.
This is third and final posting in a series on the shooting of 13 people in Tucson and its implications for health and social policy in the US. This post is by Robyn R. Liu, MD, who is a family physician in the frontier town of Tribune, KS, in the far western part of the state.
The day Gabrielle Giffords and 19 others were shot is one of those days that most Americans will remember where they were when they heard the news. What I will remember is my husband saying, “A congresswoman was shot in Arizona. She was on Sarah Palin’s crosshairs map.” As our picture of the alleged shooter became more complete, we realized he was not playing John Hinckley, Jr. to Palin’s Jodie Foster. Rather, he is in all likelihood a very disturbed, mentally ill young man.
A CNN/Opinion Research poll demonstrates that most of the public agrees, and thinks that the lack of mental health resources was in part responsible for the horrific act of that day: 41% said a “great deal,” and 29% said a “moderate amount.” When NPR went to a gun show held in Tucson just seven days after the shooting, the man at the front of the line said, “Mentally ill individual, very troubled individual that unfortunately slipped through the cracks somehow. And I think that’s what we need to look at, is how did this fellow get missed.”
As a primary care doctor in a frontier state, I can tell you, those cracks are pretty big.
I wrote a piece last week for another blog about one patient’s experience with the mental health system here in Kansas. This was a patient with insurance and a continuity relationship with a psychiatrist – and even she “fell through the cracks” more than once, although her violence was all self-directed and thus never made headlines. We do not know what Jared Lee Loughner’s health insurance status was, nor whether he had ever sought a therapeutic relationship with a mental health professional. We do know that although his behavior got him rejected from both college and the military, he was able legally to purchase a handgun and a 30-round magazine. As Dr. Dora Wang noted this week in Psychology Today, “It’s easier to get a gun than mental health care.”
I decided to do some looking into mental health services in Arizona. I went to the home page of the Arizona Medicaid program, forthrightly if a bit unfeelingly called the “Arizona Health Care Cost Containment System,” or AHCCCS. I already knew that AHCCCS was looking at cuts in Governor Jan Brewer’s new budget, since by her direction 98 people had had their transplants rescinded under this program. The Division of Behavioral Health Services website describes how the governor’s proposed 2011 budget would alter Medicaid eligibility criteria for “childless adults” like Loughner, possibly removing coverage for 5,200 Arizona citizens with “serious mental illnesses.” The writer hopes, however, that a loophole in the policy will allow “more than 80% of these folks” to maintain coverage under a different Medicaid category. Oh, thank goodness! Now only 1,040 seriously mentally ill people will suddenly find themselves high and dry in Arizona.
The longer we as a society refuse to provide universal health care, with complete parity for mental health, the wider these cracks are going to get. It wasn’t an illegal immigrant who shot down a federal judge, a pastor, two homemakers, a social worker, and a little girl in cold blood. A retired Marine is not lying in the hospital with bullet wounds he suffered trying to protect his now-dead wife because of a drug-smuggling Mexican. Arizona is worried about protecting its borders, but its greatest threat may already be inside. Imagine over 1,000 Loughners walking the streets with no means to get help: it’s absolutely chilling.
...
Postscript from Josh:
In the January 27, 2011 NY Times, columnist Gail Collins quotes Senator Tom Coburn of Oklahoma from an appearance on "Meet the Press":
“The people that are going to commit a crime or are going to do something crazy aren’t going to pay attention to the laws in the first place. Let’s fix the real problem. Here’s a mentally deranged person who had access to a gun that should not have had access to a gun.”
As Senator Coburn is a physician, he should know. And, hopefully, he will sponsor legislation to create some rational limits on gun access, as well as increasing access to mental health services. But I wouldn't hold my breath.
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Thursday, January 27, 2011
Friday, January 21, 2011
Tucson is worth struggling for...
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This guest post by William Bemis is the second of three related to the recent shootings of Gabrielle Giffords and others in Tucson (in Pima County), AZ. Shortly before the shootings, the NY Times reported on a decision by the AZ Board of Education (a state agency in the capital, Phoenix) to close a Latino studies class in a Tucson High School. Urged by family members to consider relocation, Mr. Bemis, a psychotherapist and my brother-in-law, wrote this response, speaking of the Arizona city whose City Council had previously voted to ask the state to rescind its anti-immigrant law; after the shooting, at my request, he added additional material.
No, my dear, it's time for us and others like us to re-double our efforts to not only preserve Pima County as an island of sanity in this sea of ideological madness, but help the rest of the state and the nation see that leaving all the levers of power in the hands of racist corporate stooges is not going to take us anywhere but down. Having lived in this state for over 40 years now, I've seen this before - with Evan Meacham and Fife Symington, for example. After each of these lunatic lurches to the right, the state came back to at least a more moderate centrist political configuration. Arizona will never be Massachusetts or Oregon or Minnesota, but I, for one, am not ready to leave and concede this beautiful and unique place to the hate mongering front men for big money interests.
I loved living in New York, but we could never afford it, and besides, although their antics are less spectacularly loony, I wouldn't call the New York state government an example to emulate. Where else? Illinois? Puh-leeze! California? Are we talking about the homeland of Nixon, Reagan, Robert Dornan, et al? Sadly, Californios have also had to deal with home grown right wing fanatics, que no? Oregon? A more congenial political environment, perhaps, and a beautiful state, but too much rain!
It isn't just here, is it? I think we have to take the long view. The so-called conservatives (what do they wish to conserve besides entrenched wealth?) are riding high right now, both here and in Washington, but in the next couple of years they are going to amply demonstrate the meaness and poverty of their ideas. Contrary to the self delusions of Russell Pearce, Jan Brewer, Mitch McConnell, and John Boehner, I think these folks are cruising for a fall. I am more worried about the failure of those of us who do not share their agenda to take advantage of this moment than I am of the pseudo-populist, big money financed Tea Party. They have the money, so we all have to write our more modest checks and work all the harder. Our own apathy and discouragement is the enemy.
Moments after writing the above, I heard the news that Gabrielle Giffords, our Congresswoman, had been shot by yet another disturbed young loner of the type who seem to implement "Second Amendment solutions " to their private frustration and alienation on an almost daily basis now, thereby spreading their own psychic pain to all the rest of us. Cue the required messages of horrified shock and condolences from politicians of all persuasions, including even Sarah Palin who put Gabby's district literally in the rifle sight cross hairs and who tells her followers, "Don't retreat, RELOAD!" Some of those messages are no doubt sincere, but the one politician who was the most eloquent to me was Pima County Sheriff Clarence Dupnik, who doesn't get nearly the amount of press as his counterpart in Maricopa County, possibly because he is a hardworking, low key, decent, and fair public servant, which never seems to make good copy. Sheriff Dupnik's comments about political vitriol triggering mentally unbalanced individuals goes right to the heart of the current political climate in Arizona and across the country.
Gabrielle Giffords is a self-described "Blue Dog Democrat". For me, her politics are way too centrist in an era when what used to be the core values of the Democratic Party are under siege. If only she fit the liberal label that the Tea Party would like to pin on her! Though Gabby's stances on a lot of issues frustrated me, I worked as a volunteer on her election campaigns because I knew she was absolutely the best person we could hope to have elected to Congress from her district, which is Republican overall and in many precincts virulently racist and violent. Gabby is smart, dedicated, articulate, hard-working, extremely personable, and so much better than her recent opponent whom she barely defeated that I would have been ashamed if he had won and I hadn't done what I could to put her back in office. She is surviving so far the bullet that passed through her brain, and the trauma surgeons are optimistic, but I can't help but wonder if she does survive if she will ever be able to function again at the level she did prior. I read somewhere that she was advised recently that she had been too inaccessible in the past, though I seem to remember hearing frequently over her four years in office about her holding meetings for constituents to communicate with her. I wonder now if our congresspeople, like so many others in the public eye will have to be so security conscious that normal interaction and give and take between them and their constituents will be impossible. Yet another weakening of democratic process in this country.
Some of the murdered in this incident include a nine year old girl who wanted to learn more about politics and government, a well-respected federal judge, Gabby's constituent services director, and three civic minded elderly retirees.
We couldn't afford to lose any of them, either. But, we mustn't think that the easy availability of guns had anything to do with this tragedy. "A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear Arms shall not be infringed." I suppose it would only show my hopelessly liberal anti-freedom bias to suggest that a little more regulation of our vast militia of arms bearing people might be in order.
.
This guest post by William Bemis is the second of three related to the recent shootings of Gabrielle Giffords and others in Tucson (in Pima County), AZ. Shortly before the shootings, the NY Times reported on a decision by the AZ Board of Education (a state agency in the capital, Phoenix) to close a Latino studies class in a Tucson High School. Urged by family members to consider relocation, Mr. Bemis, a psychotherapist and my brother-in-law, wrote this response, speaking of the Arizona city whose City Council had previously voted to ask the state to rescind its anti-immigrant law; after the shooting, at my request, he added additional material.
No, my dear, it's time for us and others like us to re-double our efforts to not only preserve Pima County as an island of sanity in this sea of ideological madness, but help the rest of the state and the nation see that leaving all the levers of power in the hands of racist corporate stooges is not going to take us anywhere but down. Having lived in this state for over 40 years now, I've seen this before - with Evan Meacham and Fife Symington, for example. After each of these lunatic lurches to the right, the state came back to at least a more moderate centrist political configuration. Arizona will never be Massachusetts or Oregon or Minnesota, but I, for one, am not ready to leave and concede this beautiful and unique place to the hate mongering front men for big money interests.
I loved living in New York, but we could never afford it, and besides, although their antics are less spectacularly loony, I wouldn't call the New York state government an example to emulate. Where else? Illinois? Puh-leeze! California? Are we talking about the homeland of Nixon, Reagan, Robert Dornan, et al? Sadly, Californios have also had to deal with home grown right wing fanatics, que no? Oregon? A more congenial political environment, perhaps, and a beautiful state, but too much rain!
It isn't just here, is it? I think we have to take the long view. The so-called conservatives (what do they wish to conserve besides entrenched wealth?) are riding high right now, both here and in Washington, but in the next couple of years they are going to amply demonstrate the meaness and poverty of their ideas. Contrary to the self delusions of Russell Pearce, Jan Brewer, Mitch McConnell, and John Boehner, I think these folks are cruising for a fall. I am more worried about the failure of those of us who do not share their agenda to take advantage of this moment than I am of the pseudo-populist, big money financed Tea Party. They have the money, so we all have to write our more modest checks and work all the harder. Our own apathy and discouragement is the enemy.
Moments after writing the above, I heard the news that Gabrielle Giffords, our Congresswoman, had been shot by yet another disturbed young loner of the type who seem to implement "Second Amendment solutions " to their private frustration and alienation on an almost daily basis now, thereby spreading their own psychic pain to all the rest of us. Cue the required messages of horrified shock and condolences from politicians of all persuasions, including even Sarah Palin who put Gabby's district literally in the rifle sight cross hairs and who tells her followers, "Don't retreat, RELOAD!" Some of those messages are no doubt sincere, but the one politician who was the most eloquent to me was Pima County Sheriff Clarence Dupnik, who doesn't get nearly the amount of press as his counterpart in Maricopa County, possibly because he is a hardworking, low key, decent, and fair public servant, which never seems to make good copy. Sheriff Dupnik's comments about political vitriol triggering mentally unbalanced individuals goes right to the heart of the current political climate in Arizona and across the country.
Gabrielle Giffords is a self-described "Blue Dog Democrat". For me, her politics are way too centrist in an era when what used to be the core values of the Democratic Party are under siege. If only she fit the liberal label that the Tea Party would like to pin on her! Though Gabby's stances on a lot of issues frustrated me, I worked as a volunteer on her election campaigns because I knew she was absolutely the best person we could hope to have elected to Congress from her district, which is Republican overall and in many precincts virulently racist and violent. Gabby is smart, dedicated, articulate, hard-working, extremely personable, and so much better than her recent opponent whom she barely defeated that I would have been ashamed if he had won and I hadn't done what I could to put her back in office. She is surviving so far the bullet that passed through her brain, and the trauma surgeons are optimistic, but I can't help but wonder if she does survive if she will ever be able to function again at the level she did prior. I read somewhere that she was advised recently that she had been too inaccessible in the past, though I seem to remember hearing frequently over her four years in office about her holding meetings for constituents to communicate with her. I wonder now if our congresspeople, like so many others in the public eye will have to be so security conscious that normal interaction and give and take between them and their constituents will be impossible. Yet another weakening of democratic process in this country.
Some of the murdered in this incident include a nine year old girl who wanted to learn more about politics and government, a well-respected federal judge, Gabby's constituent services director, and three civic minded elderly retirees.
We couldn't afford to lose any of them, either. But, we mustn't think that the easy availability of guns had anything to do with this tragedy. "A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear Arms shall not be infringed." I suppose it would only show my hopelessly liberal anti-freedom bias to suggest that a little more regulation of our vast militia of arms bearing people might be in order.
.
Saturday, January 15, 2011
Risk, Primitive Reactions, and Human Health Behaviors
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NPR’s “All Things Considered” recently reviewed several scary events from 2010 (“The year in fear: fright or fallacy?”). Reporter Jon Hamilton spoke with Dr. David Ropiek, Director of Risk Communication at the Harvard Center for Risk, about what made these events (Toyota’s acceleration problems, the Deepwater Horizon oil spill and the use of chemical dispersants, etc.) particularly frightening. Dr. Ropiek said that people tend to make decisions, and react positively or negatively, based on very simplistic (and usually unconscious) criteria, rather than on careful critical analysis of the relative benefits of one course of action over another, with the most important criterion being “is there immediate danger?” The reason he gave was that our basic neurobiology was unchanged over human history while our culture and society was remarkably more complex than when quick decisions were mostly about achieving immediate results (fight or flee). “We use a risk-perception system that evolved in simpler times, when the risks were bad guys with clubs, and the dark, and wolves. It's quick. But quick isn't necessarily the best for the complicated stuff we face in modern society.” Thus, for example, even though the evidence would show that the human and environmental danger of the oil spill was in the oil much more than any risk from chemical dispersants, “Just the word chemicals in your listeners' minds is currently setting off a little organ in their brain called the amygdala, which is the 24/7 radar in our brain that says - is there danger in that data?”; that is, our fears are triggered by the word (chemicals) which we have come to associate with danger.
Similarly, people can grasp the specific, and feel the pain, for an individual more easily than for a large, amorphous population. Thus, the outpouring of concern for “Baby Jessica” falling down a well in 1987, or for the child dying of leukemia, is much stronger than that for thousands of people, especially those in other countries, dying of war, disease, or even more abstract, structural violence. It is not just the one versus the many; it is the suddenness of it. We feel for the trapped Chilean miners, or the victims of a bombing; Ropiek says “… a chronic risk doesn’t ring our alarm bells the way a catastrophic, all-at-once one does. Because it concentrates the mind to see a bunch of the tribe all whacked at once.” So a particularly gory battle or atrocity is horrifying, but when there are chronic, repeated bombings and battles (as in Iraq or Afghanistan), even though they lead to much more death, we feel less.
