(As seen from the inside of the healthcare system, a slightly different version will appear at kevinmd.com/blog)
Paul Krugman’s health care columns, the archimedes movement and repairing the healthcare system frustrate me. They represent very different political philosophies, but each focuses on health care in isolation and each keeps repeating the same slogans. Jacob Hacker’s health plan, which is behind the Clinton, Edwards & Obama health plans, is very frustrating.
I agree with Hacker, Krugman, Kitzhaber and Feld that we need major reform. Reform requires more money and the will to offend powerful interests. We must begin with priorities. Our political system is broken. State and national legislators provide goodies to every special interest group. That’s how they stay in office. We spend far more money on militarism than most people realize. Check http://www.warresisters.org the claim that more than half of our federal budget goes to military expenses
Why does Congress keep funding massive supplemental off budget appropriations for Middle Eastern wars (including some high tech toys)? There are only two answers- either they feel that our country is so rich that money doesn’t matter, or they are like alcoholics who can’t break the habit because they haven’t hit bottom. Can we afford our ever-expanding military budget?
Turn to Massachusetts, whose novel healthcare plan requires everyone to have health insurance. The underfunded plan began last July; over 340,000 people are newly covered and 176,000 receive state-subsidized insurance - far more than expected. Another 55,000 are newly enrolled in Medicaid. The governor’s 2009 budget does not cover these increased costs. The deficit could be covered by a proposed tobacco tax increase but not if Mass legislators use it to fund other goodies. A recent Boson Globe Op-Ed spoke of the Mass plan as a second Big Dig- a well-intentioned thoughtless financial disaster http://www.boston.com/.... The subsidized part of the plan will probably double in size and cost over the next few years. Can the program survive? Of course it can, if it is a priority for Massachusetts voters and legislators. If not, it will crash and burn.
All Americans should worry. Failure of the Mass plan will derail national healthcare reform. Failure of Clinton, Krugman, or Obama to even discuss Massachusetts’s problems is disgraceful. The New York Times has a story about the need for more Massachusetts primary care doctors. This is true, but it considers trees rather than the forest. Primary care physicians are important; they must be networked to specialists rather than throwing up their hands and saying “call your cardiologist, neurologist, etc." for every unusual complaint. Constructing such a network needs lots of money and changed attitudes. Healthcare should be a national asset; providers should be part of a team. That’s not true today. Cost control is critical; this means a bruising battle. The same Op Ed that warned of another Big Dig recommended the old shibboleth of cost control (curb frivolous lawsuits) and warned against marketing bans or restrictions on biopharmaceutical companies.
Cost control is difficult. It’s more than drug companies, as noted in Brownlee’s recent book, Overtreated. I am a specialist who is often called by PMDs saying “parents insist that their child see a specialist for headaches”. They have ordered an expensive MRI (normal) but they can’t tell me whether or not the child has papilledema*. They have been trained to order tests, not in examining patients or individualized management of common problems like headache and backache. I don’t see residents criticized for ordering too many tests. As Pogo said, we are the enemy. We must accept limits in order to do more for more people.
The statement “Stay in Iraq until we are victorious” should elicit catcalls. Victory or defeat in Iraq are empty slogans; we must prioritize. Franklin Roosevelt had it easy in 1933 in the sense that one of third of US banks had failed. Congress knew that we were in big trouble. Our Congress can’t see this. Until they do, they won’t set priorities. Without priorities, healthcare reform is as meaningless as victory in Iraq. When we set priorities, we must recognize other needs in our society. For example, http://www.insidehighered.com/.... If we try to do a little bit for everybody, we get nowhere.
*would indicate pseudotumor cerebri, a serious disorder not detectable by scans or blood tests
** The Iraq war was a criminal venture, which will continue until a majority of Americans say, "We are willing to give up x to end the war". The Massachusetts plan was a good but underfunded idea which put PR above financial stability. It will not succeed until a majority of Bay Staters say "We are willing to give up y to make the plan work."