The initiative, the biggest expansion of Medicare since its creation in 1965, proved wildly popular. It now serves more than 35 million people, delivering critical medicines to patients who might otherwise be unable to afford them. Its price tag is far lower than expected.
Archive for the ‘Healthcare’ Category
Is the future of American health care in Oregon?
Very interesting column by Ezra Klein in the Washington Post:
“The governor has a notion that you can move away from medical billing and towards a more flexible approach to health-care spending that makes more sense for the community,” John McConnell, a health economist at Oregon Health and Science University, is telling me. Then he stops. “You’ve heard the air conditioner story, right?”
As it turns out, I have heard the air-conditioner story. Oregon Gov. John Kitzhaber (D) loves to tell the air-conditioner story. He loves to tell it so much, in fact, that it has become something of a running joke in Oregon health-policy circles. At this point, even Kitzhaber is in on it. Before he repeats it to me, he says, “I probably shouldn’t bore you with my air conditioner story.”Here’s the air conditioner story: There’s a 90-year-old woman with well-managed congestive heart failure who lives in an apartment without air conditioning. That’s actually the whole story.
Kitzhaber, a former emergency room physician, sees this as the perfect example of what’s wrong with our health-care system. “A hot day could send the temperature in her apartment high enough that it strains her cardiovascular system and kicks her into full-blown congestive heart failure,” he said. “Under the current system, Medicare will pay for the ambulance and $50,000 to stabilize her. It will not pay for a $200 window air conditioner, which is all she needs to stay in her home and out of the hospital. The difference to the health-care system is $49,800. And we could save that $49,800 without reducing her benefits or her quality of life.”
Oregon’s Two Experiments
The past few years have seen two remarkable health-care experiments in the Beaver State. One is the Oregon Health Insurance Experiment, the first randomized, controlled trial comparing Medicaid — or any kind of health insurance — with being uninsured. The other is Kitzhaber’s effort to rebuild the state’s Medicaid program around community health rather than individual fee-for-service treatments. The health-insurance experiment has gotten all the attention. But it’s the Medicaid reforms that really matter.
The Oregon health insurance experiment didn’t begin as an experiment. It began as a budget cut. From 2002 to 2008, Oregon threw 93,000 people out of its Medicaid program. In 2008, the state found it had enough money to add 10,000 of them back. The only fair thing to do, state officials figured, was draw straws. So 90,000 of the poorest residents of the richest country the world has ever known entered a lottery to win health insurance.
The 10,000 Oregonians who got Medicaid weren’t the lottery’s only winners, though. Early on, a group of eminent health economists realized the lottery offered a chance to conduct a study no one in their discipline had ever managed but everyone had always wanted: a randomized, controlled experiment comparing those who received Medicaid with those who remained uninsured. This would enable researchers to isolate the effects that insurance — at least as delivered by Oregon’s Medicaid program — had on the uninsured.
“It’s hard to overstate how excited we were,” said Amy Finkelstein of the Massachusetts Institute of Technology. “We thought it was a once-in-a-lifetime opportunity to bring the gold standard of experimental design to this question.” . . .
Medicare’s rugged start
Fascinating look back at the difficulties and dire predictions that accompanied the launch of Medicare. Take a look at the collection of anecdotes and clippings in Sarah Kliff’s article in the Washington Post.
Interesting interview with Bill Gates regarding his humanitarian work
Ezra Klein interviews Bill Gates in the Washington Post:
“I always use this chart of childhood death,” Bill Gates says. “In 1960, 25% of kids died before the age of 5. And now we’re down below 6% of kids dying before the age of 5.”
We’re sitting in a bare conference room at his foundation’s D.C. headquarters. Gates — who Bloomberg News calculates is once again the world’s richest man — is in town to talk to members of Congress about his top priority this year: Global health – and, in particular, the total eradication of polio. He wants to drive that 6 percent even lower, and he believes he can. Wiping out a disease like polio sounds impossible. But it’s actually, Gates tells me, completely achievable. Perhaps even by the end of 2013. This is a transcript of our conversation, edited for length and clarity.
Ezra Klein: Your Foundation is known for taking a particularly data-driven approach to its work. So how do you know what’s actually working when you’re in failed states with very little data-collection capacity?Bill Gates: Of all the statistics in health, death is the easiest, because you can go out and ask people, “Hey, have you had any children who died, did your siblings have any children who died?” People don’t forget that. If you say to them, “Did your kids get vaccines or not,” they might have done it and not remember, or they might think, “Oh, this person wants me to say yes, maybe I look bad if I don’t say yes.” Death is something we really understand extremely well.
But you can save a lot of lives. One thing about the childhood death rate is you really can split it into the first 30 days of life versus 30 days to 5 years. Thirty days to 5 years is all vaccine preventable stuff — it’s diarrhea, respiratory and malaria. The first 30 days, the primary healthcare system really has to engage with the mother pre-birth, and then get the mother to do things like keeping the baby warm, making sure to avoid doing things that break the baby’s skin, breast-feeding, and that’s been harder. We’ve had sites in India where we can cut those deaths down by over 50 percent just by training the mother. But the worker has to engage with the patient, hopefully speak the same language or be of the same caste so that they’re willing to trust the advice that they’re getting.
EK: What’s been the biggest surprise? What has the data shown works, or doesn’t work, that you simply didn’t expect? . . .
Glad to see the deficit problem going away
As you would expect if the economy improves and the wealthy are taxed a bit more, the deficit is declining. And health-care costs are dropping. I expect that the GOP, which has been quite agitated about the deficit and about healthcare costs, will be very pleased and I’m eager to see their happy responses. There are quite a few discussions of this:
Ezra Klein in the Washington Post:
It looks like we’ve moved to talking about possible scandals just in time, because according to the Congressional Budget Office, the debt disaster that has obsessed the political class for the last three years is pretty much solved, at least for the next 10 years or so.