We can see a murderer as a bad person, but it is harder to identify the members of the “grifter class” (coined by Matt Taibbi, “Griftopia”[1] ) who are responsible for the financial system that has visited so much evil on all of us. When people hear about something they know little or nothing about, especially if it is very complex and hard to understand, they often deal with it by putting a “frame” around it, tying it to something that seems similar enough (at least in one dimension) that they feel they can hang their hat on the analogy and judge it. For example, “chemicals=bad” in the example above is such a frame; so is dealing with universal health insurance by framing it as “socialized medicine”=”socialism”=”bad”. Unfortunately, the world is far more complex than this, and more unfortunately unscrupulous politicians and opinion-makers (my frame = “selfish evil people”) take advantage of this to obscure complexity and buy into often nonsensical self contradictions (taxes=bad, deficits=bad; let’s not have either!)
When it comes to health and medicine, the same issues come into play. People perceive immediate distress with acute problems (e.g., cough, fever, and most especially pain!) and know how much they would appreciate relief. The impact of conditions that do not cause appreciable symptoms right now but will cause really bad outcomes (death, morbidity, poor quality of life) if untreated in the future, are much harder to get people to make high priorities. The doctor sees untreated hypertension in terms of a future outcome (stroke, kidney failure), but this is more difficult for the patient. Even when s/he believes and understands it intellectually, it is much less likely that the treatment of a largely asymptomatic condition will rise to the top of life’s many more urgent priorities (food, clothing, housing, childcare, work) than if it were, say, pain.
The problem is even greater for public health, as I discussed in Public Health and Changing People's Minds (Saturday, May 15, 2010) where populations are huge, timelines are long and risk is relative. Public health addresses risks for populations, not me, or my family; translating population risk into individual prior probability is fairly difficult. For most people, even the concept of risk – that a given event will not definitely have or definitely not have a particular result, but will be somewhere on the continuum between them – is something they are not accustomed to thinking about, although they use it all the time (deciding whether to cross on a red light, for example). Consciously comparing the relative risk of different actions is very difficult, especially when the results have very different timelines. A definite immediate benefit (have that tasty fried or sweet food; throw a wrapper out the window, get a big gas-guzzler, have unprotected sex) has a lot more weight than the possibility of a bad long-term outcome (besides, next time, in the future, I’m going to go on a diet, give up smoking, use condoms). Dr. Ropiek notes that because events that cause “a bunch of the tribe to be all whacked at once” happens relatively rarely, “…we tend to downplay chronic risks like car accidents, diabetes, heart disease and the flu.” Sometimes public health officials can create that fear and mobilize the attention of the populace, as with concern about the swine flu of 1976, but that is also an example of how, when predicted risk of bad outcomes doesn’t happen, it reinforces the tendency to downplay those chronic risks.
In making decisions about medical care, this sort of perception can cut either way, depending on how a person looks at it based on personal and familial experience, cultural beliefs, and the way they “frame” medical interventions, as well as how urgent or important a solution is. Some people do not trust doctors or medicines, based on these criteria, and prefer to not take medicines or advice, even when an analysis of the relative risk shows the treatment to be definitely beneficial. Others have unrealistic expectations of what medicine can do (fueled, of course, by both doctors and direct-to-consumer drug advertising), and are angry when the doctor cannot cure their viral illness, make their back pain disappear, or compensate for all of the other parts of life that are bad and make them happy. At times of serious illness, where both treatment and non-treatment have real risks, or at end of life when people are not ready to accept that it is the end of life, even a professional evaluation of relative risk/benefit is difficult, so it is hardly surprising that people return to simpler methods of decision making (will I be able to live another day? Will it end my/his/her pain?).
Hamilton ends the interview segment with: “So Ropiek says we need to acquire a new fear - the fear of getting risk wrong.” I wish us luck on that.
[1] Taibbi, M. Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America. Random House. New York. 2010
.
NPR’s “All Things Considered” recently reviewed several scary events from 2010 (“The year in fear: fright or fallacy?”). Reporter Jon Hamilton spoke with Dr. David Ropiek, Director of Risk Communication at the Harvard Center for Risk, about what made these events (Toyota’s acceleration problems, the Deepwater Horizon oil spill and the use of chemical dispersants, etc.) particularly frightening. Dr. Ropiek said that people tend to make decisions, and react positively or negatively, based on very simplistic (and usually unconscious) criteria, rather than on careful critical analysis of the relative benefits of one course of action over another, with the most important criterion being “is there immediate danger?” The reason he gave was that our basic neurobiology was unchanged over human history while our culture and society was remarkably more complex than when quick decisions were mostly about achieving immediate results (fight or flee). “We use a risk-perception system that evolved in simpler times, when the risks were bad guys with clubs, and the dark, and wolves. It's quick. But quick isn't necessarily the best for the complicated stuff we face in modern society.” Thus, for example, even though the evidence would show that the human and environmental danger of the oil spill was in the oil much more than any risk from chemical dispersants, “Just the word chemicals in your listeners' minds is currently setting off a little organ in their brain called the amygdala, which is the 24/7 radar in our brain that says - is there danger in that data?”; that is, our fears are triggered by the word (chemicals) which we have come to associate with danger.
Similarly, people can grasp the specific, and feel the pain, for an individual more easily than for a large, amorphous population. Thus, the outpouring of concern for “Baby Jessica” falling down a well in 1987, or for the child dying of leukemia, is much stronger than that for thousands of people, especially those in other countries, dying of war, disease, or even more abstract, structural violence. It is not just the one versus the many; it is the suddenness of it. We feel for the trapped Chilean miners, or the victims of a bombing; Ropiek says “… a chronic risk doesn’t ring our alarm bells the way a catastrophic, all-at-once one does. Because it concentrates the mind to see a bunch of the tribe all whacked at once.” So a particularly gory battle or atrocity is horrifying, but when there are chronic, repeated bombings and battles (as in Iraq or Afghanistan), even though they lead to much more death, we feel less.
We can see a murderer as a bad person, but it is harder to identify the members of the “grifter class” (coined by Matt Taibbi, “Griftopia”[1] ) who are responsible for the financial system that has visited so much evil on all of us. When people hear about something they know little or nothing about, especially if it is very complex and hard to understand, they often deal with it by putting a “frame” around it, tying it to something that seems similar enough (at least in one dimension) that they feel they can hang their hat on the analogy and judge it. For example, “chemicals=bad” in the example above is such a frame; so is dealing with universal health insurance by framing it as “socialized medicine”=”socialism”=”bad”. Unfortunately, the world is far more complex than this, and more unfortunately unscrupulous politicians and opinion-makers (my frame = “selfish evil people”) take advantage of this to obscure complexity and buy into often nonsensical self contradictions (taxes=bad, deficits=bad; let’s not have either!)
When it comes to health and medicine, the same issues come into play. People perceive immediate distress with acute problems (e.g., cough, fever, and most especially pain!) and know how much they would appreciate relief. The impact of conditions that do not cause appreciable symptoms right now but will cause really bad outcomes (death, morbidity, poor quality of life) if untreated in the future, are much harder to get people to make high priorities. The doctor sees untreated hypertension in terms of a future outcome (stroke, kidney failure), but this is more difficult for the patient. Even when s/he believes and understands it intellectually, it is much less likely that the treatment of a largely asymptomatic condition will rise to the top of life’s many more urgent priorities (food, clothing, housing, childcare, work) than if it were, say, pain.
The problem is even greater for public health, as I discussed in Public Health and Changing People's Minds (Saturday, May 15, 2010) where populations are huge, timelines are long and risk is relative. Public health addresses risks for populations, not me, or my family; translating population risk into individual prior probability is fairly difficult. For most people, even the concept of risk – that a given event will not definitely have or definitely not have a particular result, but will be somewhere on the continuum between them – is something they are not accustomed to thinking about, although they use it all the time (deciding whether to cross on a red light, for example). Consciously comparing the relative risk of different actions is very difficult, especially when the results have very different timelines. A definite immediate benefit (have that tasty fried or sweet food; throw a wrapper out the window, get a big gas-guzzler, have unprotected sex) has a lot more weight than the possibility of a bad long-term outcome (besides, next time, in the future, I’m going to go on a diet, give up smoking, use condoms). Dr. Ropiek notes that because events that cause “a bunch of the tribe to be all whacked at once” happens relatively rarely, “…we tend to downplay chronic risks like car accidents, diabetes, heart disease and the flu.” Sometimes public health officials can create that fear and mobilize the attention of the populace, as with concern about the swine flu of 1976, but that is also an example of how, when predicted risk of bad outcomes doesn’t happen, it reinforces the tendency to downplay those chronic risks.
In making decisions about medical care, this sort of perception can cut either way, depending on how a person looks at it based on personal and familial experience, cultural beliefs, and the way they “frame” medical interventions, as well as how urgent or important a solution is. Some people do not trust doctors or medicines, based on these criteria, and prefer to not take medicines or advice, even when an analysis of the relative risk shows the treatment to be definitely beneficial. Others have unrealistic expectations of what medicine can do (fueled, of course, by both doctors and direct-to-consumer drug advertising), and are angry when the doctor cannot cure their viral illness, make their back pain disappear, or compensate for all of the other parts of life that are bad and make them happy. At times of serious illness, where both treatment and non-treatment have real risks, or at end of life when people are not ready to accept that it is the end of life, even a professional evaluation of relative risk/benefit is difficult, so it is hardly surprising that people return to simpler methods of decision making (will I be able to live another day? Will it end my/his/her pain?).
Hamilton ends the interview segment with: “So Ropiek says we need to acquire a new fear - the fear of getting risk wrong.” I wish us luck on that.
[1] Taibbi, M. Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America. Random House. New York. 2010
.
Sunday, January 9, 2011
The Arizona shootings: When will we ever learn?
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My heart -- and those of my family, many of whom live in her district -- go out to the family and friends of Rep. Gabrielle Giffords, and Judge John Roll and all the other victims of the shooting. As politicians of all stripes have said, it is a tragedy, and the perpetrator is obviously deranged. That said, the irresponsible rhetoric of those who would never do such a thing themselves is inflamm
atory, and sets off the "weapon", the sacrificial lamb, who carries out the attack. The parallels of this to the assassination of George Tiller are obvious -- politicians, radioheads, and bloviators engage in increasing violent rhetoric and then protest innocence when an unstable disciple carries out a violent attack. Can Sarah Palin deny her "crosshairs" post (now taken down) on her website? Can Jesse Kelly, who ran against Rep. Giffords in 2010 (not to be confused with her husband, astronaut Mark Kelly) deny his posters where he posed in Marine uniform with his M-16 and invited supporters to a shooting event to remove[1] Rep. Giffords? Can Beck, Limbaugh, et.al., deny that their rantings DO affect their dittoheads -- after all, that impact is what boosts their ratings, and their incomes.
And all the protestations that the aggressive elimination of gun control laws in Arizona and other states have nothing to do with guns being used for murder; the swaggering of gun-on-hip posses showing up in coffee shops to intimidate "liberals" not creating an environment where a murderer or assassin can legally be carrying a gun, are vapid. The NRA says "Guns don't kill people -- people kill people." That is true, but people with guns are able to kill more people, more rapidly, from a greater distance. You can bludgeon someone to death, but would John Roll be dead and Gabrielle Giffords in critical condition if Jared Loughner had attacked with a baseball bat? You can kill someone with a knife, but even if Loughner were an action-movie hero and could have thrown his knife with deadly accuracy at Rep. Giffords, would 9-year-old Christina Green be dead? Come on! Be grownups! You can't say one thing -- all guns of all types should be freely available -- and then deny the inevitable result! Well, of course you can, and it is done all the time.
If there is anyone who is eligible to be considered a hero in this tragedy, it is Pima County (Tucson area) Sheriff Clarence Dupnik, who movingly spoke of
his friends, and, in what might be a "politically risky" statement condemned the "vitriol" in the public debate that leads to such horror. (Video: http://www.cnn.com/2011/CRIME/01/09/arizona.shooting/index.html). The contrast of his obviously pained and saddened but measured, rational speech to the stormtrooper raids of his more infamous counterpart, Maricopa County (Phoenix area) Sheriff Joe Arpaio could not be greater.
We grieve for the dead and the wounded, and we grieve for our country. And we will take it back, our candlelight vigils against their M-16s.
My heart -- and those of my family, many of whom live in her district -- go out to the family and friends of Rep. Gabrielle Giffords, and Judge John Roll and all the other victims of the shooting. As politicians of all stripes have said, it is a tragedy, and the perpetrator is obviously deranged. That said, the irresponsible rhetoric of those who would never do such a thing themselves is inflamm
atory, and sets off the "weapon", the sacrificial lamb, who carries out the attack. The parallels of this to the assassination of George Tiller are obvious -- politicians, radioheads, and bloviators engage in increasing violent rhetoric and then protest innocence when an unstable disciple carries out a violent attack. Can Sarah Palin deny her "crosshairs" post (now taken down) on her website? Can Jesse Kelly, who ran against Rep. Giffords in 2010 (not to be confused with her husband, astronaut Mark Kelly) deny his posters where he posed in Marine uniform with his M-16 and invited supporters to a shooting event to remove[1] Rep. Giffords? Can Beck, Limbaugh, et.al., deny that their rantings DO affect their dittoheads -- after all, that impact is what boosts their ratings, and their incomes.And all the protestations that the aggressive elimination of gun control laws in Arizona and other states have nothing to do with guns being used for murder; the swaggering of gun-on-hip posses showing up in coffee shops to intimidate "liberals" not creating an environment where a murderer or assassin can legally be carrying a gun, are vapid. The NRA says "Guns don't kill people -- people kill people." That is true, but people with guns are able to kill more people, more rapidly, from a greater distance. You can bludgeon someone to death, but would John Roll be dead and Gabrielle Giffords in critical condition if Jared Loughner had attacked with a baseball bat? You can kill someone with a knife, but even if Loughner were an action-movie hero and could have thrown his knife with deadly accuracy at Rep. Giffords, would 9-year-old Christina Green be dead? Come on! Be grownups! You can't say one thing -- all guns of all types should be freely available -- and then deny the inevitable result! Well, of course you can, and it is done all the time.
If there is anyone who is eligible to be considered a hero in this tragedy, it is Pima County (Tucson area) Sheriff Clarence Dupnik, who movingly spoke of
his friends, and, in what might be a "politically risky" statement condemned the "vitriol" in the public debate that leads to such horror. (Video: http://www.cnn.com/2011/CRIME/01/09/arizona.shooting/index.html). The contrast of his obviously pained and saddened but measured, rational speech to the stormtrooper raids of his more infamous counterpart, Maricopa County (Phoenix area) Sheriff Joe Arpaio could not be greater.We grieve for the dead and the wounded, and we grieve for our country. And we will take it back, our candlelight vigils against their M-16s.
