percent of this is from public programs, but the growth in administrators is astonishing (see slide).
The issue is not, should not be, and absolutely cannot be seen to be, protecting the self-interest and incomes of doctors. This is not to say that doctors should not be reimbursed "fairly" for their services; certainly they have to be able to pay their staff and make a living. (Although note, above, that a lot of staff and physician time is spent on trying to get reimbursed!) In addition to any moral or ethical issues -- and it would be nice if physicians, who we ask the American people to trust with their most important assets, their lives and health -- would act, especially as an organized group, morally and ethically, there is the fact that physicians already make more money than most people. It may not always seem so if we live in the richest parts of town and thus compare ourselves to the richest people, but even the poorest paid primary care physicians are in the top few % of income, and many are in the 99+++%. Whether you think you deserve it or not, the typical employed, not to mention unemployed, American is not going to cry for you, and it is amazing that we would even think of asking them to.
Another huge cost driver is the growth of expensive technical procedures. Many of these are important diagnostic and therapeutic advances, and when evidence shows that they are beneficial they should be used, although the cost has to come down. The American people -- forget the government -- need to know that zero percent of any recommendation for a diagnostic or treatment intervention is motivated, even subconsciously, by the potential income it may bring to physicians. We must welcome, embrace, cheer -- and definitely be part of -- efforts to identify which strategies are evidence based, and for what populations, and what the cost benefit ratio is. (As to what ratio is acceptable, that is a different question, but one must be joined. It is NOT ok to say a huge cost to benefit ratio is ok for one person -- me or mine -- and not for another person.)
The basis of every effective health system is primary care, a primary care medical home. People need a doctor who knows them, who can help them work, if needed, with multiple specialists, help them interpret the jargon, help them know when two consultants who seem to the patient to be disagreeing really are not, and how to figure it out when they are. They need a doctor who knows them and their family, and what their health was like before they "fell from the sky" into the hospital, so that s/he can know when they are better. They need a primary care medical home because it is mainly primary care doctors who will be able to practice in rural areas, where 20% of the American people live and 9% of physicians practice -- and decreasing rapidly. Medical students are not entering primary care, and not going to rural areas; some of this may be lifestyle but much of it is financial. Organized medicine needs to take this issue on as its own, demanding policies that encourage a move toward a 50% primary care workforce. Even if it means some decrease in income for some specialists.
One of the letters I have seen uses anti-government scare tactics, which are indefensible. If there are members who do not believe that everyone should have access to the highest quality medical care, we are on different pages; that is a different discussion. Fear mongering of "government bureaucrats" coming between you and your doctor is just that; first of all, there are no such proposals. Secondly, the government bureaucrats could have nothing on the insurance bureaucrats. Let us not lose sight of the fact that the government -- including our congressmen and senators -- is supposed to be responsive to us. I know it may often seem as they are only responding to the biggest contributors (often including organized medicine), but for-profit insurance companies are not even supposed to care about our opinions; they are only obligated to their shareholders. A public option is necessary to ensure that all people are covered. If the insurance companies are confident that they are offering a better product, they should not be afraid of the public option competition. Indeed, it seems they are not so confident, but rather, contrary to the idea that the public sector will have "unfair" advantages, believe that they need the special privileges, "unfair advantages", that would come from hobbling the public sector. And, of course, a public option only saves a small percent of the cost of "non-medicine"; even if half of Americans were in it, we would all need to maintain our billing and collecting infrastructures for the rest.
Scare tactics that alarm our patients are inappropriate, undignified, and inappropriate. The medical profession has done well financially not because they studied hard (there are starving artists and musicians everywhere who study and practice hard) but because people trust them with their lives and health. To take any position other than that which is certain to have the greatest health benefit to all people -- lowest to highest income -- is a violation of that trust and is dishonorable. We are, we have to be, better than that.
.
The most important issue is the health of the American people, a very important component of which is access to health care. This means financial access without unreasonable barriers, geographic access, access to a primary care medical home, and access to proven, evidence-based diagnostic and treatment methods. It is also critically important that the cost of "health care" be controlled; I put it in quotes because a large part of that cost is in administrative costs. These costs, which are "waste" in the sense that they do not deliver health care to anyone, include, and are driven by, the enormous profits health insurance companies make, but are far more than that. They are in the huge billing and collecting infrastructures that the insurance companies (to try to not pay) and all providers (to try to get paid) have to have in place. Zero percent of this is from public programs, but the growth in administrators is astonishing (see slide).
