How many are underinsured?

Commonwealth Fund has just released a stunning report on underinsurance in the United States. "Insured But Poorly Protected: Number Up 60 Percent in 4 Years", finds that, "Rate of Underinsured Triples for Middle and Higher Income Families; Underinsured Go Without Needed Care and Face Medical Debt."

It's great to have these figures - even though they understate the problem. The report found that there are 25.2 million underinsured Americans - "based on their out-of-pocket health care costs relative to their incomes." That leaves a lot of underinsured people uncounted.

Here's the full text of the Health Affairs article, and here's an interview that the report's lead author, Cathy Schoen of the Commonwealth Fund, did with PBS. There's both a video and transcript there - and links to resources like this - U.S. vs. other nations.

We're not as smart: A Catholic editorial

The Diocese of Davenport's newspaper, The Catholic Messenger, has this editorial by Frank Wessling on healthcare:

We are not as smart as they are. And we’re not as kind, not as compassionate. But in this case, it’s OK — or at least there’s nothing we can do about it.

Who is smarter and more compassionate? Practically all other people living in modern industrialized societies.

How do we know that? Because they are healthier, and it costs them less to be that way than it costs us to be relatively sicker. And because, even though we know those facts, we do nothing to effectively change the situation.

It gets worse. Other nations operate at a higher moral level when they ensure that everyone, including the poorest, has access to medical care when needed.

Health care is a basic right that should come with modern civilization. The Catholic Church came to that conclusion long ago. Popes began teaching that in the 20th century. Our bishops have taught it repeatedly, especially in national election years when attention is focused on critical issues of our national life.

Yet we Catholics are still little different from other Americans in accepting the deficient — practically and morally deficient — situation that exists.

Health care for us is subject to the pressures of a highly competitive economy, with the result that there are winners and losers. Among the losers are the estimated 47 million Americans without insurance; those who avoid needed care because of high co-payments and deductibles required, those who can’t look for a better job to support their families because they fear the loss of health insurance and businesses hurt by the higher cost of health insurance as compared with foreign competition. In looking at the causes of death in this country, it has been estimated that 18,000 people die each year from the effects of no health insurance or underinsurance.

In the United States, 16 percent of gross domestic product goes for our fragmented health care system while other developed nations generally spend less than 10 percent. And their people are healthier by almost every measure, they live longer and their infant mortality is lower.

Surely we can do better.

Sister Carol Keehan, a Daughter of Charity who is president of the Catholic Health Association, laid out all of this in a May 16 speech to the City Club of Cleveland, Ohio. She called it “a very ugly picture,” and made this observation:

“In no other area that I am aware of do Americans believe that other nations are smarter or more compassionate than we are. If they can do it, it seems to me that we ought to believe we can do it as well.”

Indeed.

The American bishops' silence on this issue has been shameful. For them to adopt as vigorous a stance on this as they've had on that other healthcare issue would do much to restore their credibility with the rest of us.

Time predicts healthcare reform

Last week's Time Magazine's cover story was on the economic mess that the next president will need to clean up. The piece ends with a couple paragraphs on healthcare:

Then there's health care, which has become perhaps the biggest source of financial worry and occasional disaster among middle-class Americans. A 2005 study found that half of all personal bankruptcies in the U.S. were attributable at least in part to medical costs.

But there's real hope on this front. It is possible to conceive of a system that brings the 47 million uninsured into the fold, improves medical outcomes and costs less than what we've got now. It's possible to conceive of because many other wealthy countries already have such systems. Figuring out exactly how to make universal health care work in the U.S. is a matter better left to its own lengthy magazine article. But if you're looking for big economic change from the next Administration, this is the form it's most likely to take.

I find that comforting. It means that mainstream journalists, who aren't likely to be single-payer advocates but who are likely to be better read than the average American (not all, but it is part of the job) now get it. This writer, in any case, knows that the data is there. Other countries have shown that healthcare investment can be managed far better than we've accomplished.