The last time the CBO estimated our future deficits was February– just four short months ago. Back then, the CBO thought deficits were falling and health-care costs were slowing. Today, the CBO thinks deficits are falling even faster and health-care costs are slowing by even more.
Here’s the short version: Washington’s most powerful budget nerds have cut their prediction for 2013 deficits by more than $200 billion. They’ve cut their projections for our deficits over the next decade by more than $600 billion. Add it all up and our 10-year deficits are looking downright manageable. Following are the highlights.
1) Swoosh-shaped debt. . .
Kevin Drum at Mother Jones has a good post on the decline in the deficit and also the decline in healthcare costs.
Paul Waldman and Jaime Fuller at The American Prospect:
In case it slipped your mind during all this talk of scandal and impeachment, official Washington has spent the last couple of years gnashing its teeth about the budget deficit. Even as European austerity policies threw the continent into a period of extended despair, Republicans and their allies in the well-appointed conference rooms of “centrist” think tanks told us sternly that unemployment would have to wait; the most immediate crisis was the deficit.
Well today, the Congressional Budget Office (CBO) issued its latest deficit projection, and lo and behold, it turns out that mercilessly slashing spending and allowing some modest tax increases has an impact. They project the deficit will be $642 billion this year, lower than it has been since 2008. Not only that, the CBO’s projections of future Medicare spending have been reduced as well. Hard as it might be to wrap your head around the idea, there has been some good news of late on the fiscal front.
So here’s a bold prediction: . . .
How does your doctor stand on prescribing meds?
An interesting article by Tracy Weber, Charles Ornstein, and Jennifer LaFleur in the Washington Post, along with a ProPublica look-up so that you can see how your own physician stands in terms of prescribing drugs.. My former doctor prescribed more drugs than the average doctor, and my current doctor prescribes fewer. I had already noticed that my doctor likes to wean me off unnecessary meds, though he doesn’t hesitate to prescribe when needed. Look up your own doc.
The article begins:
Ten years ago, a sharply divided Congress decided to pour billions of dollars into subsidizing the purchase of drugs by elderly and disabled Americans. But an investigation by ProPublica has found the program, in its drive to get drugs into patients’ hands, has failed to properly monitor safety. An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive for their patients. Federal officials have done little to detect or deter these hazardous prescribing patterns. Searches through hundreds of millions of records turned up physicians such as the Miami psychiatrist who has given hundreds of elderly dementia patients the same antipsychotic, despite the government’s most serious “black box” warning that it increases the risk of death. He believes he has no other options.
Some doctors are using drugs in unapproved ways that may be unsafe or ineffective, records showed. An Oklahoma psychiatrist regularly prescribes the Alzheimer’s drug Namenda for autism patients as young as 12; he says he thinks it calms them. Autism experts said there is scant scientific support for this practice.
The data analysis showed widespread prescribing of drugs such as carisoprodol, which was pulled from the European market in 2007. In 2010 alone, health-care professionals wrote more than 500,000 prescriptions for the drug to patients 65 and older. The muscle relaxant, also known as Soma, is on the American Geriatrics Society’s list of drugs seniors should avoid.
The data, obtained under the Freedom of Information Act, makes public for the first time the prescribing practices and identities of doctors and other health-care providers. . .
Continue reading. The lookup for the database, along with a variety of interesting info, is at the link.
Free at last! from job lock
In The American Prospect Paul Waldman points out one of the great benefits of Obamacare: not being locked into a job because of health insurance:
For years, even before Barack Obama was elected, one of the many complaints liberals (mostly) had about the current employer-based health insurance system was “job lock”—if you have insurance at your job, particularly if you or someone in your family has health issues, then you’re going to be hesitant to leave that job. You won’t start your own business, or join somebody else’s struggling startup (unless they provide insurance), and this constrains people’s opportunities and dampens the country’s entrepreneurial spirit.
That this occurs is intuitively obvious—you probably know someone who has experienced it, or have experienced it yourself. And today there’s an article in that pro-Democrat hippie rag The Wall Street Journal entitled “Will Health-Care Law Beget Entrepreneurs?” Amid the worrying about the implementation of Obamacare in January, and the quite reasonable concern that the news could be filled with stories of confusion, missteps, and dirtbags like that Papa John’s guy cutting employees’ hours rather than give them insurance, to avoid the horror of increasing the cost of a pizza by a dime,11This is important: when you hear a story about an employer who cut his employees’ hours so he wouldn’t have to abide by the law, what you’re reading about is a jerk who doesn’t want to offer his employees insurance, not some inevitable consequence of the law. That’s a choice he makes. And don’t forget too that the employer mandate only applies to companies with 50 or more employers, and 96 percent of them already offer health insurance, even without a mandate. it’s a reminder that there will probably be lots of stories like this one in the news too, stories about people whose lives have been changed for the better by the fact that Americans will have something they’ve never had before: health security.
So what kind of effect could the elimination of job lock have on the economy? That’s tough to say. The study referred to in the WSJ article finds that people are much more likely to start a business if they get their health insurance from their spouse’s job than if they get it from their own job; in the former case you’d still have insurance if you started a business, while in the latter case you’d lose it. In addition, and this is particularly interesting, even though you might think of 65-year-olds as looking forward to days of golf and eating dinner at 4 p.m., a large number of people seem to start businesses pretty much the minute they become eligible for Medicare. While it’s hard to get insurance in the current private market if you’re 44, it’s basically impossible if you’re 64.So it seems that the fact that after January, job lock will be history means that more businesses will be started. How many more? . . .
So much for the reputed “efficiencies” profit-seeking brings
From an article by Wilson Andrews, Darla Cameron and Dan Keating in the Washington Post:
The article is well worth reading.