[1] “’I don't see the connection," between the fundraisers featuring weapons and Saturday's shooting’, said John Ellinwood, Kelly's spokesman. ‘I don't know this person, we cannot find any records that he was associated with the campaign in any way. I just don't see the connection.’” (AOL news)
Wednesday, January 5, 2011
Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage
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According to the New York Times, “Here is a basic truth about the deficit: In the long run, it cannot be fixed, without reining in spending on Medicare and Medicaid.” In a December 11, 2010 editorial titled “Health Care and the Deficit”, the Times lets us know that Medicare, Medicaid, and S-CHIP (the Children’s Health Insurance Program that covers low-income children whose families are too “rich” for Medicaid) account for more than 20% of federal expenditures, more than Social Security or national defense; and that, if unchecked, will rise to 40% by 2035. To the editorialist this is obviously unacceptable, and s/he reviews the proposals of the two recent “bipartisan” commissions that have made recommendations to reduce spending on these programs.
Overall, the editorial is good in that it is very critical of the recommendations of both commissions. “The most disturbing element of both reports is that, in their efforts to show quick savings, they shift much of the burden from the federal budget to individuals or, in some cases, to states. That may make the federal deficit look better, but it is a shell game that produces no real reduction in the cost of health care.” Bowles-Simpson (the conceived-of-as-a-deficit-reduction-but-changed-into-a-tax-cut panel, previously addressed in my blog of December 12, 2010 Tax Breaks for the "Masters of the Universe" or for the rest of us? ) wants mostly to save money by having greater “cost sharing” by Medicare beneficiaries.
While, as the editorialist points out, there is something to be said for people with any type of insurance not being completely insulated from the cost when they opt for probably-unnecessary expensive tests, the fact is that the fault is much less often on the part of the patient than on the part of the doctors who recommend these tests. This is particularly true when those doctors have a financial interest in doing the tests because they are highly-reimbursed for them. If this is the problem, then regulation should address it directly, by having Medicare, Medicaid, and other insurers use cost-effectiveness criteria rather than taking the real risk that “people on modest incomes might forgo needed care.”
The other panel, Domenici-Rivlin (another “bipartisan” group headed by a conservative Republican and a conservative Democrat), also recommends cost sharing, and goes even further by taxing the cost of health benefits that workers receive. It relies on the idea that, with cost sharing, beneficiaries will restrain their own spending. They are likely to – even at the cost of their own health. It also resurrects the idea of vouchers for people on Medicaid.
Yes: Medicare, Medicaid, and the entire US health system spend too much money; and yes: the cost of what is called “health care” is squeezing out spending on other critical social programs, such as education. But the recommendations of these two commissions, essentially capping spending while continuing to reward private health insurers through their “market-based” solutions, will only exacerbate the problem.
Meanwhile, following on the heels of Massachusetts’ experience in not having enough primary care doctors – or other providers – to meet the health needs of its increased number of insured citizens, California is experiencing the same problem, without even having a state-wide health reform. Documented in the PBS News Hour report aired November 18, 2010, “In California, facing down a family physician shortage”, residents of that state cannot find the primary care doctors they need to provide cost-effective care, and it is anticipated to get “worse” with health reform. Paul Leight, a health economist at the University of California Davis, states “So, we have more than 20 million Americans who now don't have health insurance who will have health insurance. And once they get health insurance, naturally, they're going to want to see a primary care physician.“ Naturally. And we don’t have nearly enough of them.
But, of course, as has been it seems endlessly documented on this blog and by study after study, including for example the Commonwealth Foundation’s 2010 report “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update”[1], the US spends far more (2-3 times more!) and gets worse health outcomes than all other developed countries. Commonwealth’s 2008 report shows that the US, in terms of health outcomes, did worse than in its original report of 2006, and spending has continued to increase. The biggest reason for the excessive cost in the US is that it is based in a system geared to profit, by insurers, drug and device makers, and health care providers (including hospitals, doctors, nursing homes, etc.) As I have pointed out (for example, in A Modest Proposal: Bribe the Insurance Companies, August 23, 2009), it is not simply the profit itself that causes the grossly bloated cost of US health care, but the inefficient system built to ensure the continuation of that profit. To suggest solutions based on increasing the role of private, profit-incented, players as a method of controlling costs is illogical. Increasing profits will come either from increasing costs or from decreasing access to care. This is not the way to go.
The goal must not be simply reducing costs, but increasing quality. The wonderful thing about health care is that our system is so bloated and inverted in its incentives and outputs – and in having far more tertiary than primary care -- that this seeming contradiction, reduce costs and increase quality, can be achieved. Different groups push for more primary care, limitations on high cost technical procedures, and a more rational health system based upon universal access and elimination of profit. Unfortunately, taken alone, each is inadequate. Here is what the evidence shows will work:
More Primary Care. We need a system based upon primary care, so that Massachusetts, California, and the rest of the country, can have the primary care providers they need. This is the focus of the Patient Centered Primary Care Collaborative (PCPCC). This means completely changing the financial incentives at every level that lead to production of more subspecialists. The “encouragements” for increasing primary care contained in ACA are inadequate. The key issue is the inverted reimbursement system in which procedure-based subspecialists make many times the income-per-hour of primary care doctors. The reimbursement system used by Medicare (upon which all other insurers base their reimbursement), currently controlled by a specialist-dominated advisory group, needs to change entirely so that potential income is eliminated from the specialty-choice decisions of medical students, and so that procedure-based profit is eliminated from the decision of hospitals about what kind of care and specialists they wish to support.
Cost-effectiveness payment. Tied to changing the mix of primary and sub-specialty providers and their reimbursement is for Medicare and other payers to not pay for, or not pay as much for, unproven high-cost therapies, whether those are new drugs or devices or unproven procedures. This does not mean denying access to some procedures or drugs across the board to all patients; it means appropriately selecting those who are most likely to benefit. This is a complex science, but an easy concept: what is likely to be cost-effective for me may well not be for you, because we are different, in disease, disease stage, intercurrent conditions, underlying reserve, etc.
Universal not-for-profit health insurance system. This is the sine qua non, the single necessary element for improving the health of all our people. It is not sufficient in itself, but without it there is no chance to control costs, or to implement reimbursement reform, or to effectively limit the use of high-cost, low-effectiveness and/or unproven technologies.
These will work, but need to all be done. Expanding primary care and limiting expenditures on high-cost procedures will not improve everyone’s health unless we have a university health insurance system that is not based upon profit; a universal health system without increased primary care or cost-effectiveness criteria for procedures will not achieve either goal of improving America’s health or saving money. They are all necessary legs for the stool of cost-effective, high-quality, universally-accessible health care to stand up.
[1] K. Davis, C. Schoen, and K. Stremikis, How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010.
.
According to the New York Times, “Here is a basic truth about the deficit: In the long run, it cannot be fixed, without reining in spending on Medicare and Medicaid.” In a December 11, 2010 editorial titled “Health Care and the Deficit”, the Times lets us know that Medicare, Medicaid, and S-CHIP (the Children’s Health Insurance Program that covers low-income children whose families are too “rich” for Medicaid) account for more than 20% of federal expenditures, more than Social Security or national defense; and that, if unchecked, will rise to 40% by 2035. To the editorialist this is obviously unacceptable, and s/he reviews the proposals of the two recent “bipartisan” commissions that have made recommendations to reduce spending on these programs.
Overall, the editorial is good in that it is very critical of the recommendations of both commissions. “The most disturbing element of both reports is that, in their efforts to show quick savings, they shift much of the burden from the federal budget to individuals or, in some cases, to states. That may make the federal deficit look better, but it is a shell game that produces no real reduction in the cost of health care.” Bowles-Simpson (the conceived-of-as-a-deficit-reduction-but-changed-into-a-tax-cut panel, previously addressed in my blog of December 12, 2010 Tax Breaks for the "Masters of the Universe" or for the rest of us? ) wants mostly to save money by having greater “cost sharing” by Medicare beneficiaries.
While, as the editorialist points out, there is something to be said for people with any type of insurance not being completely insulated from the cost when they opt for probably-unnecessary expensive tests, the fact is that the fault is much less often on the part of the patient than on the part of the doctors who recommend these tests. This is particularly true when those doctors have a financial interest in doing the tests because they are highly-reimbursed for them. If this is the problem, then regulation should address it directly, by having Medicare, Medicaid, and other insurers use cost-effectiveness criteria rather than taking the real risk that “people on modest incomes might forgo needed care.”
The other panel, Domenici-Rivlin (another “bipartisan” group headed by a conservative Republican and a conservative Democrat), also recommends cost sharing, and goes even further by taxing the cost of health benefits that workers receive. It relies on the idea that, with cost sharing, beneficiaries will restrain their own spending. They are likely to – even at the cost of their own health. It also resurrects the idea of vouchers for people on Medicaid.
Yes: Medicare, Medicaid, and the entire US health system spend too much money; and yes: the cost of what is called “health care” is squeezing out spending on other critical social programs, such as education. But the recommendations of these two commissions, essentially capping spending while continuing to reward private health insurers through their “market-based” solutions, will only exacerbate the problem.
Meanwhile, following on the heels of Massachusetts’ experience in not having enough primary care doctors – or other providers – to meet the health needs of its increased number of insured citizens, California is experiencing the same problem, without even having a state-wide health reform. Documented in the PBS News Hour report aired November 18, 2010, “In California, facing down a family physician shortage”, residents of that state cannot find the primary care doctors they need to provide cost-effective care, and it is anticipated to get “worse” with health reform. Paul Leight, a health economist at the University of California Davis, states “So, we have more than 20 million Americans who now don't have health insurance who will have health insurance. And once they get health insurance, naturally, they're going to want to see a primary care physician.“ Naturally. And we don’t have nearly enough of them.
But, of course, as has been it seems endlessly documented on this blog and by study after study, including for example the Commonwealth Foundation’s 2010 report “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update”[1], the US spends far more (2-3 times more!) and gets worse health outcomes than all other developed countries. Commonwealth’s 2008 report shows that the US, in terms of health outcomes, did worse than in its original report of 2006, and spending has continued to increase. The biggest reason for the excessive cost in the US is that it is based in a system geared to profit, by insurers, drug and device makers, and health care providers (including hospitals, doctors, nursing homes, etc.) As I have pointed out (for example, in A Modest Proposal: Bribe the Insurance Companies, August 23, 2009), it is not simply the profit itself that causes the grossly bloated cost of US health care, but the inefficient system built to ensure the continuation of that profit. To suggest solutions based on increasing the role of private, profit-incented, players as a method of controlling costs is illogical. Increasing profits will come either from increasing costs or from decreasing access to care. This is not the way to go.
The goal must not be simply reducing costs, but increasing quality. The wonderful thing about health care is that our system is so bloated and inverted in its incentives and outputs – and in having far more tertiary than primary care -- that this seeming contradiction, reduce costs and increase quality, can be achieved. Different groups push for more primary care, limitations on high cost technical procedures, and a more rational health system based upon universal access and elimination of profit. Unfortunately, taken alone, each is inadequate. Here is what the evidence shows will work:
More Primary Care. We need a system based upon primary care, so that Massachusetts, California, and the rest of the country, can have the primary care providers they need. This is the focus of the Patient Centered Primary Care Collaborative (PCPCC). This means completely changing the financial incentives at every level that lead to production of more subspecialists. The “encouragements” for increasing primary care contained in ACA are inadequate. The key issue is the inverted reimbursement system in which procedure-based subspecialists make many times the income-per-hour of primary care doctors. The reimbursement system used by Medicare (upon which all other insurers base their reimbursement), currently controlled by a specialist-dominated advisory group, needs to change entirely so that potential income is eliminated from the specialty-choice decisions of medical students, and so that procedure-based profit is eliminated from the decision of hospitals about what kind of care and specialists they wish to support.
Cost-effectiveness payment. Tied to changing the mix of primary and sub-specialty providers and their reimbursement is for Medicare and other payers to not pay for, or not pay as much for, unproven high-cost therapies, whether those are new drugs or devices or unproven procedures. This does not mean denying access to some procedures or drugs across the board to all patients; it means appropriately selecting those who are most likely to benefit. This is a complex science, but an easy concept: what is likely to be cost-effective for me may well not be for you, because we are different, in disease, disease stage, intercurrent conditions, underlying reserve, etc.
Universal not-for-profit health insurance system. This is the sine qua non, the single necessary element for improving the health of all our people. It is not sufficient in itself, but without it there is no chance to control costs, or to implement reimbursement reform, or to effectively limit the use of high-cost, low-effectiveness and/or unproven technologies.
These will work, but need to all be done. Expanding primary care and limiting expenditures on high-cost procedures will not improve everyone’s health unless we have a university health insurance system that is not based upon profit; a universal health system without increased primary care or cost-effectiveness criteria for procedures will not achieve either goal of improving America’s health or saving money. They are all necessary legs for the stool of cost-effective, high-quality, universally-accessible health care to stand up.
[1] K. Davis, C. Schoen, and K. Stremikis, How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010.
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Thursday, December 30, 2010
Immigration and the US: Happy New Year
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I sit in Arizona at Christmas, finishing Dennis Lehane’s novel “The Given Day”[1]. Set in 1919 in Boston and culminating in the landmark Boston police strike of that year, Lehane documents the “red scare” of that period, accompanied by the real number and strength of “reds”, the overt racism of the period along with the early days of the NAACP, the early days of the labor movement, the early days of John E. Hoover and the BI (later, of course, J. Edgar and the FBI), all set to a backdrop of the mid-career of Babe Ruth and the Red Sox (and his ultimate move to the New York Yankees). But from here, in Tucson, what seems most relevant today is that it documents the massive immigration (at that time in Boston mostly of Italians, Russians, and Jews) and anti-immigrant sentiment that accompanied it. So our current anti-immigrant furor is nothing new. It has deep roots, and is now, as it always has been, misguided.
Of course, American anti-immigrant movements go back much farther than 1919. Before the Russians, Italians, and Jews of the late 19th and early 20th century. Before even the Irish immigration, the xenophobic reaction to which was dramatically shown in the 2002 Martin Scorsese film “The Gangs of New York”. Before the Germans, back to the Alien and Sedition Acts of the John Adams administration at the end of the 18th century, and probably before that. Every group of European immigrants I have mentioned and more, Asians from China, Japan and the Philippines, and many others, have been vilified in their time. Each has been attacked by those already here, and ready to raise the drawbridge behind them. And they have made America great.