There is a real chance that we'll see change in the next five years - perhaps not true universal healthcare via single-payer, but surely steps in that direction.

Risk Equalization in Eire

For Americans, reading about "risk equalisation" in the Irish insurance market can only evoke a snort of disbelief. It's a concept so foreign I'm not even going to Americanize the spelling.

So what the bloody hell is "risk equalisation" you ask?

According to Medical News Today, risk equalisation is how competition in the health insurance market works to the benefit of all health insurance subscribers. It operates alongside community rating, open enrollment and lifetime cover. Here are the definitions:

• Open Enrollment entitles persons of all ages, irrespective of health status to avail of health insurance.
• Community Rating ensures that younger and older subscribers pay the same amount for similar health insurance cover and that subscribers pay the same amount for similar cover throughout their lives. This means that people can continue to afford health insurance right into those decades of their lives when they are most likely to need it.
• Risk equalisation payments involve transferring funds from insurance companies which have a disproportionate share of young, healthy subscribers to companies which have a disproportionate share of older people who are more prone to illness.

Crazy.

"This allows for an equitable market, enabling companies to compete on a equal basis, but also protecting customers through removing the incentive to engage in preferred risk selection," according to the story.

Crazy.

This would protect individuals and families at the cost of profit. It's nuts. Probably communist.

Most EU countries have supplemental insurance that a lot of people buy -- about 50 percent in Ireland. (And yes! Those private insurance costs are factored into the total costs you read about where the U.S. looks so bad.) Evidently the EU court doesn't want to model their insurance market on ours. Odd, eh? Ours is so robust. Very profitable industry.

No doubt the insurance industry will continue its assaults on the notion of protecting the consumer in this wild-eyed manner. Sooner or later, by hook or by crook, "risk equalisation" will be a boogey-man of the past.

Polish lobbyists call for private insurance

The Polish Insurance Chamber is calling for private insurance that would compete with their government programs. They say, "The PIU assumes the cost of the additional health insurance would be around zł.50 per month. Assuming a take-up of 15%, this would mean an extra zł.3.5 billion for the Polish healthcare system."

If the system is underfunded, wouldn't an increase in taxes do that more efficiently?

Brisbane. What state is that in?

A leading maternal-fetal medicine researcher has inexplicably ended up at the University of Queensland in Brisbane, Australia -- a far piece from where the only possible environment for innovative research exists -- right here in the U.S.

Only our free-for-all, ignore-the-bodies-they're recyclable-anyway market economy nurtures pharmaceutical companies -- with private health insurance footing a good part of the bill and no government negotiations for pharmaceuticals. Ask Rush Limbaugh if you don't believe me.

So this news doesn't make a bit of sense. But here it is anyway: Professor Nicholas Fisk says that the current research and development and business model of the pharmaceutical industry is failing pregnant women, and describes pregnancy as a virtual "pharma-free zone." He analyzed an industry database that tracks drugs under development since 1981 and found only 17 drugs under active development for maternal health. Only one new class of drug has been licensed in the last 20 years -- and that one case did not take place in either the U.S. or Australia.

Professor Fisk's research looks at the pharmaceutical market's "push" mechanisms (funding to encourage investment from universities and companies) and "pull" mechanisms (funding to purchase drugs once they are on the market) have not been effective in the area of maternal health.

Curiouser and curiouser. Haven't we been assured that market mechanisms are what make the U.S. unique in the world? And that they are responsible for most if not all of the pharmaceutical advances of the past decades? A different way is possible?

Professor Fisk says that manufacturers avoid the need of pregnant women because said women are likely to sue them should the drug result in fetal abnormalities, because of the small market size for conditions affecting pregnant women, the limitations of a shareholder model, and a regulatory system that allows endemic off-label use of drugs in pregnancy, discouraging pharmaceutical investment in the long term.

The professor thinks that drugs for pregnant women should instead be developed under a model like the Neglected Diseases Initiative, which does not rely on profit for innovation.