How not to die
None of us are getting out alive, so it’s worth while paying attention to choices regarding death. Jonathan Rauch has an eye-opening article in the Atlantic:
Dr. Angelo Volandes is making a film that he believes will change the way you die. The studio is his living room in Newton, Massachusetts, a suburb of Boston; the control panel is his laptop; the camera crew is a 24-year-old guy named Jake; the star is his wife, Aretha Delight Davis. Volandes, a thickening mesomorph with straight brown hair that is graying at his temples, is wearing a T-shirt and shorts and looks like he belongs at a football game. Davis, a beautiful woman of Guyanese extraction with richly braided hair, is dressed in a white lab coat over a black shirt and stands before a plain gray backdrop.
“Remember: always slow,” Volandes says.
“Sure, hon,” Davis says, annoyed. She has done this many times.
Volandes claps to sync the sound. “Take one: Goals of Care, Dementia.”
You are seeing this video because you are making medical decisions for a person with advanced dementia. Davis intones the words in a calm, uninflected voice. I’ll show you a video of a person with advanced dementia. Then you will see images to help you understand the three options for their medical care.
Her narration will be woven into a 10-minute film. The words I’m hearing will accompany footage of an elderly woman in a wheelchair. The woman is coiffed and dressed in her Sunday finest, wearing pearls and makeup for her film appearance, but her face is vacant and her mouth is frozen in the rictus of a permanent O.
This woman lives in a nursing home and has advanced dementia. She’s seen here with her daughters. She has the typical features of advanced dementia …
Young in affect and appearance, Volandes, 41, is an assistant professor at Harvard Medical School; Davis, also an M.D., is doing her residency in internal medicine, also at Harvard. When I heard about Volandes’s work, I suspected he would be different from other doctors. I was not disappointed. He refuses to let me call him “Dr. Volandes,” for example. Formality impedes communication, he tells me, and “there’s nothing more essential to being a good doctor than your ability to communicate.” More important, he believes that his videos can disrupt the way the medical system handles late-life care, and that the system urgently needs disrupting.
“I think we’re probably the most subversive two doctors to the health system that you will meet today,” he says, a few hours before his shoot begins. “That has been told to me by other people.”
“You sound proud of that,” I say.
“I’m proud of that because it’s being an agent of change, and the more I see poor health care, or health care being delivered that puts patients and families through—”
“We torture people before they die,” Davis interjects, quietly.
Volandes chuckles at my surprise. “Remember, Jon is a reporter,” he tells her, not at all unhappy with her comment.
“My father, if he were sitting here, would be saying ‘Right on,’ ” I tell him.
Volandes nods. “Here’s the sad reality,” he says. “Physicians are good people. They want to do the right things. And yet all of us, behind closed doors, in the cafeteria, say, ‘Do you believe what we did to that patient? Do you believe what we put that patient through?’ Every single physician has stories. Not one. Lots of stories.
“In the health-care debate, we’ve heard a lot about useless care, wasteful care, futile care. What we”—Volandes indicates himself and Davis—“have been struggling with is unwanted care. That’s far more concerning. That’s not avoidable care. That’s wrongfulcare. I think that’s the most urgent issue facing America today, is people getting medical interventions that, if they were more informed, they would not want. It happens all the time.”
Unwanted treatment is American medicine’s dark continent. No one knows its extent, and few people want to talk about it. The U.S. medical system was built to treat anything that might be treatable, at any stage of life—even near the end, when there is no hope of a cure, and when the patient, if fully informed, might prefer quality time and relative normalcy to all-out intervention. . .
Continue reading. The story of the author’s father had a lot of impact on me.
A healthcare program that works—so it’s being dropped…
Ezra Klein is a shining jewel in a newspaper (the Washington Post) that is overall mediocre at best, wrong-headed more often (with a great tendency to ignore any evidence that is inconsistent with the editorial worldview). Klein has an excellent column today:
When Ken Coburn has visitors to the cramped offices of Health Quality Partners in Doylestown, Pa., he likes to show them a graph. It’s not his graph, he’s quick to say. Coburn is not the sort to take credit for other’s work. But it’s a graph that explains why he’s doing what he’s doing. It’s a graph he particularly wishes the folks who run Medicare would see, because if they did, then there’s no way they’d be threatening to shut down his program.
The graph shows the U.S. death rate for infectious diseases between 1900 and 1996. The line starts all the way at the top. In 1900, 800 of every 100,000 Americans died from infectious diseases. The top killers were pneumonia, tuberculosis and diarrhea. But the line quickly begins falling. By 1920, fewer than 400 of every 100,000 Americans died from infectious diseases. By 1940, it was less than 200. By 1960, it’s below 100. When’s the last time you heard of an American dying from diarrhea?
“For all the millennia before this in human history,” Coburn says, “it was all about tuberculosis and diarrheal diseases and all the other infectious disease. The idea that anybody lived long enough to be confronting chronic diseases is a new invention. Average life expectancy was 45 years old at the turn of the century. You didn’t have 85-year-olds with chronic diseases.”
With chronic illnesses like diabetes and heart disease you don’t get better, or at least not quickly. They don’t require cures so much as management. Their existence is often proof of medicine’s successes. Three decades ago, cancer typically killed you. Today, many cancers can be fought off for years or even indefinitely. The same is true for AIDS, and acute heart failure and so much else. This, to Coburn, is the core truth, and core problem, of today’s medical system: Its successes have changed the problems, but the health-care system hasn’t kept up.
Kenneth Thorpe, chairman of the health policy and management school at Emory University, estimates that 95 percent of spending in Medicare goes to patients with one or more chronic conditions — with enrollees suffering five or more chronic conditions accounting for 78 percent of its spending. “This is the Willie Sutton rule,” he says. “If 80 percent of the spending is going to patients with five or more conditions, that’s where our health-care system needs to go.”
Health Quality Partners is all about going there. The program enrolls Medicare patients with at least one chronic illness and one hospitalization in the past year. It then sends a trained nurse to see them every week, or every month, whether they’re healthy or sick. It sounds simple and, in a way, it is. But simple things can be revolutionary.
Most care-management systems rely on nurses sitting in call centers, checking up on patients over the phone. That model has mostly been a failure. And while many health systems send a nurse regularly in the weeks or months after a serious hospitalization, few send one regularly to even seemingly healthy patients. This a radical redefinition of the health-care system’s role in the lives of the elderly. It redefines being old and chronically ill as a condition requiring professional medical management.