They come to America to escape grinding poverty or to maximize their opportunity. Most are poor, but some are doctors and engineers who believe they can do even better here than in, say India or Africa. (This is another issue, of brain drain, which I have touched on in earlier posts). Every time there are those “nativists” (some not here long themselves) who want to close the door, who worry that “they” will take “our” jobs. In Lehane’s book immigrants are leaders of the unions (as well as the radical revolutionary groups); immigrants have always mainly been workers. And is it different now, as the main focus of anti-immigrant wrath are those from Mexico? The wrath is centered here in Arizona (although, it should be noted, the sentiment is not uniform; although only symbolic, the Tucson City Council voted to oppose the state anti-immigrant law), and felt not only in the Southwest but all over the country. Does it make a difference that so many Mexican immigrants are “illegal”? Many of our citizens have been illegal. The major secondary characters in “The Given Day”, two older policemen who enforce “order” for the “Big Money” folks, came to the US from Ireland as teens, stowing away on a ship, and literally escaping into the streets of Boston, before later joining the force. Illegals, certainly, who believed themselves to be more "American" than the current generation of immigrants. And fictional, but representative of many real-life characters. Many “illegals” became citizens after serving in our armed forces, especially in World War II, when “we” needed “them”. Of course, America always needs “them”, to build our cities, our railroads, or industries; to be our engineers and storekeepers and cops and firemen and packing-house workers. We are “them”.
And we remain them, and they us, with only few exceptions. American Indians, whose “immigration” may have been in pre-history, and African-Americans, brought here in bondage, arguably the two most oppressed and discriminated-against ethnic groups. We can no more honorably close the door now than the descendants of English colonists who stole Indian land could for the Germans, or Irish, or Chinese, or Russian, or Polish, or Filipino, or Italian, or Jewish immigrants who succeeded them. They have always been the ones who did the work. Who pay taxes (so they are not caught) but receive no benefits, because we pass laws against “illegal” immigrants – denying them health care, denying them safety. Yet they are here; they get sick and injured, in working two and three jobs. And paying into benefit funds such as pensions and Social Security and Medicare for those of us, from earlier immigrations, to retire on, and receive our health care from. We can pass a health reform law that specifically excludes them from health coverage, not even allowing them to buy with their own money, but they will still need health care. We can even, in a gesture worthy of the persecutions of the 1920s, not pass the “Dream Act” so people who were brought up in this country can attend college with their classmates. Vigilantes can “patrol” the border, and fascist thugs like Maricopa County Sheriff Arpaio can terrorize entire communities. We can pass laws that make it a crime to help save the life of a person found dying in the desert. We can talk of children born to immigrant parents as “anchor babies”, and here I need to refer people to Lalo Alcaraz’ Christmas Day cartoon in his strip “La Cucaracha”. We can, and do, do all sorts of mean, short-sighted, and selfish things to oppress people, but this does not make them wise, honorable, moral, or even sensible. We can, however, be better than that.
In the coming year, I hope the Dream Act passes. And I hope that we can define ourselves, as Americans and as human beings, by our wisdom, our foresight, and the nobler parts of our nature, rather than by our narrowness, meaness, and bigotry.
Happy New Year.
[1] Lehane, Dennis. The Given Day. Harper Collins. New York. 2008.
.
.
I sit in Arizona at Christmas, finishing Dennis Lehane’s novel “The Given Day”[1]. Set in 1919 in Boston and culminating in the landmark Boston police strike of that year, Lehane documents the “red scare” of that period, accompanied by the real number and strength of “reds”, the overt racism of the period along with the early days of the NAACP, the early days of the labor movement, the early days of John E. Hoover and the BI (later, of course, J. Edgar and the FBI), all set to a backdrop of the mid-career of Babe Ruth and the Red Sox (and his ultimate move to the New York Yankees). But from here, in Tucson, what seems most relevant today is that it documents the massive immigration (at that time in Boston mostly of Italians, Russians, and Jews) and anti-immigrant sentiment that accompanied it. So our current anti-immigrant furor is nothing new. It has deep roots, and is now, as it always has been, misguided.
Of course, American anti-immigrant movements go back much farther than 1919. Before the Russians, Italians, and Jews of the late 19th and early 20th century. Before even the Irish immigration, the xenophobic reaction to which was dramatically shown in the 2002 Martin Scorsese film “The Gangs of New York”. Before the Germans, back to the Alien and Sedition Acts of the John Adams administration at the end of the 18th century, and probably before that. Every group of European immigrants I have mentioned and more, Asians from China, Japan and the Philippines, and many others, have been vilified in their time. Each has been attacked by those already here, and ready to raise the drawbridge behind them. And they have made America great.
They come to America to escape grinding poverty or to maximize their opportunity. Most are poor, but some are doctors and engineers who believe they can do even better here than in, say India or Africa. (This is another issue, of brain drain, which I have touched on in earlier posts). Every time there are those “nativists” (some not here long themselves) who want to close the door, who worry that “they” will take “our” jobs. In Lehane’s book immigrants are leaders of the unions (as well as the radical revolutionary groups); immigrants have always mainly been workers. And is it different now, as the main focus of anti-immigrant wrath are those from Mexico? The wrath is centered here in Arizona (although, it should be noted, the sentiment is not uniform; although only symbolic, the Tucson City Council voted to oppose the state anti-immigrant law), and felt not only in the Southwest but all over the country. Does it make a difference that so many Mexican immigrants are “illegal”? Many of our citizens have been illegal. The major secondary characters in “The Given Day”, two older policemen who enforce “order” for the “Big Money” folks, came to the US from Ireland as teens, stowing away on a ship, and literally escaping into the streets of Boston, before later joining the force. Illegals, certainly, who believed themselves to be more "American" than the current generation of immigrants. And fictional, but representative of many real-life characters. Many “illegals” became citizens after serving in our armed forces, especially in World War II, when “we” needed “them”. Of course, America always needs “them”, to build our cities, our railroads, or industries; to be our engineers and storekeepers and cops and firemen and packing-house workers. We are “them”.
And we remain them, and they us, with only few exceptions. American Indians, whose “immigration” may have been in pre-history, and African-Americans, brought here in bondage, arguably the two most oppressed and discriminated-against ethnic groups. We can no more honorably close the door now than the descendants of English colonists who stole Indian land could for the Germans, or Irish, or Chinese, or Russian, or Polish, or Filipino, or Italian, or Jewish immigrants who succeeded them. They have always been the ones who did the work. Who pay taxes (so they are not caught) but receive no benefits, because we pass laws against “illegal” immigrants – denying them health care, denying them safety. Yet they are here; they get sick and injured, in working two and three jobs. And paying into benefit funds such as pensions and Social Security and Medicare for those of us, from earlier immigrations, to retire on, and receive our health care from. We can pass a health reform law that specifically excludes them from health coverage, not even allowing them to buy with their own money, but they will still need health care. We can even, in a gesture worthy of the persecutions of the 1920s, not pass the “Dream Act” so people who were brought up in this country can attend college with their classmates. Vigilantes can “patrol” the border, and fascist thugs like Maricopa County Sheriff Arpaio can terrorize entire communities. We can pass laws that make it a crime to help save the life of a person found dying in the desert. We can talk of children born to immigrant parents as “anchor babies”, and here I need to refer people to Lalo Alcaraz’ Christmas Day cartoon in his strip “La Cucaracha”. We can, and do, do all sorts of mean, short-sighted, and selfish things to oppress people, but this does not make them wise, honorable, moral, or even sensible. We can, however, be better than that.
In the coming year, I hope the Dream Act passes. And I hope that we can define ourselves, as Americans and as human beings, by our wisdom, our foresight, and the nobler parts of our nature, rather than by our narrowness, meaness, and bigotry.
Happy New Year.
[1] Lehane, Dennis. The Given Day. Harper Collins. New York. 2008.
.
.
Friday, December 24, 2010
Cardiac stents and profit-driven corruption: do anti-fraud rules address the problem?
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Turns out that Baltimore may be the McAllen, Texas of cardiac stents. An article published On Monday, December 6, 2010 in the NY Times, “Doctor faces suits over cardiac stents”, by Gardiner Harris, describes the case of Dr. Mark Midei of Baltimore, who is now the target of a Senate Finance Committee investigation following a series of articles in the Baltimore Sun alleging that he put cardiac stents in many people who did not need them. Dr. Midei apparently put in as many as 30 stents per day, 1200 stents per year, in his hospital – numbers that matched hospitals 4 and 5 time as large in the northeast, and the Senate report indicates at least 585 were medically unnecessary, for which he charged Medicare $6.6M and was paid $3.8M. While the hospital, St. Joseph, is also being sued, apparently it and Dr. Midei are accusing each other of being at fault, and of trying to destroy each others’ reputations. Meanwhile, Abbott Laboratories, which manufactures the devices, is lavishing millions of dollars in favors upon Dr. Midei, a small portion of the enormous revenue he has generated for them. The report says that “The serious allegations lodged against Dr. Midei regarding the medically unnecessary implantation of cardiac stents did not appear to deter Abbott’s interest in assisting him.”
There is a lot more to say about this particular case, including a great quote: “After one particularly critical story in The Baltimore Sun, David C. Pacitti, an Abbott executive, wrote in an e-mail, ‘Someone needs to take this writer out and kick his ass.’”, but it would be a mistake to focus too much on this one; there are a lot more corrupt doctors, hospitals, and drug and device manufacturers (Abbott is both) out there.
First, the evidence. While the Times article cites “A landmark 2007 study published in The New England Journal of Medicine showed that many patients given stents would fare just as well without them,” they don’t indicate the article they are referring to (no author or reference given; the link is not to the article), but presumably it is the Swedish study by Lagerkvist, et. al, that showed increased recurrent MI (heart attack) and death with the use of drug-eluting stents compared to bare metal stents.[1] However, there are several articles in the March 8, 2007 issue of NEJM that address the safety of drug-eluting stents (i.e., stents impregnated with a drug to keep them from getting re-clotted, which as a group do not provide a consistent picture. Spaulding, et. al., from Paris, found that there was no difference in outcomes from patients with stents with the drug sirolimus compared to bare metal[2], while Stone and colleagues from Columbia found that drug-eluting stents with both sirolimus and paclitaxel had greater rates of re-thrombosis (though not heart attack or death) than bare metal.[3] Meanwhile, Kastrati and colleagues from Germany, reviewing 14 studies of sirolimus-eluting stents, also found no increase or decrease in heart attack or death, but less need for re-intervention, although at least as much re-thrombosis (clotting) as bare metal stents.[4] There are also two editorials; Farb and Boam, the official one from FDA[5] conclude “The safety and effectiveness of drug-eluting stents as compared with those of alternative treatments deserve continued study.”, while Maisel, head of an FDA committee that reviews these devices, writes “Drug-eluting stents represent an important advance in the management of coronary artery disease and have benefited many patients.“[6]
None of these articles compared stents to no stents, and there is no question that that many, many patients with coronary artery disease benefit greatly from them, getting relief of symptoms without having their chests cut open for surgery (coronary artery bypass grafting, or CABG, pronounced “cabbage”. Cute, huh?). Drug-eluting stents now require the patient take an anti-coagulant, and so the complex decision of whether they are better than bare-metal must be made for an individual patient, based on a variety of patient, stent, and anti-coagulation-risk characteristics. It is also worth noting that either stents or CABG only bypass (or stent open) already-narrowed areas in the coronary arteries. Therefore the risk of recurrent heart attack (MI) and associated death is not only from re-stenosis but the rupture of a cholesterol-laden plaque that might not previously been causing significant obstruction. These are the “sudden” MIs, which account for a larger number of heart attacks than those that come after increasing, gradual narrowing of a coronary artery (and the associated increasing chest pain, called angina pectoris).
Probably even more important are the complex interplay of financial rewards and government regulation that impact on the use of these and other devices, as well as all kinds of other treatments and interventions. There can be no justification for the obviously excessive stent placement by Dr. Midei, or the encouragement of it by Abbott and probably the hospital; as the Times article notes ”… far from questioning cardiologists who perform an unusually high number of stent procedures, many hospital executives celebrate these doctors because of the revenue they bring, which can be more than $10,000 per procedure.” In this context, the reported statement of Senator Max Baucus, Democrat of Montana and chairman of the Finance Committee, that “Hospital patients expect their care to be based on medical need, not profits…Even more disconcerting is that this could be a sign of a larger national trend of wasteful medical device use,” sounds heroic, but is it?
The hospitals have a point too, in their criticism of government regulation. Not all of the investigations by HHS, Medicare, and other government agencies are really meant to uncover such gross overuse or fraud, although this is how they are portrayed. Many of them are just about getting money for the Federal government as aggressively as possible, and if it can be called “fraud” as opposed to a “mistake” they can get huge penalties as well as refunds of Medicare money spent. A major Medicare initiative is Recovery Audit Contractors (RACs), essentially bounty hunters given a license to investigate certain hospitals for fraud. Great, except most of their work seems to be on finding whether patients were (and this is going to seem like a technical subtlety) officially “admitted” to the hospital, when the severity of their illness could have allowed them to be placed in the hospital for a day or more on “observation” status, where they are officially outpatients and reimbursed at a lower rate. If a hospital or doctor were systematically admitting people who should obviously be “observed”, this might be real fraud, what are probably honest minor errors (or differences of opinion) in the assessment of patient condition are blown up so that the RAC (and Medicare) can recover big penalties. Far from trying to systematically defraud Medicare, my hospital, the University of Kansas Hospital (which is very happy with its high cardiac-care rating by US News and is truly one of those hospitals that enjoy the large amounts of money interventional cardiology procedures provide) is spending a bunch of money to have each admission audited by an outside firm to ensure that they don’t violate these criteria and make themselves vulnerable to RAC recoveries.
So who is the “white hat”? Certainly not the drug and device makers, who are really “only in it for the money”, often not the hospitals, and sadly not always (although, honestly, most of the time) the doctors. But also not the government, seeking money to fund its wars in a down economy. Senator Baucus, famous for taking huge amounts from drug companies himself, may not be the one whom we should be trusting, but his statement that “Hospital patients [and, I would add, all patients!] expect their care to be based on medical need, not profits” is certainly a sentiment that I would endorse. Of course, the making of these profits is why the drug companies paid him. Some suspect that this might be partly why his committee, and the Congress overall, and the administration, did not pass a health reform bill that would achieve that result. Fraud is bad, and uncovering fraud is good, but RACs are not an answer to a flawed, profit-driven, health system.
[1] Lagerqvist B, James SK, Stenestrand U, Lindbäck J, Nilsson T, Wallentin L; SCAAR Study Group., Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden., N Engl J Med. 2007 Mar 8;356(10):1009-19. Epub 2007 Feb 12.
[2]Spaulding C, Daemen J, Boersma E, Cutlip DE, Serruys PW., A pooled analysis of data comparing sirolimus-eluting stents with bare-metal stents., N Engl J Med. 2007 Mar 8;356(10):989-97. Epub 2007 Feb 12.