Libertarians and free-market ideologues reading this should not be alarmed. Research has also shown that when we read or hear something that is dissonant with our deeply held ideological beliefs, we throw the facts out the window, not our beliefs. Such readers have already -- already! -- successfully rationalized this tidbit into support for their own beliefs.

Liver transplant outcomes better in UK

Maggie Mahar, author of one of the best books on our health care mess, Money-Driven Medicine: The Real Reason Health Care Costs So Much, has a good article at her blog on cherry picking numbers to "prove" that the U.S. has best health care in the world.

Mahar researched the numbers behind the Wall Street Journal column on Nataline Sarkisyan, the 17-year-old California girl who died last month after her insurance company refused to pay for a transplant. That column's author referred to an unnamed British medical journal study on survival rates for transplants for people suffering from chronic liver disease and acute liver disease.

Mahar begins her rebuttal by asking whether fact that we perform a greater number of transplants on seriously ill patients is reason to claim that U.S. health care is better — "or does it simply mean that we are more inclined to experiment on our sickest patients?"

It all depends on how well the average patient who is plucked out of the ICU to undergo a liver transplant fares. If he or she goes on to enjoy several years of high quality life, one would be inclined to say “yes”—our more aggressive care equals better care. But if too many patients suffer complications and then die in great pain twelve or 15 months later, it would be much harder to argue that “doing more” makes U.S. healthcare “better”—especially when both the money and the liver could have been spent on another patient who had a better chance of surviving.

She found the study used by the WSJ writer. She writes that indeed it found that patients' five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Ireland than the U.S. The WSJ author also cherry picked this statistic: "in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.”

Meaning that by the end of the first year, the differences canceled each other out. Mahar writes:

Begin with how the patients were faring during the first 90 days... during this time, mortality rates in the U.S. were lower (regardless of whether patients had originally suffered from acute or chronic liver diseases.) This is, in large part, the article suggests, due to lower nurse/patient ratios in the U.S. and more intensive care during the first weeks following surgery.

But what Gottlieb omits is the crucial fact that, when the researchers went back and looked at “patients who survived the first post-transplant year,” they discovered that “patients who had suffered from chronic liver disease in the U.K. and Ireland had a lower overall risk-adjusted mortality” than patients in the U.S. In other words, survival rates for patients who had a chronic disease before the transplant were better in the U.K. and Ireland. As for patients suffering from acute liver disease, longer-term survival rates past one year were just as good in the U.K. and Ireland as in the U.S. Moreover, if you checked patients in the interval between 90 days and one year, outcomes were similar in the two health care systems.

So in fact, "Outcomes in the U.K./Ireland were just as good for one group and decidedly better for the second... "

Health Insurance to Africa

Sound familiar?

Private insurance products hardly exist for the rural and urban poor and in cases where they do exist they are not affordable for them. Public Social Insurance Services are mostly insufficient and exclude people working in the informal sector. Nine out of ten people in Sub-Sahara Africa therefore do not have any access to health or accident insurance. They have to pay tremendously high fees for treatment, medical care and hospitalisation out of pocket. Especially those people living below the poverty line (more than 40% in Sub-Saharan Africa) have to take out loans, dissolve their savings or sell essential resources to pay for their treatment. Therefore, many are not in the position to make use of the required services at all. In fact, many people fall into poverty due to illness and treatment costs.

For decades now the World Bank and IMF -- a bit like loan sharks in poor neighborhoods -- have held out fat loans for poor countries. The price for accepting those loans was accepting neoliberal ideology, and privatizing public services.

The loans also weren't usually tracked very carefully, so that they became a corrupting influence for government officials who became fat and retired to Switzerland on them.

So government services were cut, including health care. The money was ineffeciently spent, and then the loans came due -- forcing a further cut in social services. Including health.

And now a German professor has a research project going for how "access to proper insurance for all can be reached successfully" -- through micro-insurance. Same as we have here!

All according to plan.