Health Quality Partners’ results have been extraordinary. According to an independent analysis by the consulting firm Mathematica, HQP has reduced hospitalizations by 33 percent and cut Medicare costs by 22 percent.
Others in the profession have taken notice. “It’s like they’ve discovered the fountain of youth in Doylestown, Pa.,” marvels Jeffrey Brenner, founder of the Camden Coalition of Healthcare Providers.
Now Medicare is thinking of shutting it off.
Lucrative potential
The origin of Doylestown’s fountain of youth is not particularly mysterious or mythic. It can be found on Page 93 of the 1997 Balanced Budget Act. Under “Subchapter D — Other Projects,” there are two pages of dull legislative language authorizing Medicare “to conduct demonstration projects for the purpose of evaluating methods, such as case management and other models of coordinated care, that (A) improve the quality of items and services provided to target individuals; and (B) reduce expenditures.”
In the health-care world, however, these yawn-inducing paragraphs sounded like the beginning of a revolution — or, perhaps, a gold rush.
The project was remarkable in two ways. First, . . .
Continue reading. From later in the story:
. . . Reif’s answer for why he worked with a group that cost him money is simple: His hospital was unusual. In 1895, 14 women came together to form Doylestown’s “Village Improvement Association,” which was dedicated to “the health and beauty” of the community. The association actually owned Doylestown Hospital, and its mission was the hospital’s mission. “I did get some heat from my senior management team,” Reif says. “When you’re doing annual budgets you see reduction in revenue. But I could always come back and say, ‘Wasn’t that our responsibility?’ ”
But not all hospitals are run by the local Village Improvement Association. Many seek to turn a profit. That makes models like Health Quality Partners something of a threat. “If we scaled what Ken is doing,” Brenner says, “you would probably shut down a third of the hospitals in the country. It’s a disruptive innovation. It just guts the current business model.” . . .
For-profit hospitals should be outlawed. All hospitals should be non-profit—for obvious reasons: a for-profit hospital constantly looks for ways to cut costs and increase profits; a non-profit can better focus on helping people regain health and then stay healthy.
How the GOP views its responsibilities to the public
Ed Kilgore posts at Washington Monthly‘s Political Animal blog:
Last week I wrote about the cynical maneuever by House Republicans to exhibit compassion for those being denied health insurance due to pre-existing conditions by shifting money into an underfunded temporary high-risk pool set up by the Affordable Care Act, noting that the Club For Growth was attacking the bill as wasteful and insufficiently deferential to the pathetic efforts of the states in this area. The bill is scheduled for a vote in the House today.
The true measure of this gambit is provided by one of its supporters, FreedomWorks, whose vice president for public policy, Dean Clancy, sent out anopen missive on the subject:
Next week, the House may take up a bill (H.R.1549, the Helping Sick Americans Now Act), which has been purported to “fix” a part of ObamaCare, and some conservatives are crying foul.
I think those conservatives are misguided.
They should support the bill, or at least not oppose it….
Contrary to the assertions of some, H.R.1549 doesn’t “fix,” “expand,” or otherwise “improve” ObamaCare. Instead, it effectively cannibalizes ObamaCare to impede its implementation. The bill would transfer $4,000,000,000 (four billion dollars) from an ObamaCare implementation slush fund to a program called the Pre-Existing Condition Plan, or PCIP). The slush fund is a big pot of money the Administration is using to set up exchanges in states that refuse to set them up (a resistance we’ve strongly encouraged). The PCIP is a subsidy for sick people, to help them obtain private health insurance coverage. PCIP is a federal version of the high-risk pool (or as I prefer to call it, preexisting-conditions or preex pool) subsidy that is employed in more than half the states to help private insurance markets work better. Democrats included PCIP in their ObamaCare takeover as a temporary bridge to the new system, which takes full effect on January 1st, 2014. In doing so, the Democrats were implicitly admitting that preex pools are a practical way to help the one percent of Americans who simply can’t access affordable health insurance due to a preexisting medical condition. PCIP is not, in itself, a good program. But if Congress had enacted only PCIP in 2010, instead of ObamaCare, America would be in a much, much better place today.
Now, I agree with those conservatives who hold that preex pool programs should be state- rather than federally run. But the harm here is slight, because PCIP is scheduled to expire on December 31st of this year. It’s a temporary subsidy, remember.
H.R.1549 should be viewed as a tactical maneuver in a larger war, cannibalizing the implementation of ObamaCare exchanges in order to gain leverage in the larger fight for health care freedom.
Pretty plain, eh? Give sick people without insurance temporary access to crappy private plans at exorbitant rates as part of a strategy aimed at pulling the rug out from under them entirely at the end of the year, all the while mewling about one’s concern for sick people.
It makes me sick.
UPDATE: After a closed meeting today, House Republican may pull this bill from the calendar due to conservative opposition to doing anything that might be perceived as “fixing” Obamacare or asserting government responsibility for the uninsured.
Pretty plain talk. The GOP really works hard to destroy government because government holds back big business from doing whatever it damn pleases.
Despite health challenges, Southern states resist Medicaid expansion
Southern politicians seem to care little for the people they represent. Tony Pugh reports for McClatchy:
BILOXI, Miss. — Michael White’s high blood pressure is acting up again.
The 51-year-old casino janitor has recurring seizures and recently awoke in an ambulance after passing out at a bus stop.
“It doesn’t hit me suddenly,” White said. “It creeps up on me. I get this feeling like I’m outside of my own body.”
If White had insurance, he’d be under the care of a primary physician and taking medications regularly. But he can’t afford job-based health insurance on his $8-an-hour wage and he earns too much to qualify for Medicaid, the state-federal health plan for poor people and those with disabilities.