The issue is not, should not be, and absolutely cannot be seen to be, protecting the self-interest and incomes of doctors. This is not to say that doctors should not be reimbursed "fairly" for their services; certainly they have to be able to pay their staff and make a living. (Although note, above, that a lot of staff and physician time is spent on trying to get reimbursed!) In addition to any moral or ethical issues -- and it would be nice if physicians, who we ask the American people to trust with their most important assets, their lives and health -- would act, especially as an organized group, morally and ethically, there is the fact that physicians already make more money than most people. It may not always seem so if we live in the richest parts of town and thus compare ourselves to the richest people, but even the poorest paid primary care physicians are in the top few % of income, and many are in the 99+++%. Whether you think you deserve it or not, the typical employed, not to mention unemployed, American is not going to cry for you, and it is amazing that we would even think of asking them to.
Another huge cost driver is the growth of expensive technical procedures. Many of these are important diagnostic and therapeutic advances, and when evidence shows that they are beneficial they should be used, although the cost has to come down. The American people -- forget the government -- need to know that zero percent of any recommendation for a diagnostic or treatment intervention is motivated, even subconsciously, by the potential income it may bring to physicians. We must welcome, embrace, cheer -- and definitely be part of -- efforts to identify which strategies are evidence based, and for what populations, and what the cost benefit ratio is. (As to what ratio is acceptable, that is a different question, but one must be joined. It is NOT ok to say a huge cost to benefit ratio is ok for one person -- me or mine -- and not for another person.)
The basis of every effective health system is primary care, a primary care medical home. People need a doctor who knows them, who can help them work, if needed, with multiple specialists, help them interpret the jargon, help them know when two consultants who seem to the patient to be disagreeing really are not, and how to figure it out when they are. They need a doctor who knows them and their family, and what their health was like before they "fell from the sky" into the hospital, so that s/he can know when they are better. They need a primary care medical home because it is mainly primary care doctors who will be able to practice in rural areas, where 20% of the American people live and 9% of physicians practice -- and decreasing rapidly. Medical students are not entering primary care, and not going to rural areas; some of this may be lifestyle but much of it is financial. Organized medicine needs to take this issue on as its own, demanding policies that encourage a move toward a 50% primary care workforce. Even if it means some decrease in income for some specialists.
One of the letters I have seen uses anti-government scare tactics, which are indefensible. If there are members who do not believe that everyone should have access to the highest quality medical care, we are on different pages; that is a different discussion. Fear mongering of "government bureaucrats" coming between you and your doctor is just that; first of all, there are no such proposals. Secondly, the government bureaucrats could have nothing on the insurance bureaucrats. Let us not lose sight of the fact that the government -- including our congressmen and senators -- is supposed to be responsive to us. I know it may often seem as they are only responding to the biggest contributors (often including organized medicine), but for-profit insurance companies are not even supposed to care about our opinions; they are only obligated to their shareholders. A public option is necessary to ensure that all people are covered. If the insurance companies are confident that they are offering a better product, they should not be afraid of the public option competition. Indeed, it seems they are not so confident, but rather, contrary to the idea that the public sector will have "unfair" advantages, believe that they need the special privileges, "unfair advantages", that would come from hobbling the public sector. And, of course, a public option only saves a small percent of the cost of "non-medicine"; even if half of Americans were in it, we would all need to maintain our billing and collecting infrastructures for the rest.
Scare tactics that alarm our patients are inappropriate, undignified, and inappropriate. The medical profession has done well financially not because they studied hard (there are starving artists and musicians everywhere who study and practice hard) but because people trust them with their lives and health. To take any position other than that which is certain to have the greatest health benefit to all people -- lowest to highest income -- is a violation of that trust and is dishonorable. We are, we have to be, better than that.
.
Sunday, August 2, 2009
Not "Special Interests": The Wealthy and Powerful
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One thing a blog might do is to provide connections between seemingly disconnected news stories. I have tried to do that, as well as focus primarily on medicine and health issues, but also with an emphasis on the social justice implications (or at least that is my attempt). I will make that effort here.