Single-payer & Nataline Sarkisyan

Christopher M. Hughes, MD, has a wonderful post in his blog, Single-Payer Healthcare Blog. Dr. Hughes replies to what has evidently become a backlash against the outcry against what happened to Nataline Sarkisyan. He writes:

The staunchest advocates for Single Payer Healthcare never, ever, disparage American medicine's ability to deliver the best care in the world in areas such as organ transplant, trauma, intensive care and other high tech endeavors. But these areas are only a sliver of overall clinical outcomes. Even at the quoted 18.5 liver transplants per million done in the US annually, this is only 5000 or so patients. So, while not being dismissive of these patients, they are not reflective of healthcare outcomes of our population. They only reflect what we already know: We spend tons of money on advancing high tech medicine and we are darn good at it. As I view the transition to single payer, I see no reason, other than "conservatives" wailing about unnecessary spending on healthcare as the system matures, for us to continue to do well in our "American specialty" of bleeding edge healthcare.

It looks like Dr. Hughes began his blog about the same time I launched Ave Cassandra, maybe a month later, and that he posts about a dozen times a month. And that he's smart. I added his blog to Ave Cassandra links.

In that Wall Street Journal commentary, I was struck by the numbers —

In 2002 -- a year comparative data is available -- U.S. doctors performed 18.5 liver transplants per one million Americans. This is significantly more than in the U.K. or in single-payer France, which performed 4.6 per million citizens, or in Canada, which performed 10 per million.

What about the differences in outcomes between ours and single-payer systems, an issue Mr. Edwards hasn't directly addressed? One recent study found that patients' five-year mortality after transplants for acute liver failure, the type from which Ms. Sarkisyan presumably suffered, was about 5% higher in the U.K. and Irleand than the U.S. The same study also found that in the period right after surgery, death rates were as much as 27% higher in the U.K. and Ireland than in the U.S., although differences in longer-term outcomes equilibrated once patients survived the first year of their transplant.

These findings aren't confined to transplanted livers. A study in the Journal of Heart and Lung Transplantation compared statistics on heart transplants over the mid 1990s. It found patients were more likely to receive hearts in the U.S., even when they were older and sicker. The rate was 8.8 transplants per one million people, compared to 5.4 in the U.K. Over the same period, about 15% of patients died while waiting for new hearts in the U.K. compared to 12% in the U.S. In 2006, there were 28,931 transplants of all organ types in the U.S., 96.8 transplants for every one million Americans. There were 2,999 total organ transplants in the U.K., 49.5 transplants for every one million British citizens.

When you read the Commonwealth Fund studies, the analysts there often say that no one country is better than others in outcomes overall — we're best at some stuff, France is best at some things, Britain for something else... but that the U.S. falls down completely when the fact that we spend so much and exclude so many is taken into account.

Unless there is other data that the WSJ author (a physician and right-wing American Enterprise Institute resident fellow) is leaving out, one would assume that transplants are one of the areas in which the U.S. is ahead in terms of practice and outcomes.

I'd be interested in knowing what else goes into these transplant numbers — for instance, the rate of donated organs and their availability, the need for transplants, whether some of our transplants are done on patients that get some other kind of treatment there, and the average age of transplant recipients in the various countries.

Ezra on healthcare comparisons

Ezra's evidently back from New Hampshire, and reading the new Health Affairs study "Measuring the Health of Nations" — which shows 101,000 excess deaths annually due to "amenable mortality -- 'deaths from certain causes that should not occur in the presence of timely and effective health care'." He notes,

Every other country posted significant progress in reducing amenable mortality. Save for us. In 2002-03, for both males and females aged under 75, America had the highest rate of amenable mortality -- which is to say, preventable deaths -- in the OECD. That means we were behind Canada, behind the United Kingdom (whom we'd beaten in 1998), behind France, behind Ireland. And not by a little -- France's preventable death rate was only 58 percent what ours was. Had we achieved the average gains -- not their rates, but simply the improvements -- posted by the other countries, we would have saved 75,000 lives. Had we achieved the gains of the top performers, we would have saved 101,000 lives.