So White takes his place in a growing line of uninsured patients outside the Bethel Free Health Clinic on the grounds of a federal housing project in Biloxi, Miss. It’s his off day, so he’s in no rush. He just wants to be one of the dozen or so patients lucky enough to see a doctor.
White is one of 300,000 Mississippians who’d likely qualify for Medicaid next year when the health care overhaul extends coverage to adults who earn up to 138 percent of the federal poverty level. That’s nearly $16,000 a year for an individual in 2013, or roughly $32,500 for a family of four.
But Mississippi and eight other contiguous Southern states, all led by Republican governors, have decided not to implement the Medicaid expansion, even though the federal government has pledged to pay all medical costs for the newly eligible enrollees in 2014, 2015 and 2016 and no less than 90 percent of their costs thereafter.
All of them – Tennessee, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Louisiana, Texas and Oklahoma – say they can’t afford it under those terms.
The wall of Southern opposition is one of the last major obstacles to President Barack Obama’s goal of universal health coverage for all Americans. If it remains intact, nearly 5 million of the newly eligible won’t have Medicaid coverage in 2022, according to estimates by the nonpartisan Kaiser Family Foundation, a health care research group.
Besides shared borders and conservative political leadership, most of the nine states have something else in common: By a host of measures – from obesity to infant mortality – all but North Carolina and Georgia are among the unhealthiest in the nation, according to the 2012 edition of America’s Health Rankings.
Mississippi and Louisiana tie for dead last among all states in the health of its residents, according to the annual report by the United Health Foundation , a nonprofit arm of the insurer UnitedHealth Group. Neither state has finished higher than 48th since the rankings began in 1990. . . .
Think what we could do with a substance that’s as durable and resistant to alteration as ignorance
Paul Krugman provides examples today in the NY Times:
President Obama will soon release a new budget, and the commentary is already flowing fast and furious. Progressives are angry (with good reason) over proposed cuts to Social Security; conservatives are denouncing the call for more revenues. But it’s all Kabuki. Since House Republicans will block anything Mr. Obama proposes, his budget is best seen not as policy but as positioning, an attempt to gain praise from “centrist” pundits.
No, the real policy action at this point is in the states, where the question is, How many Americans will be denied essential health care in the name of freedom?
I’m referring, of course, to the question of how many Republican governors will reject the Medicaid expansion that is a key part of Obamacare. What does that have to do with freedom? In reality, nothing. But when it comes to politics, it’s a different story.
It goes without saying that Republicans oppose any expansion of programs that help the less fortunate — along with tax cuts for the wealthy, such opposition is pretty much what defines modern conservatism. But they seem to be having more trouble than in the past defending their opposition without simply coming across as big meanies.
Specifically, the time-honored practice of attacking beneficiaries of government programs as undeserving malingerers doesn’t play the way it used to. When Ronald Reagan spoke about welfare queens driving Cadillacs, it resonated with many voters. When Mitt Romney was caught on tape sneering at the 47 percent, not so much.
There is, however, an alternative. . .
CVS, Rite Aid, And Other Chain Pharmacies Sell Generic Drugs At Up To 18 Times Their Cost
Sy Mukherjee reports at ThinkProgress:
According to a new Consumer Reportsinvestigative study published Thursday, there is rampant variation in the price of generic drugs as large U.S. pharmacy chains — including CVS, Rite Aid, and Target — mark up the prices of generic drug versions for common medications by as much as 18 times what wholesale chains like Costco charge. That price variance ends up costing Americans, who spend an average of $758 out-of-pocket on drugs every year, hundreds of dollars in unnecessary spending each month.
Consumer Reports compiled the data by contacting hundred of pharmacies throughout the country and asking what their drug prices were for generic versions of Lipitor, Plavix, Actos, and other common medications. The results were striking, with pharmacy representatives claiming that the higher prices were necessary for covering overhead, and considering that selling medication constitutes most of their revenue and profit margins:
Costco was the least expensive overall, and you don’t need to be a member to use its pharmacy. A few independent pharmacies came in even cheaper, though their prices varied widely, as did grocery-store pharmacies. The online retailers Healthwarehouse.com and FamilyMeds.com also had very low prices. On the other end of the spectrum, CVS, Rite Aid, and Target had the highest retail prices. [...]
A representative of CVS told us that its retail drug prices reflect other services offered by the chain, including drive-through windows, automated prescription refill systems, free outreach programs to help make sure patients are taking their prescriptions correctly, and 24-hour pharmacies. Costco pharmacies, the cheapest overall, are open only from 10 a.m. to 7 or 8:30 p.m. and are typically closed on Sundays.
“Big-box stores such as Costco and Walmart use the pharmacy as a traffic builder for their stores, whereas traditional chain stores, such as CVS, Rite Aid, and Walgreens, make the majority of their revenue and profits from the pharmacy,” says Stephen W. Schondelmeyer, Ph.D., Pharm.D., a professor of pharmacy economics at the University of Minnesota.
The study’s full findings are illustrated in this chart: . . .
Interesting: Medical costs are high in the US because prices are higher
We don’t see the doctor any more often, we don’t stay in hospitals any more frequently: we just get charged more. Ezra Klein reruns an article from a year ago because it is still relevant:
Steve Brill’s massive Time article focused national attention on the price of health-care services in the United States. Sarah Kliff got further data showing an MRI can cost anywhere from $400 to $1,861 in Washington, DC alone. But as startling as the price difference between one hospital and another, or one insurer and another, can be in America, the difference between America and other countries is even more extraordinary. I wrote this piece in March 2012. But it’s worth revisiting now.
There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher.
That may sound obvious. But it is, in fact, key to understanding one of the most pressing problems facing our economy. In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish. Workers would have much more money in their pockets. Our economy would grow more quickly, as our exports would be more competitive.
There are many possible explanations for why Americans pay so much more. It could be that we’re sicker. Or that we go to the doctor more frequently. But health researchers have largely discarded these theories. As Gerard Anderson, Uwe Reinhardt, Peter Hussey and Varduhi Petrosyan put it in the title of their influential 2003 study on international health-care costs, “it’s the prices, stupid.”
