13 June 2008

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.

06 June 2008

Podemos con Obama

Hike the gas tax

Wednesday midday I was at National Airport drinking a coffee that tasted like boiled shoe leather at the end of a bar. An outlet lured me there. National strikes me as the worst airport in America for keeping your laptop charged before you get onto the plane and can't recharge. Why so few outlets?

So there I am, answering emails and trying not to listen to the bartender talk up a couple who were slurring a bit before they even sat down. They plowed right into slugging back beers and mixed drinks. The Metro's not so bad, the bartender says to them. That's a recent discovery for her, forced by the fact that she's got an SUV. She's going to buy something smaller when she can afford it. Yep, her customers agree. They may need a few more before flying, but they're no fools. "Those SUVs," the guy says, "we all just bought 'em because they looked so cool."

Charles Krauthammer, one of the Washington Post conservatives, has a great column on how Americans have shot ourselves in the foot - or the bicycle tire, or something - with our refusal to tax gas. He doesn't mention the fact that big business and the Republican Party have engineered that situation by instilling fear and distrust of the very government that we're supposedly so proud of. Democracy or republic or whatever.

We've crippled ourselves regarding healthcare and transportation alike - both of which are essential for a vigorous economy.

If, however, you're wedded to the YoYo ideology - you're on your own - that cowboy mythology of individualism over community, then it's hard to get behind any kind of scheme that would benefit everyone - including future generations. Like, for instance, universal healthcare or a gas tax. That's despite solid data from elsewhere that it strengthens the middle class and makes children's lives better. Not a problem in America, where we're all on the verge of winning the Powerball, and will no longer be part of that middle class anyway. And our kids? YoYo.

Enough ranting. Here's Krauthammer:
Unfortunately, instead of hiking the price ourselves by means of a gasoline tax that could be instantly refunded to the American people in the form of lower payroll taxes, we let the Saudis, Venezuelans, Russians and Iranians do the taxing for us -- and pocket the money that the tax would have recycled back to the American worker...

Want to wean us off oil? Be open and honest. The British are paying $8 a gallon for petrol. Goldman Sachs is predicting we will be paying $6 by next year. Why have the extra $2 (above the current $4) go abroad? Have it go to the U.S. Treasury as a gasoline tax and be recycled back into lower payroll taxes.

Announce a schedule of gas tax hikes of 50 cents every six months for the next two years. And put a tax floor under $4 gasoline, so that as high gas prices transform the U.S. auto fleet, change driving habits and thus hugely reduce U.S. demand -- and bring down world crude oil prices -- the American consumer and the American economy reap all of the benefit.

05 June 2008

Medicare Meets Mephistopheles

That's the title of a 2006 Cato Institute rip on Medicare. Here's the spin, via Amazon: "Let's say you're the devil, and you want to corrupt the American republic. How would you go about it? According to David Hyman, you might create something like Medicare, the federal health care program for the elderly. Hyman submits that Medicare may be the greatest trick the devil ever played. Medicare feeds on the avarice of doctors and other providers, turns seniors into health care gluttons, and makes regions of the United States green with envy over the dollars showered on other regions... With epic political battles over Medicare and the future of limited government looming just over the horizon, Hyman uses satire to cast a critical eye on this mediocre government program."

You can pick upMedicare Meets Mephistopheles, for $1.40 from Amazon or $14.95 from Cato. Your choice as a consumer in a market that actually works - unlike the free-market healthcare biz. The New England Journal of Medicine had a January 2007 review:
Hyman is surely correct that current financial trends in Medicare funding are unsustainable and will eventually erode public support. But in focusing on Medicare's inadequacies and mocking the system as an intergenerational scam (my word, not his), Hyman overlooks the reason why Medicare was enacted in the first place and why it retains considerable public support. At its inception, Medicare addressed the palpable medical needs of the elderly and the failure of the private insurance market to meet those needs. The program reflected a set of values and social commitments that included universalism, government responsibility for social welfare, and public accountability.

More important, Hyman ignores the reality that many of Medicare's flaws are at least rivaled, and perhaps exceeded, in the private sector. It is doubtful that the private sector would match Medicare's considerable strengths in providing access to health care that was unavailable before the program was introduced. Whatever its failures, there is evidence that the program has clearly improved the lives of its intended beneficiaries. As J. Lubitz and colleagues wrote in Health Affairs ("Three Decades of Health Care Use by the Elderly, 1965–1998") in 2001, "Our findings are consistent with the idea that Medicare-funded services have improved the health of the elderly." Is there any legitimate nonideological reason to believe that consumer-driven health care will better serve the elderly than Medicare? I am dubious.