Repeat that to yourself: 101,000 lives. That's more than the total population of Boulder, Colorado.

101,000 excess deaths in U.S.

A recent study published in Health Affairs show that there aren't just 18,000 deaths a year because of our idiotic system, there are actually 101,000 excess deaths annually. France, Japan and Australia rated best and the United States worst. The study focused on preventable deaths due to treatable conditions in 19 industrialized nations. The U.S. health care system's shortcomings resulted in 101,000 more deaths than if we'd had a system based on care rather than profit.

Researchers Ellen Nolte and Martin McKee of the London School of Hygiene and Tropical Medicine tracked deaths that they deemed could have been prevented by access to timely and effective health care, and ranked nations on how they did.

They called such deaths an important way to gauge the performance of a country's health care system.

Nolte said the large number of Americans who lack any type of health insurance -- about 47 million people in a country of about 300 million, according to U.S. government estimates -- probably was a key factor in the poor showing of the United States compared to other industrialized nations in the study.

"I wouldn't say it (the last-place ranking) is a condemnation, because I think health care in the U.S. is pretty good if you have access. But if you don't, I think that's the main problem, isn't it?" Nolte said in a telephone interview.

Spain was fourth best, followed in order by Italy, Canada, Norway, the Netherlands, Sweden, Greece, Austria, Germany, Finland, New Zealand, Denmark, Britain, Ireland and Portugal. The United States comes in last.

Good comment on this at Cronespeaks:

As a Canadian, I do not want to see the USA get universal health care or free universal education. Much of Canada’s increasing economic advantage comes from the malaise and stupidity of directly competing demographic areas in the USA; and we are winning because of our healthcare and educational advantages.

Recently, Toyota chose Ontario Canada over Alabama as a site for their largest manufacturing site. Why?

Toyota cited a much more highly educated workforce and the savings in healthcare costs as the deciding factors in choosing Canada. Please keep your present system in the USA — it’s “Merkan, so it’s gotta be the ‘best’!

It could be that Stuart Butler, Canada's anti-Michael Moore "brilliant" filmmaker, Stuart Browning might sign her on to help him... You think he'd go for that?

Bravo, Ootpoot!

Maine paper pushes single-payer

This isn't quite an endorsement of single-payer, but it's pretty close. The Bangor Daily News evidently has a readership close enough to Canada that they're not fooled by the propaganda slurring Canada's system. The editorial reads:

Much of American health care is already run quite satisfactorily on a single payer basis: Medicare, Medicaid and the veterans’ health system.

Government run health plans, usually single payer plans, are good enough for Canada, Britain, France, Denmark, Sweden, Germany, Australia, New Zealand and most other developed countries. Why can’t they even be considered and debated by candidates for the U.S. presidency?

Cancer & single-payer

Timothy Noah over at Slate has a good article examining the right's new health care canard (they found something beyond waiting times for nonemergency surgery in Canada!) Turns out we need to be scared, real scared, as W might say, of dyin' of cancer if single-payer becomes the law of the land.

See, the Lancet came out with a study that shows the British cancer survival rates for five years out are far less than ours — near the bottom, in fact of 23 European countries — all of which have universal health care, virtually all of which do so through public financing. How that shows that single-payer is to blame is hard to say.

In fact, looking at the entire chart, Noah points out that with the exception of Britain, wealth correlates with survival rates. So what's with Britain?

It's hard to say, but one reader notes that the entire debate is a bit off kilter, since in fact:

The biggest determinant of cancer survival statistics is something called lead time bias - people only appear to live longer because they are diagnosed earlier; the relationship between early detection and cure for most cancers is weak. In addition, some cancers detected by early screening grow so slowly that they are unlikely to cause problems for an elderly person before he or she dies of something else. As a result, in most developed countries, increased cancer survival times and cure rates correlate with increasing cancer rates but its largely an illusion of more agressive testing.