On July 31, 2009, the New York Times has a lead article titled “Big banks paid billions in bonuses amid Wall St. Crisis” by Louise Story and Eric Dash (http://www.nytimes.com/2009/07/31/business/31pay.html?_r=1&hp). I have often made clear my feelings about those big bankers and financiers (that they should have all their money taken away and either be put in prison or in surplus FEMA trailers), but apparently the bankers do not share that opinion. The information for this story came from NY Attorney General Andrew Cuomo, and reports that “At Goldman Sachs, for example, bonuses of more than $1 million went to 953 traders and bankers, and Morgan Stanley awarded seven-figure bonuses to 428 employees. Even at weaker banks like Citigroup and Bank of America, million-dollar awards were distributed to hundreds of workers…. ‘If the bank lost money, where do you get the money to pay the bonus?’ said Mr. Cuomo." Good question; apparently the answer is either directly (from our deposits or loan payments), or indirectly (from TAFP funds), from you and me. “Some compensation experts questioned whether the bonuses should have been paid at all while the banks were receiving government aid.” You can add some non-compensation experts, like me, to that group.
On the health reform front, we are treated to news reports that President Obama’s popularity has slid to 53% with only 42% approving and 47% opposing their understanding of the President and Congress’ health plans (NPR July 28, 2009, and widely reported). I have been following the health reform debate pretty closely and I am not sure I understand what the President’s health reform plan is; even the ones that are proposed variously in the House and Senate keep changing, and are hard to tell even with a scorecard, such as that offered by the Kaiser Family Foundation website, http://www.kff.org/healthreform/upload/healthreform_sbs_full.pdf.
Thus, there is a possibility that most of the Americans surveyed for this report also may not have a clear understanding. One of the reasons, of course, is the reporting in the media, which is always interested in conflict, as it sells better, and in the case, at least, of much of TV news – the source of most Americans’ information – frequently biased. One source of bias, even among less egregious offenders than Fox, is the constant parade of Republicans, a group whose contribution to the health debate has been limited to attacks and scare tactics.
The Republicans, of course, have no plan; it is a lot easier to shoot arrows at the Democratic proposal – any proposal – than themselves offer an actual plan that might be criticized. And, of course, it would be torn to shreds, since the only values that the Republicans share on health care is making sure that the wealthiest are protected in their wealth, that insurance and pharmaceutical companies make out like bandits, and that there be no government sponsored health plan, which effectively means not only would the currently uninsured be left out, but the currently underinsured and scared would be at even more risk.
The President has said the right things: Everyone must be covered. Costs must be controlled. There is no “null” option, the alternative is to continue things as they are and see massive growth in health care costs combined with more and more uninsured and underinsured people getting less and less health care that they need resulting in worsening health status for Americans. But the health plans being proposed by the Congress with the support of the White House are second rate (that is to say, they will not cover everyone and save money the way that a single player plan would). However, the big mistake is that the Congress has not supported the President’s play. Committed to repeating the mistakes of the Clinton health plan, they insist on compromises to try – absolutely without hope of success – to get bipartisan support. This is a mistake, as the Republicans have no credibility and are worthy of no respect or attention; this is, after all, the party of Alabama Senator Jeff Sessions, who voted against the confirmation of Sonia Sotomayor in the Judiciary Committee the same day because she has a judicial philosophy that is not consistent with the American ideal of Blind Justice. I suppose Sessions – whose own Supreme Court nomination faltered on the fact that he was tied to the Ku Klux Klan – has managed to pull the sheet over his own eyes.
Unfortunately, too many of the Democrats, as well as Republicans, are in the pockets of the lobbyists of wealthy billionaires and the huge companies, especially insurers and pharmaceutical companies but also large hospitals and hospital chains who stand to lose a great deal of money if we enact real health reform. After all, if there is “waste” in this system – and I think most informed people believe that there is – it is going into someone’s pocket. I call “waste” all those billions – hundreds of billions – of dollars spent on “health care” that is not spent on health care at all but insurance company profits and bloated administrative structures that are designed (on the insurance company side) to not pay, and (on the provider side) to try to get the insurance companies to pay. And the enormous mark-ups for certain drugs, such as cancer chemotherapy drugs. If we save all this money, certain companies won’t make it, and they are lobbying like heck to keep their piece of this huge, bloated, tasteless pie.