[3] Stone GW, et al., Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents, N Engl J Med. 2007 Mar 8;356(10):998-1008. Epub 2007 Feb 12.
[4] Kastrati A, et. al., Analysis of 14 trials comparing sirolimus-eluting stents with bare-metal stents, N Engl J Med. 2007 Mar 8;356(10):1030-9. Epub 2007 Feb 12.
[5] Farb A, Boam AB., Stent thrombosis redux--the FDA perspective.,N Engl J Med. 2007 Mar 8;356(10):984-7. Epub 2007 Feb 12.
[6] Maisel WH., Unanswered questions--drug-eluting stents and the risk of late thrombosis, N Engl J Med. 2007 Mar 8;356(10):981-4. Epub 2007 Feb 12.
Turns out that Baltimore may be the McAllen, Texas of cardiac stents. An article published On Monday, December 6, 2010 in the NY Times, “Doctor faces suits over cardiac stents”, by Gardiner Harris, describes the case of Dr. Mark Midei of Baltimore, who is now the target of a Senate Finance Committee investigation following a series of articles in the Baltimore Sun alleging that he put cardiac stents in many people who did not need them. Dr. Midei apparently put in as many as 30 stents per day, 1200 stents per year, in his hospital – numbers that matched hospitals 4 and 5 time as large in the northeast, and the Senate report indicates at least 585 were medically unnecessary, for which he charged Medicare $6.6M and was paid $3.8M. While the hospital, St. Joseph, is also being sued, apparently it and Dr. Midei are accusing each other of being at fault, and of trying to destroy each others’ reputations. Meanwhile, Abbott Laboratories, which manufactures the devices, is lavishing millions of dollars in favors upon Dr. Midei, a small portion of the enormous revenue he has generated for them. The report says that “The serious allegations lodged against Dr. Midei regarding the medically unnecessary implantation of cardiac stents did not appear to deter Abbott’s interest in assisting him.”
There is a lot more to say about this particular case, including a great quote: “After one particularly critical story in The Baltimore Sun, David C. Pacitti, an Abbott executive, wrote in an e-mail, ‘Someone needs to take this writer out and kick his ass.’”, but it would be a mistake to focus too much on this one; there are a lot more corrupt doctors, hospitals, and drug and device manufacturers (Abbott is both) out there.
First, the evidence. While the Times article cites “A landmark 2007 study published in The New England Journal of Medicine showed that many patients given stents would fare just as well without them,” they don’t indicate the article they are referring to (no author or reference given; the link is not to the article), but presumably it is the Swedish study by Lagerkvist, et. al, that showed increased recurrent MI (heart attack) and death with the use of drug-eluting stents compared to bare metal stents.[1] However, there are several articles in the March 8, 2007 issue of NEJM that address the safety of drug-eluting stents (i.e., stents impregnated with a drug to keep them from getting re-clotted, which as a group do not provide a consistent picture. Spaulding, et. al., from Paris, found that there was no difference in outcomes from patients with stents with the drug sirolimus compared to bare metal[2], while Stone and colleagues from Columbia found that drug-eluting stents with both sirolimus and paclitaxel had greater rates of re-thrombosis (though not heart attack or death) than bare metal.[3] Meanwhile, Kastrati and colleagues from Germany, reviewing 14 studies of sirolimus-eluting stents, also found no increase or decrease in heart attack or death, but less need for re-intervention, although at least as much re-thrombosis (clotting) as bare metal stents.[4] There are also two editorials; Farb and Boam, the official one from FDA[5] conclude “The safety and effectiveness of drug-eluting stents as compared with those of alternative treatments deserve continued study.”, while Maisel, head of an FDA committee that reviews these devices, writes “Drug-eluting stents represent an important advance in the management of coronary artery disease and have benefited many patients.“[6]
None of these articles compared stents to no stents, and there is no question that that many, many patients with coronary artery disease benefit greatly from them, getting relief of symptoms without having their chests cut open for surgery (coronary artery bypass grafting, or CABG, pronounced “cabbage”. Cute, huh?). Drug-eluting stents now require the patient take an anti-coagulant, and so the complex decision of whether they are better than bare-metal must be made for an individual patient, based on a variety of patient, stent, and anti-coagulation-risk characteristics. It is also worth noting that either stents or CABG only bypass (or stent open) already-narrowed areas in the coronary arteries. Therefore the risk of recurrent heart attack (MI) and associated death is not only from re-stenosis but the rupture of a cholesterol-laden plaque that might not previously been causing significant obstruction. These are the “sudden” MIs, which account for a larger number of heart attacks than those that come after increasing, gradual narrowing of a coronary artery (and the associated increasing chest pain, called angina pectoris).
Probably even more important are the complex interplay of financial rewards and government regulation that impact on the use of these and other devices, as well as all kinds of other treatments and interventions. There can be no justification for the obviously excessive stent placement by Dr. Midei, or the encouragement of it by Abbott and probably the hospital; as the Times article notes ”… far from questioning cardiologists who perform an unusually high number of stent procedures, many hospital executives celebrate these doctors because of the revenue they bring, which can be more than $10,000 per procedure.” In this context, the reported statement of Senator Max Baucus, Democrat of Montana and chairman of the Finance Committee, that “Hospital patients expect their care to be based on medical need, not profits…Even more disconcerting is that this could be a sign of a larger national trend of wasteful medical device use,” sounds heroic, but is it?
The hospitals have a point too, in their criticism of government regulation. Not all of the investigations by HHS, Medicare, and other government agencies are really meant to uncover such gross overuse or fraud, although this is how they are portrayed. Many of them are just about getting money for the Federal government as aggressively as possible, and if it can be called “fraud” as opposed to a “mistake” they can get huge penalties as well as refunds of Medicare money spent. A major Medicare initiative is Recovery Audit Contractors (RACs), essentially bounty hunters given a license to investigate certain hospitals for fraud. Great, except most of their work seems to be on finding whether patients were (and this is going to seem like a technical subtlety) officially “admitted” to the hospital, when the severity of their illness could have allowed them to be placed in the hospital for a day or more on “observation” status, where they are officially outpatients and reimbursed at a lower rate. If a hospital or doctor were systematically admitting people who should obviously be “observed”, this might be real fraud, what are probably honest minor errors (or differences of opinion) in the assessment of patient condition are blown up so that the RAC (and Medicare) can recover big penalties. Far from trying to systematically defraud Medicare, my hospital, the University of Kansas Hospital (which is very happy with its high cardiac-care rating by US News and is truly one of those hospitals that enjoy the large amounts of money interventional cardiology procedures provide) is spending a bunch of money to have each admission audited by an outside firm to ensure that they don’t violate these criteria and make themselves vulnerable to RAC recoveries.
So who is the “white hat”? Certainly not the drug and device makers, who are really “only in it for the money”, often not the hospitals, and sadly not always (although, honestly, most of the time) the doctors. But also not the government, seeking money to fund its wars in a down economy. Senator Baucus, famous for taking huge amounts from drug companies himself, may not be the one whom we should be trusting, but his statement that “Hospital patients [and, I would add, all patients!] expect their care to be based on medical need, not profits” is certainly a sentiment that I would endorse. Of course, the making of these profits is why the drug companies paid him. Some suspect that this might be partly why his committee, and the Congress overall, and the administration, did not pass a health reform bill that would achieve that result. Fraud is bad, and uncovering fraud is good, but RACs are not an answer to a flawed, profit-driven, health system.
[1] Lagerqvist B, James SK, Stenestrand U, Lindbäck J, Nilsson T, Wallentin L; SCAAR Study Group., Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden., N Engl J Med. 2007 Mar 8;356(10):1009-19. Epub 2007 Feb 12.
[2]Spaulding C, Daemen J, Boersma E, Cutlip DE, Serruys PW., A pooled analysis of data comparing sirolimus-eluting stents with bare-metal stents., N Engl J Med. 2007 Mar 8;356(10):989-97. Epub 2007 Feb 12.
[3] Stone GW, et al., Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents, N Engl J Med. 2007 Mar 8;356(10):998-1008. Epub 2007 Feb 12.
[4] Kastrati A, et. al., Analysis of 14 trials comparing sirolimus-eluting stents with bare-metal stents, N Engl J Med. 2007 Mar 8;356(10):1030-9. Epub 2007 Feb 12.
[5] Farb A, Boam AB., Stent thrombosis redux--the FDA perspective.,N Engl J Med. 2007 Mar 8;356(10):984-7. Epub 2007 Feb 12.
[6] Maisel WH., Unanswered questions--drug-eluting stents and the risk of late thrombosis, N Engl J Med. 2007 Mar 8;356(10):981-4. Epub 2007 Feb 12.
Saturday, December 18, 2010
ACA, ACOs, and Meaningful Competition
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Criticisms of the new health law, the Affordable Care Act (ACA), have come from all sides. While many of them are justified, they also miss many of the law’s positives. It doesn’t assure the reliable, cost-controlled security of a real universal health insurance program, but it will lead to coverage of tens of millions of more Americans, and will eliminate the ability of insurance companies to engage in health risk underwriting, the practice that allows them to deny coverage to those with pre-existing conditions. These are points that the President made in his recent interview on Jon Stewart’s Daily Show. "Individual mandates", i.e., forcing everyone to buy insurance, while it is a touchstone for the right and is the issue found unconstitutional by a Virginia federal judge (and which will probably go to the Supreme Court), was the price that insurance companies demanded for assuring coverage for everyone. As I have often written, you have to have all the healthy people in if you are going to cover the sick; there are many more healthy, but all of us can become sick.
Apparently, a lot of people understand this. A recent poll by Marist College and McClatchy newspapers shows a majority (51%, but still a majority) of Americans want to continue (16%) or increase (35%) the benefits of ACA, with 44% going the other direction. “Among groups with pluralities who want to expand it: women, minorities, people younger than 45, Democrats, liberals, Northeasterners and those making less than $50,000 a year. Lining up against the law, 11 percent want to amend it to rein it in; 33 percent want to repeal it. Among groups with pluralities favoring repeal: men, whites, those older than 45, those making more than $50,000 annually, conservatives, Republicans and tea party supporters.” OK, these are the “usual suspects”, except that it amazing and saddening to me that older people who are receiving Medicare can be opposed to expanding benefits to others. Maybe they are just ignorant of Medicare and the current law (as reflected in “Keep the government’s hands off my Medicare!”); this is also sad, but would explain what would otherwise be an enormously, almost immoral, selfishness. Yes, more educated Medicare recipients are concerned that the benefits for that program will be scaled back (and there are unquestionably threats to do so!) but this does not justify opposition to extending those benefits to the rest of the country.
A new set of problems is described by Robert Pear in the New York Times, on Sunday, November 21, 2010, “As health law spurs mergers, risks are seen”. The focus of his article is the planned “accountable care organization” (ACO), a relationship between one or more hospitals (or “health systems”), doctors, nursing homes, and home health care agencies. The idea behind creating ACOs is that, by coordination of care and sharing of information, people’s health can be improved and money can be saved. There is a lot of sense to this approach. If a patient is discharged from a hospital to home, or to a nursing home, and there is more sharing of information with the home health agency, or nursing home, or the primary care doctor who will be responsible for care when they leave the hospital, there is greater likelihood that there will not be lapses in the patient’s care. Similarly, if the person’s health deteriorates to the point of needing to be re-admitted, it would be best if 1) all that could have been done in the non-hospital setting to possibly prevent that from happening was done, and 2) all the information about what was done was transmitted to the hospital.
The organizations most cited by health reformers as having been successful in controlling costs and improving quality are those that are already “integrated”, where the system that owns the hospital(s) also employs the physicians and controls the nursing homes and home health care agencies, or else has very close and dependent financial relationships with them, such as Intermountain Health Care, Geisinger Health System, and Kaiser-Permanente. Information – and money, including money saved by having fewer expensive readmissions, is shared among the various participants. So ACA creates financial incentives for others to create such relationships, the ACOs. The issue raised in Pear’s article are that many forms that these ACOs might take run the risk of violating existing laws that are in place to prevent kickbacks, monopolistic practice, and other forms of corruption. For example, it is illegal for a health system for offering contingency payments a physician who is not an employee – such as for admitting patients to the hospital, keeping stays shorter, etc. This makes sense too.
So we have two conflicting things that “make sense”: greater collaboration and aligned incentives can create greater efficiency and save money, but they can also lead to oligopoly and corrupt relationships. Monopoly is more efficient, but creates the opportunity for exploitation. Modern business practices, based on the work of people such as W. Edwards Deming[1], emphasize the importance of long-term relationships with suppliers so that they can learn and better meet your needs over time, something there would be no incentive to do if doing so cost them money, and you were likely to pull your business the next year because someone else bid lower. Governments usually have policies requiring contracts given to the lowest bidder, but there is a danger that the work will be of lower quality.
Much of the criticism of ACA from the “right” has been about lack of “choice”, but as we look at implementation of the health care law, we need to be careful that ideology does not trump actual health outcomes. Two recent studies show the risks of the “law of unintended consequences” of policies that encourage consumer choice and a market approach to health coverage. In “Health care use and decision making among lower income families in high-deductible health plans”[2], Kullgren and colleagues demonstrate that, in fact, as might be anticipated, poor people who choose to spend less out-of-pocket money by enrolling in such high-deductible plans pay the price later in not accessing health care and having poorer outcomes. Millet, et al, in “Unhealthy competition: consequences of health plan choice in California Medicaid”[3], show that, perhaps less intuitively, Medicaid (Medi-Cal) patients in California counties where they have a choice of plans are less likely to be enrolled all year than where they do not have such choice, and “Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.”
Ideally, a single-payer, Medicare-for-all, system eliminates the risks that people will not enroll or have gaps in enrollment, that there will be people left out, that people will, for understandable and reasonable short-term financial reasons, make choices that can have long-term adverse effects on their health, and that there will be different standards for quality of care for people with different insurance. But even that does not address the system of provision of care. The ACA law seeks to encourage communication and efficiency, but critics see danger in merger and oligopoly, which could limit options for consumers and in itself create risks to health care access and quality.
What could the solution be? One might be to have cooperative relationships with open-source access to information. Thus, your health information would not be in the control of a given hospital, health care system, or doctor, but rather be controlled by you, and made available to whichever provider – hospital, doctor, nursing home, etc. -- that you chose to provide your care. The information would not be in proprietary electronic medical record format, but rather in an interoperable format that could be utilized by any provider. Incentives could exist globally, not simply within a single organization, to produce the highest quality care rather than the highest profit margin. This would be an excellent example of real competition.
[1] See Mary Walton, The Deming Management Method, Berkeley Publishing Group, New York (originally published Dodd Mead, NY, 1986).