As it’s difficult to get good data on prices, that paper blamed prices largely by eliminating the other possible culprits. They authors considered, for instance, the idea that Americans were simply using more health-care services, but on close inspection, found that Americans don’t see the doctor more often or stay longer in the hospital than residents of other countries. Quite the opposite, actually. We spend less time in the hospital than Germans and see the doctor less often than the Canadians.
“The United States spends more on health care than any of the other OECD countries spend, without providing more services than the other countries do,” they concluded. “This suggests that the difference in spending is mostly attributable to higher prices of goods and services.”
On Friday, the International Federation of Health Plans — a global insurance trade association that includes more than 100 insurers in 25 countries — released more direct evidence. It surveyed its members on the prices paid for 23 medical services and products in different countries, asking after everything from a routine doctor’s visit to a dose of Lipitor to coronary bypass surgery. And in 22 of 23 cases, Americans are paying higher prices than residents of other developed countries. Usually, we’re paying quite a bit more. The exception is cataract surgery, which appears to be costlier in Switzerland, though cheaper everywhere else.
Prices don’t explain all of the difference between America and other countries. But they do explain a big chunk of it. The question, of course, is why Americans pay such high prices — and why we haven’t done anything about it.
“Other countries negotiate very aggressively with the providers and set rates that are much lower than we do,” Anderson says. They do this in one of two ways. In countries such as Canada and Britain, prices are set by the government. In others, such as Germany and Japan, they’re set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail. . .
The GOP case in favor of waste in healthcare
Philip Longman in The Washington Monthly has an interesting article:
Why are you reading this when you could be doing jumping jacks?
And how come you’ve gone on to read this sentence when you could be having a colonoscopy?
You and I could be doing all sorts of things right now that we have reason to believe would improve our health and life expectancy. We could be working out at the gym, or waiting in a doctor’s office to have our bodies scanned and probed for tumors and polyps. We could be using this time to eat a steaming plate of broccoli, or attending a support group to help us overcome some unhealthy habit.
Yet you are not doing those things right now, and the chances are very strong that I am not either. Why not?
Even people who take their health very seriously calculate costs and benefits. Time spent at the gym, for example, is time we cannot spend playing with our kids, or making the money we need to pay for our ever-rising health insurance premiums. Submitting to a colonoscopy, while minimally costing time, money, and discomfort, may not provide us with any personal benefit whatsoever—all of which we put into the mix before deciding if this is the day we have the test done.
In short, in our day-to-day lives we regularly apply a kind of informal cost-benefit analysis to the decisions we make about health care. To take another example, say you decide it’s worth the effort to lose twenty pounds and firmly resolve to do so. Then your mind will instantly turn to mulling what would be the most cost-effective way to go about it: eat less or exercise more, for example, or perhaps take a pill or undergo a liposuction operation or some combination of all of those.
In making this decision, you may well act on assumptions that are shortsighted or misinformed. You may ascribe more effectiveness to those interventions that seem easy (taking a diet pill) than to those that seem hard (giving up sweets and sweating it out in the gym more often).
Similarly, you may underestimate the risk that a liposuction will bring with it a hospital infection and other complications that will get you killed. Your decision may also be constrained by lack of money to throw at the problem, or lack of time, or competing ambitions. Yet however imperfectly, your mental energies will be directed at how to achieve your goal of losing those twenty pounds at the least cost in other things that matter to you.
This pattern of “rationing,” if you will, our own health and health care on the basis of perceived costs and benefits is arguably a defining feature of what makes us human. Certainly my fat cat does not deliberate the pros and cons of how and whether to overcome her obesity.
Yet here is a curious fact about humans, in the United States, at least. Though we spend more per person on health care than any other people on earth, and with results that are no better and often worse than all other advanced nations, we have allowed conservatives and corporate interests to bind us with laws that explicitly forbid the use of formal cost-benefit analysis to determine how health care dollars are spent. Until we get our heads around this contradiction, we are in big trouble.
The stunning inefficiency of the U.S. health care system as a whole is now beyond dispute. To see the magnitude of aggregate waste, one only has to look at the gross disparities in how medicine is practiced in different parts of the country and with what results.
The best-known work in this area comes from the Dartmouth Atlas Project. For more than a decade, researchers there have systematically reviewed the medical records of deceased Medicare patients nationwide, including those who suffered from specific chronic conditions during their last two years of life. And by doing so, the researchers have uncovered striking anomalies that point to vast inefficiencies.
In Miami, for example, the Dartmouth researchers have discovered that the average number of doctor visits for a Medicare patient during the last two years of his or her life is 106. But in Minneapolis, among Medicare patients suffering from the same chronic conditions, the average number of doctor visits during the last two years of life is only twenty-six. Yet in both cities, all of these patients are equally dead at the end of two years.
The implication is unavoidable. The much higher volume and intensity of medicine as it is practiced in Miami as compared to Minneapolis may benefit some patients in some ways. But all the extra exams, as well as the extra tests, drugs, and operations that doctors in Miami regularly order for their patients, bring no aggregate gain in life expectancy. . .
Continue reading. Later in the article, this stunning paragraph:
Yet while we know the system as a whole is grossly inefficient, it remains easy for those responsible for the waste to escape detection, let alone accountability. The biggest single reason is that, due to the insistence of conservatives allied with drug manufacturers and medical device makers, the federal government is not allowed to consider the cost-effectiveness of different treatments in deciding how to invest health care dollars.
Clear picture of GOP goals
Look to their actions, not their words. Paul Krugman in the NY Times today:
Conservatives like to say that their position is all about economic freedom, and hence making government’s role in general, and government spending in particular, as small as possible. And no doubt there are individual conservatives who really have such idealistic motives.
When it comes to conservatives with actual power, however, there’s an alternative, more cynical view of their motivations — namely, that it’s all about comforting the comfortable and afflicting the afflicted, about giving more to those who already have a lot. And if you want a strong piece of evidence in favor of that cynical view, look at the current state of play over Medicaid.
