I am a 70 year old retired physician with 45 years of being in the trenches of health care. This diary is a letter I wrote in response to an email I received from an old friend ("B") who is an educated right-winger (no, it's not an oxymoron). My father was a physician and I grew up in a household where "socialized medicine" was a dirty word. Eventually, he came around, and at the end of his life was an advocate of national health care. It's encouraging to see that, according to the recent NEJM/Mt Sinai study, my colleagues are finally beginning to see the light.
B wrote:
M,
I embrace a public option for those who need it as long as it is truly a competitive option. The way current legislation is worded, the public option is advantaged and the restrictions, requirements and limitations governing private competition would eventually squeeze out private options and incent companies to abandon their current offerings. It scares me to think of the public option as eventually becoming the only option. In general terms, I like a public option as a safety net for those who can't get coverage elsewhere coupled with open insurance competition across state line, individual tax credits or deductions for insurance costs, and tort reform. Like so many other sensitive issues, the politicians take an all or nothing approach when the common sense solution seems to be a combination of the good pieces of all sides. Both sides lie, distort, and misrepresent which has made me very much a cynic towards government and their ability to craft an efficient solution to just about anything they do. If you want to get something screwed up, just let the government handle it.
Thanks,
B
My reply:
Hi B,
I appreciate your recent thoughts regarding the issue of health care reform. As expected, we have significant disagreements as to the solution to this serious problem. I have tried to encapsulate my views with the following observations. I hope you will take my comments in the spirit for which they were intended and respond in kind.
The US now spends over 17 % of GDP on health care, more than twice that of all other industrialized countries. Yet, according to WHO, we rank about 37th in the world in quality of care 6th out of 6 among the major Western industrial societies, according to the study of the Commonwealth Fund. Although the White House has been controlled by Republicans for 20 of the past 28 years, the only meaningful attempt to reform our health care system was initiated by President Clinton. Neither Reagan, G.H.W. Bush or GW Bush initiated any type of health care reform, other than the Medicare part D boondoggle, which was essentially a gift to the big pharmaceutical companies and left seniors with a big doughnut hole.
You mention that you favor some type of public option for the poor, and that’s a good start. We both agree that competition is a good thing and hopefully you would agree that in the unlikely event that such a public option proves to be more efficient and provide higher quality of care at a lower cost than private insurers, we should all be allowed the choice of participating. Yet you write, "The way current legislation is worded, the public option is advantaged and the restrictions, requirements and limitations governing private competition would eventually squeeze out private options and incent companies to abandon their current offerings." What specific restrictions, requirements and limitations are you referencing?
I agree that there are many lies being spread, although most of them, from my perspective, seem to be coming from those who oppose any type of reform. They include the following:
- HR 3200 would pay for the health care of illegal aliens.
Led by Joe (Sons of the Confederacy) Wilson, this has become a rallying cry for some. However, the bill clearly states:
H.R. 3200: Sec 246 — NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.
- Government Health Care is Unconstitutional
Article 1, section 8:. The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;
I suppose some of these same folks would argue that Medicare is unconstitutional.
The corollary to this one is the claim that the Tenth Amendment delegates health care to the individual states. This one has recently been trotted out by the Governor of Minnesota, Tim Pawlenty, a lawyer. I understand that the University of Minnesota may not be Harvard Law, but surely the governor took some kind of course in Constitutional Law and would understand that with very rare exception (2/55) the Supreme Court has ruled that issues that affect the general population are not subject to the Tenth Amendment.
- The government is going to kill Grandma
Do I really have to discuss this one? Provisions for voluntary counseling on end-of-life issues has been part of Medicare for 10 years. As far as I know, the government has not euthanized anyone. One of the biggest proponents of this type of provision is arch conservative Sen. Isakson of Georgia, hardly a bleeding heart liberal.
- This will lead to socialized medicine
Interestingly, Ronald Reagan leveled this same charge against Medicare in 1964
Although I, personally, would prefer a single payer national health care plan, there is nothing in the bill that would come even close to creating this. Insurance companies will not be outlawed, but will be forced to compete. Those who prefer a plan that offers better options would be free to exercise their choice of plans. Competition is the bedrock of capitalism, after all.
And when one examines health systems in other countries, they are hardly "socialized." The NHI systems (Canada, Taiwan) rely on private-sector doctors, hospitals, and labs but pay for their services through a government insurance plan. The Bismark Model countries(France, Germany, Netherlands, Switzerland, Japan) offer universal coverage using private providers and private insurance plans – with government exercising various degrees of regulatory control over insurance coverage, pricing, etc. Even in the Beveridge Model (Britain, Spain), the primary care doctors, who provide most of the care, are private business people and often are ferociously capitalistic.