To call these “special interests” is, on the face of it, accurate, but deceptive because the term is without meaning. It has been developed and put forward precisely to hide the influence of wealthiest and most powerful corporations by conflating them with much smaller and weaker groups as “special interests”. Let us be clear: the influence of the Health Insurance Association of American or PhARMA is not the same as that of, say, those seeking rights for the transgendered. Or even of labor unions. These groups are powerful in our lives outside government all the time – hey, that is the problem, that the health insurance companies deny us coverage if we have pre-existing conditions, won’t insure us if we don’t work for a big company and don’t have the money to pay, makes us pay huge deductible and coinsurances, and still won’t pay the bills all too often. The one area of society that should be responsive to the needs of the people and not big corporations is our elected government, but the fact is that those companies have bought Congress too. After all, they have to run again and that requires a lot of money and it is a proven fact that wealthy individuals and corporations contribute a lot more money than poor and middle-class people. (What is it with those poor folks? Why don’t they contribute more to their congressmen?)
Which, of course, brings us back to the beginning of this piece. The problem facing health reform is the same problem facing reform of the financial and banking system. Money talks. Even after the gigantic disaster perpetrated by the banks and financial houses, the one that took down YOUR retirement, as well as, coincidentally, the entire US and world economy, they still have way more power than you do, and Congress is still feeding their interests. My last blog post addressed the “Tragedy of Meaning”, and how we like to explain suicide by people (like Adolph Merckle) as their reacting to bad events rather than because they suffer from depression. The best argument for that is in the first paragraph of this piece – of all those financial leaders who brought this ruin on all of us who are not committing hara-kiri but are demanding, expecting, and getting huge payoffs. The position being put forward that some of them are not the same individuals who were in charge before is nonsense; they have the same values, beliefs, and arrogance.
What can regular people do? We can be clear that we need a health reform plan that 1) covers everyone, every single one of us, 2) covers our needed services based on evidence, 3) doesn’t pretend that choice of insurance companies is the same as choice of doctors or hospitals. And that makes for every one of us to have access to all of the proven preventive and treatment modalities for the diseases we have or might get. And to write that email or make that phone call to our congressman daily if we have to. Start, for example, with urging them to vote for the Weiner Amendment in the House, which will come to the floor in September, that calls on the House to replace the current, flawed, patchwork HR 3200 health bill with HR 676, the Improved and Enhanced Medicare for All Bill, which will put us all in the same program (Medicare, the most popular government program in history) and at the same time revise payment structure to encourage what is GOOD for us rather than what is PROFITABLE for providers.
If the President and the Congress would just take the lead in not only saying, but proposing a plan, that would cover everyone and pay for it using the dollars currently wasted on both insurance company profit and the huge administrative infrastructure necessary to run that system; to say and propose a plan that says “we want health and health care for the American people and do not care a whit for the insurance industry”, the American people would be behind it.
Time to send that email.
.
One thing a blog might do is to provide connections between seemingly disconnected news stories. I have tried to do that, as well as focus primarily on medicine and health issues, but also with an emphasis on the social justice implications (or at least that is my attempt). I will make that effort here.
On July 31, 2009, the New York Times has a lead article titled “Big banks paid billions in bonuses amid Wall St. Crisis” by Louise Story and Eric Dash (http://www.nytimes.com/2009/07/31/business/31pay.html?_r=1&hp). I have often made clear my feelings about those big bankers and financiers (that they should have all their money taken away and either be put in prison or in surplus FEMA trailers), but apparently the bankers do not share that opinion. The information for this story came from NY Attorney General Andrew Cuomo, and reports that “At Goldman Sachs, for example, bonuses of more than $1 million went to 953 traders and bankers, and Morgan Stanley awarded seven-figure bonuses to 428 employees. Even at weaker banks like Citigroup and Bank of America, million-dollar awards were distributed to hundreds of workers…. ‘If the bank lost money, where do you get the money to pay the bonus?’ said Mr. Cuomo." Good question; apparently the answer is either directly (from our deposits or loan payments), or indirectly (from TAFP funds), from you and me. “Some compensation experts questioned whether the bonuses should have been paid at all while the banks were receiving government aid.” You can add some non-compensation experts, like me, to that group.
On the health reform front, we are treated to news reports that President Obama’s popularity has slid to 53% with only 42% approving and 47% opposing their understanding of the President and Congress’ health plans (NPR July 28, 2009, and widely reported). I have been following the health reform debate pretty closely and I am not sure I understand what the President’s health reform plan is; even the ones that are proposed variously in the House and Senate keep changing, and are hard to tell even with a scorecard, such as that offered by the Kaiser Family Foundation website, http://www.kff.org/healthreform/upload/healthreform_sbs_full.pdf.