[2] Kullgren JT et al., “Health care use and decision making among lower income families in high-deductible health plans”, Archives of Internal Medicine, 2010;170(21):1918-25. (Hyperlink is to abstract as full text not available free on line.)
[3] Millet C, Chattopadhyay A, Bindman AB, “Unhealthy competition: consequences of health plan choice in California Medicaid”, American Journal of Public Health Nov2010;100(11):2235-40. (Hyperlink is to abstract as full text not available free on line.)
.
Criticisms of the new health law, the Affordable Care Act (ACA), have come from all sides. While many of them are justified, they also miss many of the law’s positives. It doesn’t assure the reliable, cost-controlled security of a real universal health insurance program, but it will lead to coverage of tens of millions of more Americans, and will eliminate the ability of insurance companies to engage in health risk underwriting, the practice that allows them to deny coverage to those with pre-existing conditions. These are points that the President made in his recent interview on Jon Stewart’s Daily Show. "Individual mandates", i.e., forcing everyone to buy insurance, while it is a touchstone for the right and is the issue found unconstitutional by a Virginia federal judge (and which will probably go to the Supreme Court), was the price that insurance companies demanded for assuring coverage for everyone. As I have often written, you have to have all the healthy people in if you are going to cover the sick; there are many more healthy, but all of us can become sick.
Apparently, a lot of people understand this. A recent poll by Marist College and McClatchy newspapers shows a majority (51%, but still a majority) of Americans want to continue (16%) or increase (35%) the benefits of ACA, with 44% going the other direction. “Among groups with pluralities who want to expand it: women, minorities, people younger than 45, Democrats, liberals, Northeasterners and those making less than $50,000 a year. Lining up against the law, 11 percent want to amend it to rein it in; 33 percent want to repeal it. Among groups with pluralities favoring repeal: men, whites, those older than 45, those making more than $50,000 annually, conservatives, Republicans and tea party supporters.” OK, these are the “usual suspects”, except that it amazing and saddening to me that older people who are receiving Medicare can be opposed to expanding benefits to others. Maybe they are just ignorant of Medicare and the current law (as reflected in “Keep the government’s hands off my Medicare!”); this is also sad, but would explain what would otherwise be an enormously, almost immoral, selfishness. Yes, more educated Medicare recipients are concerned that the benefits for that program will be scaled back (and there are unquestionably threats to do so!) but this does not justify opposition to extending those benefits to the rest of the country.
A new set of problems is described by Robert Pear in the New York Times, on Sunday, November 21, 2010, “As health law spurs mergers, risks are seen”. The focus of his article is the planned “accountable care organization” (ACO), a relationship between one or more hospitals (or “health systems”), doctors, nursing homes, and home health care agencies. The idea behind creating ACOs is that, by coordination of care and sharing of information, people’s health can be improved and money can be saved. There is a lot of sense to this approach. If a patient is discharged from a hospital to home, or to a nursing home, and there is more sharing of information with the home health agency, or nursing home, or the primary care doctor who will be responsible for care when they leave the hospital, there is greater likelihood that there will not be lapses in the patient’s care. Similarly, if the person’s health deteriorates to the point of needing to be re-admitted, it would be best if 1) all that could have been done in the non-hospital setting to possibly prevent that from happening was done, and 2) all the information about what was done was transmitted to the hospital.
The organizations most cited by health reformers as having been successful in controlling costs and improving quality are those that are already “integrated”, where the system that owns the hospital(s) also employs the physicians and controls the nursing homes and home health care agencies, or else has very close and dependent financial relationships with them, such as Intermountain Health Care, Geisinger Health System, and Kaiser-Permanente. Information – and money, including money saved by having fewer expensive readmissions, is shared among the various participants. So ACA creates financial incentives for others to create such relationships, the ACOs. The issue raised in Pear’s article are that many forms that these ACOs might take run the risk of violating existing laws that are in place to prevent kickbacks, monopolistic practice, and other forms of corruption. For example, it is illegal for a health system for offering contingency payments a physician who is not an employee – such as for admitting patients to the hospital, keeping stays shorter, etc. This makes sense too.
So we have two conflicting things that “make sense”: greater collaboration and aligned incentives can create greater efficiency and save money, but they can also lead to oligopoly and corrupt relationships. Monopoly is more efficient, but creates the opportunity for exploitation. Modern business practices, based on the work of people such as W. Edwards Deming[1], emphasize the importance of long-term relationships with suppliers so that they can learn and better meet your needs over time, something there would be no incentive to do if doing so cost them money, and you were likely to pull your business the next year because someone else bid lower. Governments usually have policies requiring contracts given to the lowest bidder, but there is a danger that the work will be of lower quality.
Much of the criticism of ACA from the “right” has been about lack of “choice”, but as we look at implementation of the health care law, we need to be careful that ideology does not trump actual health outcomes. Two recent studies show the risks of the “law of unintended consequences” of policies that encourage consumer choice and a market approach to health coverage. In “Health care use and decision making among lower income families in high-deductible health plans”[2], Kullgren and colleagues demonstrate that, in fact, as might be anticipated, poor people who choose to spend less out-of-pocket money by enrolling in such high-deductible plans pay the price later in not accessing health care and having poorer outcomes. Millet, et al, in “Unhealthy competition: consequences of health plan choice in California Medicaid”[3], show that, perhaps less intuitively, Medicaid (Medi-Cal) patients in California counties where they have a choice of plans are less likely to be enrolled all year than where they do not have such choice, and “Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.”
Ideally, a single-payer, Medicare-for-all, system eliminates the risks that people will not enroll or have gaps in enrollment, that there will be people left out, that people will, for understandable and reasonable short-term financial reasons, make choices that can have long-term adverse effects on their health, and that there will be different standards for quality of care for people with different insurance. But even that does not address the system of provision of care. The ACA law seeks to encourage communication and efficiency, but critics see danger in merger and oligopoly, which could limit options for consumers and in itself create risks to health care access and quality.
What could the solution be? One might be to have cooperative relationships with open-source access to information. Thus, your health information would not be in the control of a given hospital, health care system, or doctor, but rather be controlled by you, and made available to whichever provider – hospital, doctor, nursing home, etc. -- that you chose to provide your care. The information would not be in proprietary electronic medical record format, but rather in an interoperable format that could be utilized by any provider. Incentives could exist globally, not simply within a single organization, to produce the highest quality care rather than the highest profit margin. This would be an excellent example of real competition.
[1] See Mary Walton, The Deming Management Method, Berkeley Publishing Group, New York (originally published Dodd Mead, NY, 1986).
[2] Kullgren JT et al., “Health care use and decision making among lower income families in high-deductible health plans”, Archives of Internal Medicine, 2010;170(21):1918-25. (Hyperlink is to abstract as full text not available free on line.)
[3] Millet C, Chattopadhyay A, Bindman AB, “Unhealthy competition: consequences of health plan choice in California Medicaid”, American Journal of Public Health Nov2010;100(11):2235-40. (Hyperlink is to abstract as full text not available free on line.)
.
Sunday, December 12, 2010
Tax Breaks for the "Masters of the Universe" or for the rest of us?
.
The fact is that the wealthiest are doing great and everyone else is being penalized. This cannot be justified by any reasonable economics, voodoo, trickle-down, Friedmanesque or anything else. The elite have a Congress that they have bought and paid for, as discussed in his November 28, 2010 column, Still the Best Congress Money Can Buy, by the NY Times’ Frank Rich. He refers us to recent Times articles documenting the recent enormous corporate profits (“Corporate Profits were the highest on record last quarter” by Catherine Rampell, November 23, 2010) and profligate spending by the Wall St. “masters of the universe”[1] (With a Swagger, Wallets Out, Wall Street Dares to Celebrate, November 23, 2010, by Suzanne Craig and Kevin Roose), while the Times’ editorial page reminds us that while they grow wealthier regular people, who still can’t get jobs, also can’t even get their unemployment benefits extended (The Unemployed Held Hostage, Again, November 28, 2010).
Our health system has long been terrible, in lack of equitable access for many while there have been enormous profits for the insurance and pharmaceutical industries, in excessive interventions and procedures for the well-insured masquerading as the “best health care system in the world”, quantity masquerading as quality even for those who have had health coverage. As developing countries such as India seek to develop their own health systems, the US is notable as a model for what should not be done (see the interview with Nobel-prize winning economist Joseph Stiglitz in the Times of India 'The US model of private health insurers is inefficient, expensive' (thanks to Don McCanne in his wonderful Quote of the Day). The ACA was a first step to fixing it, but scarcely a final one. It is time to stop talking about how to inflict more economic pain on the bulk of Americans, unemployed and working, until we stop giving the store away to the elite.
Surowiecki notes that “seniors think of Medicare as an “entitlement”—something that they have a right to because they paid for it”. Why not? Even though he notes that today they “get far more out of Medicare than they ever put in,” he adds, appropriately, that “There’s nothing wrong with this: the U.S. is rich enough so that the elderly shouldn’t have to worry about having health insurance; before Medicare, roughly half of them didn’t have it”. He’s right on that. And we all should have it – Medicare for all, coverage for all of us. After 45 years of it working for seniors, it is time for it to be an entitlement for everyone. Something, finally, for the 99% who are not the “masters of the universe”. Sounds good to me.
[1] A phrase coined by Tom Wolfe to refer to Wall St titans in his 1987 book The Bonfire of the Vanities, Farrar Straus and Giroux.
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In an Associated Press story from November 28, 2010, “Tax break for employer health plans a target again” (it was widely picked up; here I’ve given the link to the Pensacola News-Journal), Ricardo Alonso-Zaldivar writes about the resurgence of interest in eliminating the employer tax break for contributions to employee health plans. This proposal, put forward from time to time, has been given new prominence by the recommendations of Erskine Bowles and Alan Simpson, the. not dumb and dumber but right-and-righter co-chairs of the President’s task force on deficit reduction, which they have morphed into a task force on cutting taxes. For Bowles and Simpson, it is one of only a number of proposals they make that would take away middle-class tax benefits, and not even the least popular: that honor would almost certainly go to the elimination of the mortgage interest deduction.
The employer’s ability to deduct contributions to their employees’ health insurance goes back to the post-World War II era, when there was tremendous competition for workers (imagine that!) and wage and price controls made it impossible for businesses to compete on the basis of pay, so fringe benefits – specifically health insurance – became a real perk. The unions liked it because they could bargain for this benefit for their members. The losers, of course, were all of us, who did not get a national health insurance program. And for many years this benefit has been a real advantage to being employed by a company with a collective bargaining agreement, and clearly unions will strongly oppose any effort to make it more difficult for them to achieve this benefit.
Meanwhile, some Medicare recipients, concerned about maintaining one of the few benefits the elderly still have, have come out against much of the health reform bill. Many of the most vocal opponents are the wealthy elderly, but unfortunately many middle- and working-class seniors are in this group. This is the subject of James Surowiecki’s piece “Greedy Geezers?” in the New Yorker, Nov 22, 2010, as noted by Tallgrass Activist David Kingsley. While the title might be offensive, many of his points are well taken: “There’s a colossal irony here: the very people who currently enjoy the benefits of a subsidized, government-run insurance system are intent on keeping others from getting the same treatment.” One example of what seniors can see as real cutbacks to their benefits are the cuts to the Medicare Advantage program. Medicare Advantage (also known as Medicare Part “C”) is a program that basically takes your Medicare payment, and an additional payment from you, and enrolls you in an HMO that provides you benefits beyond that which traditional Medicare offers (such as glasses, hearing aids, a better drug benefit, especially before Part “D” was enacted). It was created by the Reagan administration as a way to, at least in part, privatize Medicare, and was accompanied by higher payments from the federal government to these insurers than was spent on traditional Medicare beneficiaries. This was a corrupt program that ACA was right to eliminate, but because those seniors enrolled in it were getting a benefit, they receive a cut. Of course, the cut (appropriately) is much greater to the insurance company, which was getting most of the benefit (the extra benefits received by the enrollees were worth much less than the insurance companies were being paid).
What a great example of divide and conquer! Bowles-and-Simpson’s (now they are one, ostensible bipartisanship aside) proposals, while they were supposed to be about deficit reduction, are all about decreasing taxes. And especially decreasing taxes on the wealthiest Americans and corporations, a strategy that has been demonstrated by the last decade to be extraordinarily beneficial to – the wealthiest Americans and corporations. Trickle down economics, decried by George HW Bush as “voodoo economics” during the 1980 election, are no less so now, although to call them that insults voodoo. Interviewed on NPR’s “All Things Considered”, Bowles-and-Simpson are asked about the criticism of their proposals by economist and NY Times columnist Paul Krugman, who says it is about redistributing wealth upward. While Simpson says Krugman has “lost his marbles”, he doesn’t address Krugman’s criticisms.
The employer’s ability to deduct contributions to their employees’ health insurance goes back to the post-World War II era, when there was tremendous competition for workers (imagine that!) and wage and price controls made it impossible for businesses to compete on the basis of pay, so fringe benefits – specifically health insurance – became a real perk. The unions liked it because they could bargain for this benefit for their members. The losers, of course, were all of us, who did not get a national health insurance program. And for many years this benefit has been a real advantage to being employed by a company with a collective bargaining agreement, and clearly unions will strongly oppose any effort to make it more difficult for them to achieve this benefit.
Meanwhile, some Medicare recipients, concerned about maintaining one of the few benefits the elderly still have, have come out against much of the health reform bill. Many of the most vocal opponents are the wealthy elderly, but unfortunately many middle- and working-class seniors are in this group. This is the subject of James Surowiecki’s piece “Greedy Geezers?” in the New Yorker, Nov 22, 2010, as noted by Tallgrass Activist David Kingsley. While the title might be offensive, many of his points are well taken: “There’s a colossal irony here: the very people who currently enjoy the benefits of a subsidized, government-run insurance system are intent on keeping others from getting the same treatment.” One example of what seniors can see as real cutbacks to their benefits are the cuts to the Medicare Advantage program. Medicare Advantage (also known as Medicare Part “C”) is a program that basically takes your Medicare payment, and an additional payment from you, and enrolls you in an HMO that provides you benefits beyond that which traditional Medicare offers (such as glasses, hearing aids, a better drug benefit, especially before Part “D” was enacted). It was created by the Reagan administration as a way to, at least in part, privatize Medicare, and was accompanied by higher payments from the federal government to these insurers than was spent on traditional Medicare beneficiaries. This was a corrupt program that ACA was right to eliminate, but because those seniors enrolled in it were getting a benefit, they receive a cut. Of course, the cut (appropriately) is much greater to the insurance company, which was getting most of the benefit (the extra benefits received by the enrollees were worth much less than the insurance companies were being paid).