The closes thing to a "socialized" system, in which government owns the hospitals and employs the doctors and nurses, is the U.S. Department of Veterans Affairs, by all measures on of the most effective systems in the U.S.
- This will lead to health care "rationing."
We have been rationing health care in this county for years. The most egregious examples are the denials of care for so-called "pre-existing conditions" or simply the inability to provide health care for millions of uninsured Americans. However, if "rationing" means not giving doctors and patients everything they want, that is not necessarily a bad thing. Much of what is going on in medicine today is absolute nonsense, ranging from expensive medicines that are no better than aspirin, to surgeries like back fusion and bypass grafts that have no proven value for the vast majority of patient that are subject to these procedures. Hopefully, someday we will develop national practice guidelines, based on evidence-based medicine. Health care is too precious a resource to be infected with charlatanism, marketing hype and junk science.
I do agree that there may be longer waiting times for some types of services. However, I already have to schedule my doctors’ appointment a couple of weeks in advance and from my reviews I know that in California it is not unusual to wait several weeks and even several months for many surgeries. Maybe there is a niche market there for some insurance company or consortium of doctors for people who have enough money and want to get bumped to the front of the line. There is already such a product in some places, known as "boutique" medicine. However, judging from some of the doctors involved, I’m not convinced that those patients get any better care – and in some instances, far worse. (Think Michael Jackson, Lucille Ball, Jeff Chandler, etc)
- High drug prices are necessary to cover the costs of research and development
I just tossed this one in because it’s one of my favorites. The fact is that drug companies spend 10-15% of their budget on R&D and 90% of that is on D. Nearly all of the research is done at universities, funded by and under the auspices of the NIH. Most of the development (D) is spent in manufacturing and phase III and phase IV testing. Phase III testing is done primarily to assure the FDA that the product is safe. Most Phase IV testing is done to develop "off-label" and often spurious uses for a drug that is already FDA approved. A typical example of this is the use of anti-convulsants for the treatment of chronic pain syndromes. The fact that it doesn’t work has not deterred doctors from continuing to prescribe them. And the list goes on and on......
Another type of "development" is budgeted under the rubric of "education." That is when the drug companies host lavish seminars for doctors (always at five star resorts) to educate them as to how to use their drugs. I personally think this should be in the marketing budget, but since that already accounts for about 30% of their budget (think TV ads for Viagra, Cialis, P.A.D. [whatever that is!], etc).
Obviously, I could write a book about how dreadful big Pharma is, but fortunately other have beaten me to the punch. I strongly recommend "The Truth About the Drug Companies," by Marcia Angell, MD, former editor of the New England Journal and "Worried Sick" by my old friend Nortin Hadler MD, professor of medicine at UNC School of Medicine.
- The Obama plan will cost $1 trillion dollars over 10 years!
Normally, I stay away from issues of economics, because I only got as far as Econ 101 at Princeton. Plus, cost estimates are generally partially educated guesses that tend to be nothing more than opinions. However, the CBO initially estimated the figure of $1 trillion, and that has gotten a lot of play. On the other hand, Obama says that over 10 years, the plan will be deficit neutral. Hard to know who to believe.
I did have a chance to review the more recent numbers from the CBO and JCT (Joint Tax Committee). According to CBO’s and JCT’s assessment, enacting H.R. 3200 would result in a net increase in the federal budget deficit of $240 billion over the 2010-2019 period. That estimate reflects a projected 10-year cost of the bill’s insurance coverage provisions of $1,042 billion, partly offset by net spending changes that CBO estimates would save $219 billion over the same period, and by revenue provisions that JCT estimates would increase federal revenues by about $583 billion over those 10 years. Thus, CBO and JCT estimate that by the end of the 10-year period, in 2019, the coverage provisions would add $240 billion to the federal deficit.
And while I am on the subject of economics, one of the things I find difficult to understand is the objection of the rest of the business world to developing a system that truly drives down health care costs. I can vividly recall the general manager of the old GM plant in Van Nuys bemoaning the cost of health care benefits that was factored into each new car they produced. Makes me wonder if this isn’t part of the reason that Toyota and Airbus seem to have a competitive edge in the world marketplace. Plus, a new study from the Center for Economic and Policy Research suggests that we are lagging behind the rest of the Western world in small business development due, at least in part, to the inequities of the health care cost burden.
OK, that’s my partial list of "lies" as seen from the left. Feel free to rebut! And give me your list of "lies" as seen from the right and I will return the favor.