Thus, there is a possibility that most of the Americans surveyed for this report also may not have a clear understanding. One of the reasons, of course, is the reporting in the media, which is always interested in conflict, as it sells better, and in the case, at least, of much of TV news – the source of most Americans’ information – frequently biased. One source of bias, even among less egregious offenders than Fox, is the constant parade of Republicans, a group whose contribution to the health debate has been limited to attacks and scare tactics.
The Republicans, of course, have no plan; it is a lot easier to shoot arrows at the Democratic proposal – any proposal – than themselves offer an actual plan that might be criticized. And, of course, it would be torn to shreds, since the only values that the Republicans share on health care is making sure that the wealthiest are protected in their wealth, that insurance and pharmaceutical companies make out like bandits, and that there be no government sponsored health plan, which effectively means not only would the currently uninsured be left out, but the currently underinsured and scared would be at even more risk.
The President has said the right things: Everyone must be covered. Costs must be controlled. There is no “null” option, the alternative is to continue things as they are and see massive growth in health care costs combined with more and more uninsured and underinsured people getting less and less health care that they need resulting in worsening health status for Americans. But the health plans being proposed by the Congress with the support of the White House are second rate (that is to say, they will not cover everyone and save money the way that a single player plan would). However, the big mistake is that the Congress has not supported the President’s play. Committed to repeating the mistakes of the Clinton health plan, they insist on compromises to try – absolutely without hope of success – to get bipartisan support. This is a mistake, as the Republicans have no credibility and are worthy of no respect or attention; this is, after all, the party of Alabama Senator Jeff Sessions, who voted against the confirmation of Sonia Sotomayor in the Judiciary Committee the same day because she has a judicial philosophy that is not consistent with the American ideal of Blind Justice. I suppose Sessions – whose own Supreme Court nomination faltered on the fact that he was tied to the Ku Klux Klan – has managed to pull the sheet over his own eyes.
Unfortunately, too many of the Democrats, as well as Republicans, are in the pockets of the lobbyists of wealthy billionaires and the huge companies, especially insurers and pharmaceutical companies but also large hospitals and hospital chains who stand to lose a great deal of money if we enact real health reform. After all, if there is “waste” in this system – and I think most informed people believe that there is – it is going into someone’s pocket. I call “waste” all those billions – hundreds of billions – of dollars spent on “health care” that is not spent on health care at all but insurance company profits and bloated administrative structures that are designed (on the insurance company side) to not pay, and (on the provider side) to try to get the insurance companies to pay. And the enormous mark-ups for certain drugs, such as cancer chemotherapy drugs. If we save all this money, certain companies won’t make it, and they are lobbying like heck to keep their piece of this huge, bloated, tasteless pie.
To call these “special interests” is, on the face of it, accurate, but deceptive because the term is without meaning. It has been developed and put forward precisely to hide the influence of wealthiest and most powerful corporations by conflating them with much smaller and weaker groups as “special interests”. Let us be clear: the influence of the Health Insurance Association of American or PhARMA is not the same as that of, say, those seeking rights for the transgendered. Or even of labor unions. These groups are powerful in our lives outside government all the time – hey, that is the problem, that the health insurance companies deny us coverage if we have pre-existing conditions, won’t insure us if we don’t work for a big company and don’t have the money to pay, makes us pay huge deductible and coinsurances, and still won’t pay the bills all too often. The one area of society that should be responsive to the needs of the people and not big corporations is our elected government, but the fact is that those companies have bought Congress too. After all, they have to run again and that requires a lot of money and it is a proven fact that wealthy individuals and corporations contribute a lot more money than poor and middle-class people. (What is it with those poor folks? Why don’t they contribute more to their congressmen?)
Which, of course, brings us back to the beginning of this piece. The problem facing health reform is the same problem facing reform of the financial and banking system. Money talks. Even after the gigantic disaster perpetrated by the banks and financial houses, the one that took down YOUR retirement, as well as, coincidentally, the entire US and world economy, they still have way more power than you do, and Congress is still feeding their interests. My last blog post addressed the “Tragedy of Meaning”, and how we like to explain suicide by people (like Adolph Merckle) as their reacting to bad events rather than because they suffer from depression. The best argument for that is in the first paragraph of this piece – of all those financial leaders who brought this ruin on all of us who are not committing hara-kiri but are demanding, expecting, and getting huge payoffs. The position being put forward that some of them are not the same individuals who were in charge before is nonsense; they have the same values, beliefs, and arrogance.