What a great example of divide and conquer! Bowles-and-Simpson’s (now they are one, ostensible bipartisanship aside) proposals, while they were supposed to be about deficit reduction, are all about decreasing taxes. And especially decreasing taxes on the wealthiest Americans and corporations, a strategy that has been demonstrated by the last decade to be extraordinarily beneficial to – the wealthiest Americans and corporations. Trickle down economics, decried by George HW Bush as “voodoo economics” during the 1980 election, are no less so now, although to call them that insults voodoo. Interviewed on NPR’s “All Things Considered”, Bowles-and-Simpson are asked about the criticism of their proposals by economist and NY Times columnist Paul Krugman, who says it is about redistributing wealth upward. While Simpson says Krugman has “lost his marbles”, he doesn’t address Krugman’s criticisms.
The fact is that the wealthiest are doing great and everyone else is being penalized. This cannot be justified by any reasonable economics, voodoo, trickle-down, Friedmanesque or anything else. The elite have a Congress that they have bought and paid for, as discussed in his November 28, 2010 column, Still the Best Congress Money Can Buy, by the NY Times’ Frank Rich. He refers us to recent Times articles documenting the recent enormous corporate profits (“Corporate Profits were the highest on record last quarter” by Catherine Rampell, November 23, 2010) and profligate spending by the Wall St. “masters of the universe”[1] (With a Swagger, Wallets Out, Wall Street Dares to Celebrate, November 23, 2010, by Suzanne Craig and Kevin Roose), while the Times’ editorial page reminds us that while they grow wealthier regular people, who still can’t get jobs, also can’t even get their unemployment benefits extended (The Unemployed Held Hostage, Again, November 28, 2010).
Our health system has long been terrible, in lack of equitable access for many while there have been enormous profits for the insurance and pharmaceutical industries, in excessive interventions and procedures for the well-insured masquerading as the “best health care system in the world”, quantity masquerading as quality even for those who have had health coverage. As developing countries such as India seek to develop their own health systems, the US is notable as a model for what should not be done (see the interview with Nobel-prize winning economist Joseph Stiglitz in the Times of India 'The US model of private health insurers is inefficient, expensive' (thanks to Don McCanne in his wonderful Quote of the Day). The ACA was a first step to fixing it, but scarcely a final one. It is time to stop talking about how to inflict more economic pain on the bulk of Americans, unemployed and working, until we stop giving the store away to the elite.
Surowiecki notes that “seniors think of Medicare as an “entitlement”—something that they have a right to because they paid for it”. Why not? Even though he notes that today they “get far more out of Medicare than they ever put in,” he adds, appropriately, that “There’s nothing wrong with this: the U.S. is rich enough so that the elderly shouldn’t have to worry about having health insurance; before Medicare, roughly half of them didn’t have it”. He’s right on that. And we all should have it – Medicare for all, coverage for all of us. After 45 years of it working for seniors, it is time for it to be an entitlement for everyone. Something, finally, for the 99% who are not the “masters of the universe”. Sounds good to me.
[1] A phrase coined by Tom Wolfe to refer to Wall St titans in his 1987 book The Bonfire of the Vanities, Farrar Straus and Giroux.
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Wednesday, December 8, 2010
Medicine and Social Justice Index, Year 2
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Continuing a "tradition" I started a year ago, here is a topically-organized list of the postings on Medicine and Social Justice for its second year, December 2009-November 2010.
General Medical
Tuesday, November 23, 2010: Lung Cancer Screening: Benefits, Costs, and Opportunity Costs for the Public Health
Thursday, November 11, 2010: Hospital Readmissions: Who pays, who decides, and for whom?
Saturday, October 30, 2010: Breast cancer screening: conflicting evidence? what are the important questions for health?
Monday, August 2, 2010: Calcium, Heart Attack and Osteoporosis
Friday, July 16, 2010: Rosiglitazone and the "Holy Grail"
Tuesday, July 6, 2010: Statins and scientific integrity
Friday, April 16, 2010: VISA and colchicine: maybe the banks and Pharma really ARE in it for the money! (Guest post by Stephen Griffith, MD)
Saturday, January 16, 2010: Cancer Care and Hospital Advertising
Health and Public Health, General
Monday, November 29, 2010: Compromised public health ethics across the pond: Britain too!
Sunday, October 24, 2010: Health and income: "what's new?" or a good resource
Wednesday, October 13, 2010: "Top Doctors": Who are they -- and who are they not necessarily?
Friday, September 24, 2010: Capability: understanding why people may not adopt healthful behaviors
Saturday, September 18, 2010: Shared Medical Decision Making: Between Autonomy and Authoritarianism
Sunday, September 12, 2010: Social Determinants, Personal Responsibility, and Health System Outcomes
Tuesday, September 7, 2010: Drugs, Tobacco, Doctors and the Health of the Public
Friday, August 20, 2010: The AAFP, Coca-Cola, and Ethics: Serving the public interest?
Saturday, May 15, 2010: Public Health and Changing People's Minds
Sunday, May 9, 2010: Health Outcomes: The interaction of class and health behaviors
Saturday, March 27, 2010: Comparative effectiveness research
Sunday, March 21, 2010: Doctors, morality and behavior: where is the moral compass?
Saturday, February 6, 2010: The Public’s Health: Smoking and Salt
Wednesday, January 27, 2010: Health is more than Medical Care
Health reform, Health Policy and Workforce
Wednesday, November 17, 2010: Disparities in physician income are related to disparities in health
Friday, November 5, 2010: Training rural family doctors
Monday, October 18, 2010: Lower Costs in Grand Junction: More Primary Care, Less High Tech
Thursday, October 7, 2010: Primary Care Grants from HRSA: not enough, not wisely done
Wednesday, July 28, 2010: The political campaign and the future of health reform
Thursday, July 22, 2010: Improving quality and access still requires coverage for all
Saturday, June 26, 2010: Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost
Thursday, May 27, 2010: Universal Coverage and Primary Care: The US needs both
Thursday, April 22, 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?
Sunday, April 11, 2010: Doctors and Health Reform: How should a physician's politics affect their patient care?
Wednesday, March 17, 2010: The Sharp End of Ideology (Guest post by Robert Ferrer, MD MPH)
Monday, March 8, 2010: Why we need health reform (announcement of a guest post by me on Health Strong, " http://healthstrong.org/2010/03/why-we-need-health-reform/#more-508 )
Friday, March 5, 2010: Top Ten Reasons for Future Subspecialist Physicians To Be Concerned (Guest post by Robert Bowman, MD)
Saturday, February 27, 2010: Democrats have a bad plan; Republicans have no plan
Thursday, February 18, 2010: Poverty, Primary Care and the Cost of Medical Care
Saturday, February 13, 2010: Insurance company greed: To know them is to not trust them
Monday, February 1, 2010: Haiti and Health Reform: We need real leadership
Thursday, January 21, 2010: Harvard Medical School limits outside income: a good start
Wednesday, December 23, 2009: Health Reform: The good, the bad, and the bigoted
Monday, December 14, 2009: Tommy Douglas and the Canadian Health System
Primary Care
Friday, October 1, 2010: The Challenge of Global Health and Primary Care
Wednesday, September 1, 2010: Advice for building a new primary care based health system for Armenia: How "knowing the future" can inform our actions now (Guest post by Heidi Chumley, MD)
Saturday, August 14, 2010: Primary Care, IMGs, and the Health of the People
Monday, July 12, 2010: Primary care specialty choice: student characteristics
Tuesday, June 8, 2010: Reinventing Primary Care: Themes and Challenges
Thursday, May 27, 2010: Universal Coverage and Primary Care: The US needs both
Friday, May 21, 2010: Primary Care: What takes so much time? And how are we paying for it?
Wednesday, April 28, 2010: Primary Care and Rural Areas
Thursday, April 22, 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?
Monday, April 5, 2010: Primary Care and the Medical Home, Today and Tomorrow
Thursday, February 18, 2010: Poverty, Primary Care and the Cost of Medical Care
Thursday, January 7, 2010: Primary Care and Residency Expansion
Thursday, December 10, 2009: Free clinics should open our eyes to the real problems
Sunday, December 6, 2009: Health Care Needs Should Guide Health Reform
International Health and Medicine
Monday, November 29, 2010: Compromised public health ethics across the pond: Britain too!
Wednesday, September 1, 2010: Advice for building a new primary care based health system for Armenia: How "knowing the future" can inform our actions now (Guest post by Heidi Chumley, MD)
Friday, October 1, 2010: The Challenge of Global Health and Primary Care
Wednesday, June 2, 2010: Who will care for the underserved? The role of off-shore medical schools
Monday, February 1, 2010: Haiti and Health Reform: We need real leadership
Monday, January 11, 2010: Health Workers and the Afghanistan-Pakistan War (Guest blog by Seiji Yamada, MD)
Monday, December 14, 2009: Tommy Douglas and the Canadian Health System
Medical Education
Thursday, August 26, 2010: Medicine, science, and humanities: what is their role in medical education?
Saturday, August 14, 2010: Primary Care, IMGs, and the Health of the People
Sunday, August 8, 2010: The White Coat Ceremony: New medical students and hope for the future
Monday, July 12, 2010: Primary care specialty choice: student characteristics
Sunday, June 20, 2010: A New Way of Ranking Medical Schools: Social Mission
Wednesday, June 2, 2010: Who will care for the underserved? The role of off-shore medical schools
Thursday, January 7, 2010: Primary Care and Residency Expansion
Thursday, December 10, 2009: Free clinics should open our eyes to the real problems
Social Justice
Thursday, July 1, 2010: Arrested at the G20: David Wachsmuth
Monday, June 14, 2010: Oil Slicks and Abortion: Who do we regulate?
Saturday, May 15, 2010: Public Health and Changing People's Minds
Sunday, May 9, 2010: Health Outcomes: The interaction of class and health behaviors
Tuesday, May 4, 2010: Big Finance & Big Oil -- Teabaggers and Racism
Wednesday, March 31, 2010: Obama and the Seder: Freedom and Multiculturalism
Wednesday, March 17, 2010: The Sharp End of Ideology (Guest post by Robert Ferrer, MD MPH)
Saturday, March 13, 2010: Who owns US policy: let’s not forget who the bad guys are
Sunday, January 3, 2010: The business of America...or is America a business?
Tuesday, December 29, 2009: Quotes for the New Year
Friday, December 18, 2009: The trauma of joblessness: who is evil?
Wednesday, December 2, 2009: Food stamp use increases: who should the government be working for?
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Continuing a "tradition" I started a year ago, here is a topically-organized list of the postings on Medicine and Social Justice for its second year, December 2009-November 2010.
General Medical
Tuesday, November 23, 2010: Lung Cancer Screening: Benefits, Costs, and Opportunity Costs for the Public Health
Thursday, November 11, 2010: Hospital Readmissions: Who pays, who decides, and for whom?
Saturday, October 30, 2010: Breast cancer screening: conflicting evidence? what are the important questions for health?
Monday, August 2, 2010: Calcium, Heart Attack and Osteoporosis
Friday, July 16, 2010: Rosiglitazone and the "Holy Grail"
Tuesday, July 6, 2010: Statins and scientific integrity
Friday, April 16, 2010: VISA and colchicine: maybe the banks and Pharma really ARE in it for the money! (Guest post by Stephen Griffith, MD)
Saturday, January 16, 2010: Cancer Care and Hospital Advertising
Health and Public Health, General
Monday, November 29, 2010: Compromised public health ethics across the pond: Britain too!
Sunday, October 24, 2010: Health and income: "what's new?" or a good resource
Wednesday, October 13, 2010: "Top Doctors": Who are they -- and who are they not necessarily?
Friday, September 24, 2010: Capability: understanding why people may not adopt healthful behaviors
Saturday, September 18, 2010: Shared Medical Decision Making: Between Autonomy and Authoritarianism
Sunday, September 12, 2010: Social Determinants, Personal Responsibility, and Health System Outcomes
Tuesday, September 7, 2010: Drugs, Tobacco, Doctors and the Health of the Public
Friday, August 20, 2010: The AAFP, Coca-Cola, and Ethics: Serving the public interest?
Saturday, May 15, 2010: Public Health and Changing People's Minds
Sunday, May 9, 2010: Health Outcomes: The interaction of class and health behaviors
Saturday, March 27, 2010: Comparative effectiveness research
Sunday, March 21, 2010: Doctors, morality and behavior: where is the moral compass?
Saturday, February 6, 2010: The Public’s Health: Smoking and Salt
Wednesday, January 27, 2010: Health is more than Medical Care
Health reform, Health Policy and Workforce
Wednesday, November 17, 2010: Disparities in physician income are related to disparities in health
Friday, November 5, 2010: Training rural family doctors
Monday, October 18, 2010: Lower Costs in Grand Junction: More Primary Care, Less High Tech
Thursday, October 7, 2010: Primary Care Grants from HRSA: not enough, not wisely done
Wednesday, July 28, 2010: The political campaign and the future of health reform
Thursday, July 22, 2010: Improving quality and access still requires coverage for all
Saturday, June 26, 2010: Mirror on the Wall: Commonwealth Fund report continues to show US has poor outcomes at high cost
Thursday, May 27, 2010: Universal Coverage and Primary Care: The US needs both
Thursday, April 22, 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?
Sunday, April 11, 2010: Doctors and Health Reform: How should a physician's politics affect their patient care?
Wednesday, March 17, 2010: The Sharp End of Ideology (Guest post by Robert Ferrer, MD MPH)
Monday, March 8, 2010: Why we need health reform (announcement of a guest post by me on Health Strong, " http://healthstrong.org/2010/03/why-we-need-health-reform/#more-508 )
Friday, March 5, 2010: Top Ten Reasons for Future Subspecialist Physicians To Be Concerned (Guest post by Robert Bowman, MD)
Saturday, February 27, 2010: Democrats have a bad plan; Republicans have no plan
Thursday, February 18, 2010: Poverty, Primary Care and the Cost of Medical Care
Saturday, February 13, 2010: Insurance company greed: To know them is to not trust them
Monday, February 1, 2010: Haiti and Health Reform: We need real leadership
Thursday, January 21, 2010: Harvard Medical School limits outside income: a good start
Wednesday, December 23, 2009: Health Reform: The good, the bad, and the bigoted
Monday, December 14, 2009: Tommy Douglas and the Canadian Health System
Primary Care
Friday, October 1, 2010: The Challenge of Global Health and Primary Care
Wednesday, September 1, 2010: Advice for building a new primary care based health system for Armenia: How "knowing the future" can inform our actions now (Guest post by Heidi Chumley, MD)
Saturday, August 14, 2010: Primary Care, IMGs, and the Health of the People
Monday, July 12, 2010: Primary care specialty choice: student characteristics
Tuesday, June 8, 2010: Reinventing Primary Care: Themes and Challenges
Thursday, May 27, 2010: Universal Coverage and Primary Care: The US needs both
Friday, May 21, 2010: Primary Care: What takes so much time? And how are we paying for it?
Wednesday, April 28, 2010: Primary Care and Rural Areas
Thursday, April 22, 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?