You mentioned a few things that would constitute your idea of reform, so let me have a go at those. I don’t quite understand how these will significantly increase health care quality or reduce the cost of health care (17% of GDP) or increase availability of health care to all, but here are my thoughts on the specific proposals you have mentioned:
- Tax deductions or tax credits for health care premiums
Of course I’m as happy as the next guy to get a tax break. But I worry that this won’t really do anything to bring down the overall cost of health care. Plus, this looks a lot like government subsidized health care for the wealthy. If there were a concomitant increase in the top tax brackets, I could probably support this idea
- Open competition across state lines
Competition is always a good thing. However, I am concerned that this may allow some insurers to circumvent State laws and engage in predatory practices to the detriment of the health care consumer. Interestingly, this also seems to be the concern of the Florida State Insurance Commissioner, a Republican and appointee of Jeb Bush:
Florida Insurance Commissioner Kevin McCarty said health insurance plans operating outside of the state's regulations are driving up premiums for regulated plans and leaving consumers vulnerable to "predatory practices."
These out-of-state associations - which include companies like Golden Rule and Assurant - are governed by the health insurance laws of their home states. Their plans for groups and individuals don't get their rates approved by Florida, don't have to cover pre-existing conditions and can raise rates or non-renew policies shortly after members get sick, said McCarty, who led a health insurance panel in Miami on Aug. 20.
In the individual and small-group marketplace, these out-of-state associations only cover young and healthy people, and do it at a low rate - as long as they stay healthy. But this takes them away from the regulated health plans, leaving them a sicker population that requires higher premiums for all, McCarty said.
"It's a horrific process," he said. "There's no question there's an advantage in the marketplace for out-of-state groups, and it's a disadvantage to businesses in Florida that want a regulated product and our regulated insurance companies."
McCarty wants these out-of-state groups to be required to follow Florida's insurance regulations, but he recognizes that would be a tough sell in the Legislature because of the associations' clout.
Florida Association of Health Plans Executive VP Rich Robleto also wants a level playing field with regard to consumer protections. While there are some legitimate out-of-state groups, like the National Association of Realtors, too often, companies are taking advantage of the system by forming groups like the "National Association of Air Breathers," Robleto said.
These out-of-state certificates are more affordable for some individuals and small group plans, but members often don't understand the drawbacks, said Nathan Rosenberg, head of insurance agency Complete Analysis in Coral Springs.
"Some of the applications say that if you become sick, you aren't covered if it happens in the first year," he said.
(South Florida Business Journal 9/9/09)
- Tort Reform
Ah, the old stand-by! As I mentioned in our conversation over Gibson’s prime steak, medical malpractice accounts for about 1-2% of health care costs. Tort reform has already been tried in California and Texas, and as far as I know, has had little, if any impact on either health care costs or the way doctors practice medicine. I know that some say that the cost of "defensive medicine" is one of the real culprits, but I have just not seen that in either my own experience or in the thousands of cases that I have reviewed. There was an interesting article a couple of months ago in the New Yorker about some hospital and medical community in Texas that was charging rates much higher than the Mayo Clinic, all in the name of defensive medicine. Turns out that they were simply using that as a cover-up to explain all the money they were making on unnecessary testing and procedures.
While there are certainly instances of malpractice, and these deserve to be prosecuted, much of what is construed as malpractice arises out of the uncertainty that results from an essentially unregulated discipline. The basic test for medical negligence is whether the action conforms to the "standards of the medical community." However, there are really few standards of practice that are actually based on scientific evidence-based guidelines. The establishment of such guidelines would be extremely beneficial in reducing the uncertainties of medical practice and hence the risk of malpractice. For example, if a person comes in with low back pain, the doctor may be tempted to request an MRI to be sure that he doesn’t miss an osteosarcoma of one of the vertebrae. However, if there is a written guideline that says the only indication for MRI is clinical evidence of nerve root pathology or "other compelling evidence of tumor or infection" the doctor need not worry about not ordering an MRI unless those clinical findings are present. If he is sued, he now has written proof of the "standard in the community."
I should add that, regarding testing such as MRI, I think one of the driving forces behind doctor behavior is ensuring the patient that they are doing "everything they can" and not appearing to be behind the times in utilizing technology. It’s much easier and less time consuming to simply order an MRI than to explain to a patient why such testing is unnecessary.
In short, nationally applied, evidence-based medical guidelines are going to be essential, not only to the delivery of the highest quality of care, but also to resolving the uncertainty that leads to malpractice actions and unnecessary utilization of resources.
And it wouldn’t hurt to develop a national licensure for doctors as well as a licensing board that actually cracks down on incompetent physicians. The sad truth is that in almost every state you will lose your license for dealing drugs or having sex with a patient, but not for being incompetent!