Some background: Medicaid, which provides health insurance to lower-income Americans, is a highly successful program that’s about to get bigger, because an expansion of Medicaid is one key piece of the Affordable Care Act, a k a Obamacare.
There is, however, a catch. Last year’s Supreme Court decision upholding Obamacare also opened a loophole that lets states turn down the Medicaid expansion if they choose. And there has been a lot of tough talk from Republican governors about standing firm against the terrible, tyrannical notion of helping the uninsured.
Now, in the end most states will probably go along with the expansion because of the huge financial incentives: the federal government will pay the full cost of the expansion for the first three years, and the additional spending will benefit hospitals and doctors as well as patients. Still, some of the states grudgingly allowing the federal government to help their neediest citizens are placing a condition on this aid, insisting that it must be run through private insurance companies. And that tells you a lot about what conservative politicians really want.
Consider the case of Florida, whose governor, Rick Scott, made his personal fortune in the health industry. At one point, by the way, the company he built pleaded guilty to criminal charges, and paid $1.7 billion in fines related to Medicare fraud. Anyway, Mr. Scott got elected as a fierce opponent of Obamacare, and Florida participated in the suit asking the Supreme Court to declare the whole plan unconstitutional. Nonetheless, Mr. Scott recently shocked Tea Party activists by announcing his support for the Medicaid expansion.
But his support came with a condition: he was willing to cover more of the uninsured only after receiving a waiver that would let him run Medicaid through private insurance companies. Now, why would he want to do that?
Don’t tell me about free markets. This is all about spending taxpayer money, and the question is whether that money should be spent directly to help people or run through a set of private middlemen.
And despite some feeble claims to the contrary, privatizing Medicaid will end up requiring more, not less, government spending, because there’s overwhelming evidence that Medicaid is much cheaper than private insurance. Partly this reflects lower administrative costs, because Medicaid neither advertises nor spends money trying to avoid covering people. But a lot of it reflects the government’s bargaining power, its ability to prevent price gouging by hospitals, drug companies and other parts of the medical-industrial complex.
For there is a lot of price-gouging in health care — a fact long known to health care economists but documented especially graphically in a recent article in Time magazine. As Steven Brill, the article’s author, points out, . . .
Increasingly familiar story: Career crunch
David Segal reports in the NY Times on the gloomy situation for veterinarians:
HAYLEY SCHAFER chose her dream job at the age of 5. Three years later, her grandmother told her that if she wrote it down, the dream would come true. So she found a piece of blue construction paper and scrawled on it with a pencil: “Veterianian.” “No one told me how to spell it,” she remembers. “They just said, ‘Sound it out.’ ”
At the age of 30, she still has the sign, which is framed on her desk at the Caring Hearts Animal Clinic in Gilbert, Ariz., where she works as a vet. She also has $312,000 in student loans, courtesy of Ross University School of Veterinary Medicine, on the Caribbean island of St. Kitts. Or rather, $312,000 was what she owed the last time she could bring herself to log into the Sallie Mae account that tracks the ever-growing balance.
“It makes me sick, watching it increase,” she says. “There’s also the stress of how am I going to save for retirement when I have this bear to pay off.”
They don’t teach much at veterinary school about bears, particularly the figurative kind, although debt as large and scary as any grizzly shadows most vet school grads, usually for decades. Nor is there much in the curriculum about the prospects for graduates or the current state of the profession. Neither, say many professors and doctors, looks very promising. The problem is a boom in supply (that is, vets) and a decline in demand (namely, veterinary services). Class sizes have been rising at nearly every school, in some cases by as much as 20 percent in recent years. And the cost of vet school has far outpaced the rate of inflation. It has risen to a median of $63,000 a year for out-of-state tuition, fees and living expenses, according to the Association of American Veterinary Medical Colleges, up 35 percent in the last decade.
This would seem less alarming if vets made more money. But starting salaries have sunk by about 13 percent during the same 10-year period, in inflation-adjusted terms, to $45,575 a year, according to the American Veterinary Medical Association. America may be pet-crazed and filled with people eager to buy expensive fetch toys and heated cat beds. But the total population of pets is going down, along with the sums that owners are willing to spend on the health care of their animals, one of the lesser-known casualties of the recession.
Today, the ratio of debt to income for the average new vet is roughly double that of M.D.’s, according to Malcolm Getz, an economist at Vanderbilt University. To practitioners in the field, such numbers are ominous, and they portend lean times for new graduates.
“We’re calling for more bodies coming through the veterinary educational pipeline at higher and higher cost at the very point in time that we need fewer and fewer,” says Dr. Eden Myers, a vet in Mount Sterling, Ky., who runs the Web site JustVetData, where she crunches numbers about the profession. “And they are going to get paid less and less.”
For years, the veterinary medical association contended that the United States needed more vets, not fewer, especially in rural areas. To support this view, in 2007, the organization helped underwrite a study, hoping to bolster a call for government assistance to help meet a putative shortfall of 15,000 vets by 2024.
The results, released last year, came to a strikingly different conclusion. Titled “Assessing the Current and Future Workforce Needs in Veterinary Medicine” and conducted under the auspices of the National Academy of Sciences, the study found little evidence of vet shortages. It also concluded that “the cost of veterinary education is at a crisis point.” . . .
Rwanda’s Historic Health Recovery: What the U.S. Might Learn
Fascinating article in The Atlantic by Neal Emery:
Over the last decade in Rwanda, deaths from HIV, TB, and malaria dropped by 80 percent, maternal mortality dropped by 60 percent, life expectancy doubled — all at an average health care cost of $55 per person per year.
Amidst the barrage of stories about failing states and civil wars that characterize the dour American media coverage of the developing world, the reinvention of Rwanda offers hope. Since the genocide with which its name is still synonymous in the United States, Rwanda has doubled its life expectancy and now offers a replicable model for delivery of high quality health care with limited resources.