What can regular people do? We can be clear that we need a health reform plan that 1) covers everyone, every single one of us, 2) covers our needed services based on evidence, 3) doesn’t pretend that choice of insurance companies is the same as choice of doctors or hospitals. And that makes for every one of us to have access to all of the proven preventive and treatment modalities for the diseases we have or might get. And to write that email or make that phone call to our congressman daily if we have to. Start, for example, with urging them to vote for the Weiner Amendment in the House, which will come to the floor in September, that calls on the House to replace the current, flawed, patchwork HR 3200 health bill with HR 676, the Improved and Enhanced Medicare for All Bill, which will put us all in the same program (Medicare, the most popular government program in history) and at the same time revise payment structure to encourage what is GOOD for us rather than what is PROFITABLE for providers.
If the President and the Congress would just take the lead in not only saying, but proposing a plan, that would cover everyone and pay for it using the dollars currently wasted on both insurance company profit and the huge administrative infrastructure necessary to run that system; to say and propose a plan that says “we want health and health care for the American people and do not care a whit for the insurance industry”, the American people would be behind it.
Time to send that email.
.
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] (http://jama.ama-assn.org/cgi/content/full/302/4/432?home). 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.
“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” (http://www.nytimes.com/2009/07/25/health/policy/25doctors.html?_r=1&hp). 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?
.
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” (http://www.nytimes.com/2009/07/25/health/policy/25doctors.html?_r=1&hp). 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.
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 http://help.senate.gov/BAI09A84_xml.pdf 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.” http://www.nytimes.com/2009/07/03/health/policy/03health.html?_r=1&ref=health
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 http://commerce.senate.gov/public/_files/PotterTestimonyConsumerHealthInsurance.pdf.
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, http://help.senate.gov/BAI09A84_xml.pdf 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 http://jama.ama-assn.org/cgi/content/full/301/24/2589 . 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 http://hsc.unm.edu/community/CountyReportCards/documents/CountyReports09.pdf, 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.
.
The heath reform bill that will come out of the Senate HELP Committee http://help.senate.gov/BAI09A84_xml.pdf 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.” http://www.nytimes.com/2009/07/03/health/policy/03health.html?_r=1&ref=health
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 http://commerce.senate.gov/public/_files/PotterTestimonyConsumerHealthInsurance.pdf.
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, http://help.senate.gov/BAI09A84_xml.pdf 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 http://jama.ama-assn.org/cgi/content/full/301/24/2589 . 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 http://hsc.unm.edu/community/CountyReportCards/documents/CountyReports09.pdf, 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”, http://content.nejm.org/cgi/content/full/361/1/4, 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, http://content.nejm.org/cgi/content/full/NEJMp0904133, http://content.nejm.org/cgi/content/full/NEJMp0905631, 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”, http://content.nejm.org/cgi/content/full/361/1/6, 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.
.
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”, http://content.nejm.org/cgi/content/full/361/1/4, 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, http://content.nejm.org/cgi/content/full/NEJMp0904133, http://content.nejm.org/cgi/content/full/NEJMp0905631, 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”, http://content.nejm.org/cgi/content/full/361/1/6, 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, http://www.who.int/whr/2000/en/index.html.
“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, http://news.bbc.co.uk/2/hi/health/8117561.stm, 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 http://www.iom.edu/Object.File/Master/17/748/Fact%20sheet%205%20Quality.pdf.
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 http://www.rand.org/pubs/research_briefs/RB9174/index1.html. 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?
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, http://www.who.int/whr/2000/en/index.html.
“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, http://news.bbc.co.uk/2/hi/health/8117561.stm, 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 http://www.iom.edu/Object.File/Master/17/748/Fact%20sheet%205%20Quality.pdf.
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 http://www.rand.org/pubs/research_briefs/RB9174/index1.html. 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 (http://www.nytimes.com/2009/06/26/opinion/26truscott.html), 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.
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 (http://www.nytimes.com/2009/06/26/opinion/26truscott.html), 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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