By the way, one of the biggest lies regarding malpractice is that premium are directly related to the actual cost of malpractice actions. Several years ago when there was a huge malpractice crisis, several investigations in California revealed that the primary driver of insurance premiums was not the cost of malpractice suits, but an attempt by the carriers to recoup losses they had sustained to their investments during the ‘70’s.
Now, I understand that one of the big differences in our philosophies is the role of government in a free society. You prefer less, I prefer more. However, the old canard that government is essentially "evil" is a tired old Manichaeistic worldview that ascribes good or evil to all things. Government is neither good or evil. However, it is necessary for civilized societies (Unless, of course, you prefer tribalism or anarchy) Grover Norquist once famously wanted to "drown government in a bathtub." But he never offered a viable alternative. Ronald Reagan said that "government is not the solution, government is the problem." But he never said what the problem was and never provided a solution.
Lincoln envisioned a government "of the people, by the people and for the people," and I subscribe to that ideal. I think governments fail when they are administered incompetently ("heck of a job, Brownie!") or when they are dominated by special interests, and particularly monied interests, that are not consistent with the best interests of the people. And just as Eisenhower warned against the military-industrial complex, in great part owing to his familiarity with the military, so, too, I am concerned about the medical-industrial complex.
I am all for capitalism and believe it to be a wonderful source of invention and goods and services that add to the betterment of society. However, when large corporations become bound by fascia to government in an alliance that primarily serves the interests of the corporations and those that hold the power of government, the interests of the people are generally not well served. It always boggles the mind that those who are so quick to bandy about the term "fascism" actually have so little understanding of the meaning of that term.
I do think that there are some things that governments can do well, some better than others. Education and infrastructure come to mind, as well as defense, of course, and police and fire protection and protection from those that would poison our air or water or market things that are dangerous to our well-being. I also like the postal service. Although much maligned, I doubt that any entrepreneur could develop and implement a system that allows us to send letters that are delivered in 1-2 days for 44 cents. Here on the island we are totally dependent on mail services and I have discovered that unless I absolutely need something in 2-3 days (we don’t get anything overnight), Express US Mail is just as good and much cheaper than either FedEx or UPS. Of course if I really need something fast, the commercial carriers are the answer.
Similarly we, as a society, provide free elementary and secondary education for all and that seems to work reasonably well (although those countries with national as opposed to local educational systems seem to consistently score higher on standardized testing). But, even within our system, there remains the option for those with wealth to send their children to private schools. Perhaps this is a model that is applicable to healthcare?
As for government and healthcare, we do know this: Those countries that have national health care systems spend less than half as a percentage of GDP as compared to the United States. Administrative costs are about one-third. Yet, by nearly every measure, the quality of care exceeds that in the U.S. Their doctors are just as good and their research labs may be better. Dr. Angell writes that in 2000 and 2001, the last two years this info was available, there were seven actually "new" drugs approved by the FDA (i.e. not a reformulation of a previous compound). All seven of those drugs were developed in either Europe or Canada. Not a single new drug was developed in the US. And while much is being made of the recent Nobel Prizes in Medicine for the discovery of telomerases, it is important to understand that this research was mainly funded and controlled through government grants.
But even in the United States, people don’t seem to realize that about half of all health care is government run. That includes Medicare, DOD, VA, etc. And there is general agreement that the highest quality and most efficiently run programs are Medicare and the VA. The administrative costs of Medicare are about 2-3% as compared to the 20% administrative costs for private insurers. Of course Medicare doesn’t have to spend all that money on advertising, lobbying and schmoozing doctors.
I suspect I am going to lose this battle and I fear that if the most recent Senate concoction is passed the insurers and big Pharma will win again. And that’s really too bad. Not for me, of course, because we are financially set, I have Medicare and SJ will be there soon and under the current system all my MRK and LLY stocks will continue to do well. But I do worry for this country, for this great experiment in democracy, this so-called "Shining City on a Hill," that we cannot provide for the least of us; that we cannot even match the other great democracies of the Western world in that regard.
As you know, SJ and I are atheists. But although I do not accept the divinity of Jesus or am even certain there ever was such a person, I am a great admirer of the teaching ascribed to his entity. I was fortunate enough to attend Sunday school as a child and be exposed to some of those teachings, many of which have served me well and been the foundation for much of my personal sense of morality. I particularly recall the verse from Matthew in which Jesus discusses how we will be judged. And although I do not think there is an afterlife, I would hope that my own life, both as a physician and a person, would be judged thusly: "Most certainly I tell you, inasmuch as you did it to one of the least of these my brothers, you did it to me." Perhaps this is what Otto van Bismark meant when he first proposed the German program in 1881 and referred to it as "a program of applied Christianity."
That my own country will not even attempt to achieve this standard causes profound sadness.
Regards,
M