Still, Hyman's bracing critique reflects the fact that neither Medicare's problems nor the ascendancy of market-based approaches to solving them can be ignored any longer. In an era of rampant individualism, the attempt to defend Medicare's collective ethos has the aura of a reactionary battle waged to save an old order in the midst of its last throes. Those who support the social obligations underlying Medicare must demonstrate anew why market-based solutions are unappealing and why governmental investment in health care is morally justified.
Here's hoping that Obama means new hope for social obligations.

Military benefits from desperation

The Wall Street Journal blog shares a NYT article on how healthcare reform could hurt military recruiting goals. Turns out that when an illegitimate war drags on, when troops are abused, and when people realize that a war is illegitimate and troops are being abused, young people don't sign up to fight.

The NYT piece is accompanied by a chart showing that in the late '80s, 25 percent of young people figured they'd sign up for military service during the next few years. Now only 13 percent think that's a reasonable choice.

Young people signing on to military service evidently say they're partly motivated by medical need for their young families. Tricare for their spouses and children is a trade-off for signing up for Bush's war. "It seems a bit perverse that the incentives for a young person with children to join are greater than the incentives for his childless friend," writes Floyd Norris in the Times. "But that is the way it is. All that could change if the push for some kind of national health insurance program were to be successful."

03 June 2008

Donna Smith's new blog

The indomitable Donna Smith has a new blog at guaranteedhealthcare.org that I'll begin checking regularly. It's got 11 contributors, and so is almost certain to have new news and comments several times a day. Most, if not all the commentators are with the California Nurses Association and the National Nurses Organizing Committee.

Nurses, whether they're aligned with the American Nurses Association or the NNOC or SEIU are foot soldiers, sergeants and include a few generals the the battle for universal health care. It's doubtful we can get there without their help. All their help. So it's sad to see the division between the unions. Shades of Hilary and Barack.

02 June 2008

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.”

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.

Geography & healthcare

Consumer Reports has published an article on the Dartmouth Atlas of Health Care - a wonderful thing. Consumer Reports is really on a tear about healthcare, and this article provides our friends and neighbors information about a big part of what's wrong with U.S. healthcare.

Because physicians are paid on a fee-for-procedure, cost-plus basis, the incentives are to do more procedures, rather than just the right procedures. Physicians and nurses are generally ethical people, but they're just human. Add the need to pay for that MRI machine to the old lady's son insisting on "Do whatever's necessary, doc," and you end up with unnecessarily aggressive treatments - something proven out by the crazy regional differences on how many procedures patients are getting some places - without better outcomes.
Geography and health care
The amount of medical care that people get for serious illnesses varies enormously from place to place. In the last two years of life, the average patient spent 11 days in the hospital in Bend, Ore., and 35 days in Manhattan. In those same two years, patients visited the doctor an average of 34 times in Ogden, Utah, and 109 times in Los Angeles.

The Dartmouth Atlas based those findings on the Medicare claims records of millions of patients who died from (in order of prevalence) congestive heart failure, chronic pulmonary (lung) disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular (circulatory) disease, diabetes with organ damage, and severe chronic liver disease. Together those ailments account for about 90 percent of deaths of people older than 65.

Over the years, Dartmouth research has yielded some startling insights:
  • The local supply of doctors and hospitals has more influence on the amount and type of care that patients receive than their actual medical conditions have. The more medical resources a region has, the more aggressive the treatments are.
  • In the regions that deliver the most care, patients have a slightly higher death rate than patients with the same conditions treated in areas that treat less aggressively.
  • Patients treated most aggressively are no more satisfied with their care.
  • The cost differences are vast. Average Medicare spending over the last two years of life for all hospitals ranged from a high of $81,143 in Manhattan to a low of $29,116 in Dubuque, Iowa.
So the Dartmouth folks are big on best practices, as are other medical systems that keep down healthcare costs - and simultaneously maintain good access. (Note in the Consumer Reports' articles that "Patients in the high-spending, aggressive-care regions waited longer in emergency rooms and doctors' offices than patients in lower-spending regions did.")

Linda Gorman, from the libertarian Independence Institute and a commissioner on Colorado's Blue Ribbon Commission for Health Care Reform, was always vehemently against "best practices." She argued that the science was too soft, that it was subjective, that by God if a patient wants bad care then it's their right to get it - or something along those lines.

These are folks who also consider the science behind global warming to be a bunch of hooey. I don't know whether they also think the moon landing was a hoax.

Part of progress - and survival - comes from measuring cause and effects and paying attention to the answers. Dartmouth has come up with some pretty good answers here - information that's important whether we get a healthcare system or remain stuck with laissez-faire, for-profit healthcare. If we had a healthcare system, we could move more quickly and surely with this information towards more efficient and humane standards. Until that day, we'll muddle through and probably get partway there. Or not.