Scary if true. The good news is that Europe probably has fewer cancers to begin with because their environmental regulations are stronger and their auto lobby wasn't powerful enough to destroy all of their mass transit, biking, and pedestrian options. So people move more with fewer toxins.

Plus, early detection and prevention is indeed good for most ailments. Like, say, appendicitis.

Jim Spencer reappears!

The Denver Post's fine columnist Jim Spencer was given the boot earlier this year — a matter of rationing liberal views, evidently.

We all missed him — and so I was pleased to see his byline on this column: "In the Matter of Health Care Versus Baloney" at Colorado Confidential, Colorado's preeminent progressive blog.

Spencer, as always, did his homework responding to the Rocky Mountain News's scurrilous attack on Health Care for All Colorado's proposal to the Blue Ribbon Commission for Health Care Reform. The title of that RMN piece? "Single-payer Baloney."

They got just about everything wrong. No. They got everything wrong.

Unlike the Rocky, which didn't evidently do any research, no quotes, no references, and they certainly didn't get in touch with us or the Colorado Nurses, Jim quoted Donna Smith:

But on the business side, the U.S. system “doesn’t even make economic sense,” said Donna Smith of Aurora, whose family health problems forced her and her husband to declare bankruptcy. “Single payer would lower the burden on American businesses.”

Smith and her husband, Larry, appear in Michael Moore’s documentary “SICKO,” which lambastes the U.S. health care model. Smith testified before Congress in July about the inability of many Americans to afford health care. She just started a group called American Patients for Universal Health Care.

If you’re worried that Smith isn’t objective because she has a dog in this fight, then check with Colorado’s own financial consultant on health care reform. The Lewin Group has issued a preliminary finding that cumulatively, a single payer health system will save Colorado money on health care.

The Rocky did print Fran Ricker's and my rebuttal on Saturday — which was good of them, since it's a combined circulation that day of both Rocky subscribers and Denver Post subscribers.

Hillary says it right

For all those who hate Hillary, take a look at this. In "Hillary Lashes Out at Health Care Critic," she answers someone accusing her of being for "socialized" medicine, like they have in Canada.

"Do you think Medicare is socialized medicine? Clinton asked, turning the tables on her inquisitor, who did not identify himself.

"To a degree," he responded.

"Well, then you are in a small minority in America," Clinton said to applause, before explaining that Medicare allows patients to choose their doctors even though the federal government foots the bill with money deducted from workers' paychecks.

Clinton then asserted that "on balance" countries with uniform national systems of health care, including Japan, Australia and Canada, offer their citizens better health care than the U.S. The answer left her questioner shaking his head in disagreement.

"I can give you the statistics and you can shake your head," Clinton said sharply. "You come and introduce yourself to the staff. And we'll try to give you some information if you're interested in being educated instead of being rhetorical."

A bad deal

Healthcare cost comparisons

Healthcare eats up more than 16 percent of U.S. GNP. The average for other industrialized nations, all of which guarantee their citizens healthcare, is 11 percent. Here's what it looks like in a bar graph. Note how low Britain's spending is — it's too bad they don't push it up a point or two, so that they could eliminate the waits.

On the other hand, with all that the U.S. spends, why on earth don't we all have gold-plated coverage?

Now take a look at the dollars spent, per person. These numbers are a couple years old — we now spend more than $7,000 per person. That's including the 17 percent of us who have no healthcare coverage, and for the 17 percent or more of us who are underinsured. We already spend the money. Let's redirect it into healthcare and away from insurance administration and profits.

Swiss researchers make do

Did anyone notice that part of the news about amniotic stem cells was from Switzerland?

"Swiss scientists Dorthe Schmidt and Simon Hoerstrup of University Hospital Zurich have used amniotic stem cells to grow heart valves. They are currently testing them in sheep."

How on earth did that happen? I thought that the crippling effects of European single-payer healthcare, especially all that bargaining with big pharmaceutical companies, precluded European advances in medicine.