Monday, April 5, 2010: Primary Care and the Medical Home, Today and Tomorrow
Thursday, February 18, 2010: Poverty, Primary Care and the Cost of Medical Care
Thursday, January 7, 2010: Primary Care and Residency Expansion
Thursday, December 10, 2009: Free clinics should open our eyes to the real problems
Sunday, December 6, 2009: Health Care Needs Should Guide Health Reform
International Health and Medicine
Monday, November 29, 2010: Compromised public health ethics across the pond: Britain too!
Wednesday, September 1, 2010: Advice for building a new primary care based health system for Armenia: How "knowing the future" can inform our actions now (Guest post by Heidi Chumley, MD)
Friday, October 1, 2010: The Challenge of Global Health and Primary Care
Wednesday, June 2, 2010: Who will care for the underserved? The role of off-shore medical schools
Monday, February 1, 2010: Haiti and Health Reform: We need real leadership
Monday, January 11, 2010: Health Workers and the Afghanistan-Pakistan War (Guest blog by Seiji Yamada, MD)
Monday, December 14, 2009: Tommy Douglas and the Canadian Health System
Medical Education
Thursday, August 26, 2010: Medicine, science, and humanities: what is their role in medical education?
Saturday, August 14, 2010: Primary Care, IMGs, and the Health of the People
Sunday, August 8, 2010: The White Coat Ceremony: New medical students and hope for the future
Monday, July 12, 2010: Primary care specialty choice: student characteristics
Sunday, June 20, 2010: A New Way of Ranking Medical Schools: Social Mission
Wednesday, June 2, 2010: Who will care for the underserved? The role of off-shore medical schools
Thursday, January 7, 2010: Primary Care and Residency Expansion
Thursday, December 10, 2009: Free clinics should open our eyes to the real problems
Social Justice
Thursday, July 1, 2010: Arrested at the G20: David Wachsmuth
Monday, June 14, 2010: Oil Slicks and Abortion: Who do we regulate?
Saturday, May 15, 2010: Public Health and Changing People's Minds
Sunday, May 9, 2010: Health Outcomes: The interaction of class and health behaviors
Tuesday, May 4, 2010: Big Finance & Big Oil -- Teabaggers and Racism
Wednesday, March 31, 2010: Obama and the Seder: Freedom and Multiculturalism
Wednesday, March 17, 2010: The Sharp End of Ideology (Guest post by Robert Ferrer, MD MPH)
Saturday, March 13, 2010: Who owns US policy: let’s not forget who the bad guys are
Sunday, January 3, 2010: The business of America...or is America a business?
Tuesday, December 29, 2009: Quotes for the New Year
Friday, December 18, 2009: The trauma of joblessness: who is evil?
Wednesday, December 2, 2009: Food stamp use increases: who should the government be working for?
.
Friday, December 3, 2010
Matthew Freeman Memorial Lecture, Dec 6, 2010
This event is free and open to the public. For more information and to RSVP, contact Nancy Michaels at nmichaels@roosevelt.edu
Matthew Freeman LECTURE & SOCIAL JUSTICE Award
GENDER DIS-INTEGRATION AND THE DISCIPLINE OF “LGBT” A TRANSFEMINIST PERSPECTIVE -- Anne Enke
Monday, December 6 11 a.m. - 12:30 p.m.
Matthew Freeman LECTURE & SOCIAL JUSTICE Award
GENDER DIS-INTEGRATION AND THE DISCIPLINE OF “LGBT” A TRANSFEMINIST PERSPECTIVE -- Anne Enke
Monday, December 6 11 a.m. - 12:30 p.m.
Roosevelt University, Chicago, IL
430 S. Michigan Ave. Sullivan Room - 2nd Floor
Matthew Freeman was a Roosevelt student committed to working for a world with true justice, equality and fairness. Matthew died days before he would have received his degree. Through the support of his parents, his legacy continues with this annual lecture and award presentation. This year’s Matthew Freeman Social Justice Awards will be presented to Roosevelt students Oneka Ijeoma and Renee Farwell for their commitment to bettering our world through activism.
The Mansfield Institute for Social Justice and Transformation and the Department of Political Science and Public Administration present the annual Matthew Freeman Lecture and Social Justice Award Ceremony.
This year’s distinguished lecturer is Anne Enke, Professor of Gender and Women’s Studies, History and LGBT Studies at the University of Wisconsin. Professor Enke is the author of Finding the Movement: Sexuality, Contested Space and Feminist Activism (Duke University Press, 2007).
Matthew Freeman was a Roosevelt student committed to working for a world with true justice, equality and fairness. Matthew died days before he would have received his degree. Through the support of his parents, his legacy continues with this annual lecture and award presentation. This year’s Matthew Freeman Social Justice Awards will be presented to Roosevelt students Oneka Ijeoma and Renee Farwell for their commitment to bettering our world through activism.
The Mansfield Institute for Social Justice and Transformation and the Department of Political Science and Public Administration present the annual Matthew Freeman Lecture and Social Justice Award Ceremony.
This year’s distinguished lecturer is Anne Enke, Professor of Gender and Women’s Studies, History and LGBT Studies at the University of Wisconsin. Professor Enke is the author of Finding the Movement: Sexuality, Contested Space and Feminist Activism (Duke University Press, 2007).
Monday, November 29, 2010
Compromised public health ethics across the pond: Britain too!
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Not long ago, I wrote of the “consumer alliance” between the American Academy of Family Physicians (AAFP) and the Coca-Cola company (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). In that piece, I also noted the close relationship between the American Dietetic Association (ADA) and Hershey’s. For the record, I did not believe that these were, um, healthful, for the American people. I cited the work of Howard Brody, who looked at the ethics of the conflict of interest specifically in the Coca-Cola/AAFP case (and yes, there is definitely a conflict of interest whether or not that conflict results in prejudicial outcomes).
It turns out that this kind of arrangement is not limited to the United States. Indeed, Dr Alex Scott-Samuel, Director of EQUAL (Equity in Health Research and Development Unit) in the Division of Public Health at theUniversity of Liverpool, brings our attention to an article in the British newspaper the Guardian. It reports that in the United Kingdom, the “…Department of Health is putting the fast food companies McDonald's and KFC and processed food and drink manufacturers such as PepsiCo, Kellogg's, Unilever, Mars and Diageo at the heart of writing government policy on obesity, alcohol and diet-related disease”, an apparently far more malignant development.
The potential advantage of a government-run national health system is that it can insure that health care is provided for everyone, as I have often lauded. The public health role, however, is one that is even more commonly a public one, even in the United States, but in the UK the influence of the Department of Health over public health policy is even greater than in the US because they do not have independent state governments with their own health departments and health policies. We are, of course, familiar with the “fox guarding the henhouse” method of making public policy, which seemed to have reached its apex in the GW Bush administration with the big oil companies writing energy policy. Or maybe not; recently we discovered from a recent NPR investigative report (we need more of those) that the noxious Arizona immigration law was actually written by the private, for-profit prison industry as a way to increase business! (“They even named it. They called it the 'Support Our Law Enforcement and Safe Neighborhoods Act.’")
Is, then, the public’s health just another example of this type of “consumer alliance” (I really love this term!) – the British call them “responsibility deals”, more enigmatic, perhaps, but not more accurate – or is it another matter? Clearly, as demonstrated by the BP oil spill in the Gulf of Mexico, energy policy is critically related to health. And a law that makes it illegal for a person, a US citizen, to stop an offer humanitarian life-saving help to someone they find wandering and half-dead in the Arizona desert, not to mention imprisons and deports those who are not legally here, impacts on their health. Certainly these policies impact the rest of their lives.
Maybe it is because this is happening in the UK that makes it stand out. Maybe because some of us, myself included, have seen the UK and other European countries (and certainly there are many differences between European countries) as more focused on the health of their citizens. I know that there have been any number of problems with and criticisms of British health and social policy, including those of Julian Tudor Hart (“the inverse care law”[1], Medical Student Selection, December 14, 2008) and Sir Michael Marmot (the “Whitehall studies”, Health Outcomes: The interaction of class and health behaviors, May 9, 2010), and continued by current public health experts and scholars. I guess that the presence of the British National Health Service and its universal access have been so overwhelmingly positive in this regard that I have regarded such criticisms as those of people who “don’t know how good they have it”. Let me be clear: I never doubted that the concerns were valid, but rather that they may minimize the good things present in the system; in the same way I know that those in US cities with public hospitals are correct when they point to the underfunding, second class care, and inequities that they suffer, but at least, unlike where I live, they have public hospitals.
This initiative is, clearly, malignant. It is unquestionable “conflict of interest” for those whose interest is in selling more of their products, however unwholesome they may be, to be involved in the writing of public health policy around the use of, and advertisement of, those products. And, moreover, they will certainly ensure the insertion of policies that benefit themselves at the same time as they harm the public’s health. Note that it goes beyond food (and junk food); not only does the “food network to tackle diet and health problems includes processed food manufacturers, fast food companies,”, but “The alcohol responsibility deal network is chaired by the head of the lobby group the Wine and Spirit Trade Association.” Wow. One consumer advocate noted "This is the equivalent of putting the tobacco industry in charge of smoke-free spaces." It’s quite an achievement. Even Philip Morris couldn’t get to chair the cigarette control board!
Obviously, that this is occurring shortly after the Conservative Party has taken control of the British government is not a coincidence. It is part of a very successful strategy to transfer not all most, but virtually all, wealth and power to those who are already most wealthy and powerful. In the US, despite the control of the White House and both houses of Congress by the supposedly more progressive Democratic party, this consolidation is proceeding apace, clearly helped by Supreme Court decisions such as Citizens United that essentially removed all limits on corporate contributions to political campaigns.
Having input from corporations that stand to benefit from legislation or policy is one thing, as long as it is balanced by input from consumer groups – and the welfare of the people is the final criterion for making a decision, not maximizing corporate profit. In this case, the case of the public’s health, the decision should be clear cut.
[1] Tudor Hart, Julian, “Three decades of the inverse care law”, Br Med J, 2000 Jan 1;320(7226):15-8.
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Not long ago, I wrote of the “consumer alliance” between the American Academy of Family Physicians (AAFP) and the Coca-Cola company (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). In that piece, I also noted the close relationship between the American Dietetic Association (ADA) and Hershey’s. For the record, I did not believe that these were, um, healthful, for the American people. I cited the work of Howard Brody, who looked at the ethics of the conflict of interest specifically in the Coca-Cola/AAFP case (and yes, there is definitely a conflict of interest whether or not that conflict results in prejudicial outcomes).
It turns out that this kind of arrangement is not limited to the United States. Indeed, Dr Alex Scott-Samuel, Director of EQUAL (Equity in Health Research and Development Unit) in the Division of Public Health at theUniversity of Liverpool, brings our attention to an article in the British newspaper the Guardian. It reports that in the United Kingdom, the “…Department of Health is putting the fast food companies McDonald's and KFC and processed food and drink manufacturers such as PepsiCo, Kellogg's, Unilever, Mars and Diageo at the heart of writing government policy on obesity, alcohol and diet-related disease”, an apparently far more malignant development.
The potential advantage of a government-run national health system is that it can insure that health care is provided for everyone, as I have often lauded. The public health role, however, is one that is even more commonly a public one, even in the United States, but in the UK the influence of the Department of Health over public health policy is even greater than in the US because they do not have independent state governments with their own health departments and health policies. We are, of course, familiar with the “fox guarding the henhouse” method of making public policy, which seemed to have reached its apex in the GW Bush administration with the big oil companies writing energy policy. Or maybe not; recently we discovered from a recent NPR investigative report (we need more of those) that the noxious Arizona immigration law was actually written by the private, for-profit prison industry as a way to increase business! (“They even named it. They called it the 'Support Our Law Enforcement and Safe Neighborhoods Act.’")
Is, then, the public’s health just another example of this type of “consumer alliance” (I really love this term!) – the British call them “responsibility deals”, more enigmatic, perhaps, but not more accurate – or is it another matter? Clearly, as demonstrated by the BP oil spill in the Gulf of Mexico, energy policy is critically related to health. And a law that makes it illegal for a person, a US citizen, to stop an offer humanitarian life-saving help to someone they find wandering and half-dead in the Arizona desert, not to mention imprisons and deports those who are not legally here, impacts on their health. Certainly these policies impact the rest of their lives.
Maybe it is because this is happening in the UK that makes it stand out. Maybe because some of us, myself included, have seen the UK and other European countries (and certainly there are many differences between European countries) as more focused on the health of their citizens. I know that there have been any number of problems with and criticisms of British health and social policy, including those of Julian Tudor Hart (“the inverse care law”[1], Medical Student Selection, December 14, 2008) and Sir Michael Marmot (the “Whitehall studies”, Health Outcomes: The interaction of class and health behaviors, May 9, 2010), and continued by current public health experts and scholars. I guess that the presence of the British National Health Service and its universal access have been so overwhelmingly positive in this regard that I have regarded such criticisms as those of people who “don’t know how good they have it”. Let me be clear: I never doubted that the concerns were valid, but rather that they may minimize the good things present in the system; in the same way I know that those in US cities with public hospitals are correct when they point to the underfunding, second class care, and inequities that they suffer, but at least, unlike where I live, they have public hospitals.
This initiative is, clearly, malignant. It is unquestionable “conflict of interest” for those whose interest is in selling more of their products, however unwholesome they may be, to be involved in the writing of public health policy around the use of, and advertisement of, those products. And, moreover, they will certainly ensure the insertion of policies that benefit themselves at the same time as they harm the public’s health. Note that it goes beyond food (and junk food); not only does the “food network to tackle diet and health problems includes processed food manufacturers, fast food companies,”, but “The alcohol responsibility deal network is chaired by the head of the lobby group the Wine and Spirit Trade Association.” Wow. One consumer advocate noted "This is the equivalent of putting the tobacco industry in charge of smoke-free spaces." It’s quite an achievement. Even Philip Morris couldn’t get to chair the cigarette control board!
Obviously, that this is occurring shortly after the Conservative Party has taken control of the British government is not a coincidence. It is part of a very successful strategy to transfer not all most, but virtually all, wealth and power to those who are already most wealthy and powerful. In the US, despite the control of the White House and both houses of Congress by the supposedly more progressive Democratic party, this consolidation is proceeding apace, clearly helped by Supreme Court decisions such as Citizens United that essentially removed all limits on corporate contributions to political campaigns.
Having input from corporations that stand to benefit from legislation or policy is one thing, as long as it is balanced by input from consumer groups – and the welfare of the people is the final criterion for making a decision, not maximizing corporate profit. In this case, the case of the public’s health, the decision should be clear cut.
[1] Tudor Hart, Julian, “Three decades of the inverse care law”, Br Med J, 2000 Jan 1;320(7226):15-8.
.
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