Dr. Paul Farmer, Chair of the Department of Global Health and Social Medicine at Harvard Medical School and co-founder of Partners In Health, says that, “Rwanda has shown on a national level that you can break the cycle of poverty and disease.”
In the wake of the genocide that killed nearly one million people in 1994, such a turnaround seemed nearly impossible. Rwanda was a failed state mired in poverty and chaos. The genocide decimated Rwanda’s health facilities and workforce, allowing infectious diseases to run rampant and more than one in four children to die before their fifth birthday. Normally in such situations, economic development stagnates because disease cripples workers and the national economy, leaving the country too poor to effectively reduce the burden of disease. With a life expectancy of only 30 the year after the genocide, Rwanda looked poised to follow this pattern.Over the last ten years, Rwanda’s health system development has led to the most dramatic improvements of health in history. Rwanda is the only country in sub-Saharan Africa on track to meet most of the Millennium Development Goals. Deaths from HIV, TB, and malaria have each dropped by roughly 80 percent over the last decade and the maternal mortality ratio dropped by 60 percent over the same period. Even as the population has increased by 35 percent since 2000, the number of annual child deaths has fallen by 63 percent. In turn, these advances bolstered Rwanda’s economic growth: GDP per person tripled to $580, and millions lifted themselves from poverty over the last decade.
The rest of the world, wealthy countries and well as poor, can learn from Rwanda’s rapid rise. Too often, though, experts imply that Rwanda’s results are inseparable from the genocide.
In this explanation, the genocide created a “clean slate” on which Rwanda could build a new health system thanks to an influx of health aid from wealthy countries feeling guilty about what happened. However, in the years immediately following the genocide, Rwanda received the least health aid of anywhere in sub-Saharan Africa, as many organizations wrote the country off as a lost cause. Even today, Rwanda achieves its superb improvement while spending only $55 per person on health care and public health per year — 22nd among the 49 countries in sub-Saharan Africa.
Rwanda achieves exceptional results not from how much money they spend on health, but from how they spend it. A recent article in BMJ, led by Farmer, examined World Health Organization data and sought to identify why Rwanda developed so rapidly, and to clarify the lessons for other countries. Rather than a single cause, the authors identified a series of interconnected factors that contributed to the country’s turnaround.First and foremost, credit belongs to . . .
Continue reading. Interesting to read how Rwanda is far ahead of the US in healthcare: way ahead.
20 years of the Family and Medical Leave Act
Joe Conason writes in Alternet:
When Bill Clinton signed the Family and Medical Leave Act on Feb. 5, 1993 almost exactly 20 years ago as the first legislative act of his presidency, its establishment as law marked a progressive victory after nearly a decade of ferocious opposition by corporate lobbyists, Republican legislators, conservative media and right-wing pundits.
Leading the opposition was the U.S. Chamber of Commerce, whose spokeswoman Virginia Lamp denounced the act as “a dangerous precedent.” (She would eventually marry Supreme Court Justice Clarence Thomas and move on to employment with the Koch brothers.) With the honorable exception of the Catholic Church and a number of moderate Republicans in Congress, the self-proclaimed “pro-family” forces in American political life eagerly aided and abetted the Chamber’s attempt to kill the act. Mandating a federal right to unpaid leave, even if restricted to certain workers in larger businesses, would place the nation on a slippery path toward European socialism, or worse, according to the Chamber and its Republican allies and impose untold damage on business.But now we know, as with so many other warnings from the far right about the supposedly ruinous consequences of social progress, how the actual results have differed from those predictions. And with two decades of experience, it is clear that the difference has been dramatic.Put simply, the act’s protections have proved vital for millions of families across the country, whether in times of joy or hardship. Debra Ness, the president of the National Partnership for Women and Families, which drafted the original bill and assembled the victorious coalition that supported it, estimates that the law has been used over 100 million times “by women who needed medical care during difficult pregnancies, fathers who took time to care for children fighting cancer, adult sons and daughters caring for frail parents, and workers taking time to recover from their own serious illnesses.” The latest Department of Labor survey of employees and employers indicates that up to 14 million employees took leave in 2011.Released this week to coincide with the act’s anniversary, that study not only demonstrates how vital it is to American families but how beneficial it has been for the national workforce and economy. Indeed, rather than imposing an insufferable burden on business, the act has enhanced productivity and profit as well as protecting children, the ill and the elderly.According to the DOL study — which was subcontracted to Abt Associates, one of the country’s oldest and most respected private consulting firms — most employers have not found compliance particularly burdensome. Only 1 percent of the covered worksites told Abt that they had “great difficulty” in administering leave and 14 percent reported “some difficulty.” Fewer than 10 percent of worksites reported any negative effects on productivity, morale, absenteeism, turnover or “business profitability.” Some larger worksites had more problems, but overall, the vast majority reported that the act had posed no serious issues.Most impressively, for every worksite that reported a negative impact on productivity, there were nearly three that said the impact has been positive; and for every worksite that reported a negative impact on profitability, there were nearly five that said the impact has been positive.Encouraging as those statistics may be, they highlight a less encouraging fact — namely that America remains far behind other advanced industrial nations in the social benefits and protections provided to its working families. The United States is the only country in the Organization for Economic Cooperation and Development that lacks a national paid parental leave policy.In a global study conducted by researchers at Harvard and McGill universities, the results revealed that all advanced countries and many developing nations — 169 out of 173 studied — offer guaranteed leave with income to women following childbirth; and 98 of these countries offer 14 or more weeks of paid leave. (The three other nations offering no paid leave whatsoever were Liberia, Papua New Guinea and Swaziland.) The researchers found 66 countries that provide fathers with either paid paternity leave or a right to paid parental leave, with 31 countries offer 14 or more weeks of paid leave.Aside from important changes providing leave to military families, initially left without coverage under the act, Congress has made no significant improvements in . . .
What the profit motive brings to medicine
The free hand of the market, indeed! This gruesome tragedy is driven purely by profit-seeking.
