Monday, August 31, 2009

TR Reid Busts International Health Care Myths

This was in my Pittsburgh Post-Gazette, but also in other papers as well. TR Reid, of PBS "Sick Around the World" has done the leg work and homework to become perhaps the most knowledgable journalist in the world on internation health care.

As Americans search for the cure to what ails our health-care system, we've overlooked an invaluable source of ideas and solutions: the rest of the world. All the other industrialized democracies have faced problems like ours, yet they've found ways to cover everybody -- and still spend far less than we do.

I've traveled the world from Oslo to Osaka to see how other developed democracies provide health care. Instead of dismissing these models as 'socialist,' we could adapt their solutions to fix our problems. To do that, we first have to dispel a few myths about health care abroad:

Myth 1: It's all socialized medicine out there.
Not so.

Read on about myths 2-5:

MYTH 2: Overseas, care is rationed through limited choices or long lines.
MYTH 3: Foreign health-care systems are inefficient, bloated bureaucracies.
MYTH 4: Cost controls stifle innovation.
MYTH 5: Health insurance has to be cruel.

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Friday, August 28, 2009

The pope's social encyclical -- Part 2 | National Catholic Reporter

The pope's social encyclical -- Part 2 National Catholic Reporter:

Pope Benedict also chastises those who think that a 'market economy has an inbuilt need for a quota of poverty and underdevelopment in order to function at its best.' On the contrary, the market is not merely 'an engine for wealth creation.' It must also function 'as a means of pursuing justice through redistribution' (n. 35).

In the most recent presidential campaign in the United States, the concept of redistribution was hung around the neck of one of the major-party candidates as if he were a Socialist. If so, that term of opprobrium would apply to Pope Benedict XVI as well.

If it weren't for the sex stuff, the Pope and Catholic tradition would be out there with Michael Moore and ralph Nader...

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Thursday, August 27, 2009

"Common Sense" Health Care Reform Principles

Uwe Reinhardt Economix Blog

The All-American Wish List for Health Reform

  1. Only patients and their own doctors should decide what clinical response is appropriate for a given medical condition, even if that response involves
    unproven clinical procedures or technology.
  2. Neither government bureaucrats nor private insurance bureaucrats should ever refuse to pay for whatever patients and their doctors have decided to do in response to a given medical condition. An insurer’s refusal to pay for a medical procedure is tantamount to rationing health care.
  3. Rationing health care is un-American.
  4. Cost-effectiveness analysis should never be the basis of any coverage decision by public or private third-party payers in health care, for to do so would put a price on human life — which, in America, unlike everywhere else, is priceless.
  5. Government should not require individuals to purchase health insurance. Such a mandate would violate the constitutional rights of freedom-loving Americans.
  6. Americans have a moral right to life-saving and potentially highly expensive medical care, should they fall critically ill, even if they are uninsured and could not possibly pay for that care with their own financial resources. (Why else would God have created hospitals and their emergency rooms?)
  7. Government should stay out of health care. Specifically, government should not control health care prices, nor should it increase its spending on health care, which is out of control.
  8. Even small reductions to the future growth of Medicare spending — called “cuts” in Washington parlance — unfairly burden the elderly, along with the
    doctors and hospitals that serve them and the manufacturers of health products, lest the pace of technical innovation be impaired.

And so on, and so forth. Any health policy analyst over the age of 40 could easily double the list. It might make for a good parlor game at a bar.

Readers may believe I am jesting. But follow the editorial pages or punditry, especially of the conservative news media, over some time.

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Who Is My Neighbor? - The Treatment

Who Is My Neighbor? - The Treatment

A dissection of Tom Cobun's shameful response to his constituent with health insurance issues...

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Monday, August 24, 2009

Forum: Before you die, speak up

Forum: Before you die, speak up:

I am an intensive care physician. My days are mostly spent working with a dedicated, caring team resuscitating people from septic shock and respiratory failure back to health.

Unfortunately, many of our patients, already near the end of life with serious advanced illnesses, would not want and will not benefit from these heroic measures that we've inflicted on them -- but the paperwork and orders necessary to prevent them are not in place.

In these cases, we work, a bit too late, to put things right and to do right by these people who entrust us to do our best for them. We are privileged to help those who will get better and to comfort those who will not. But we can do better.

I wrote this a few years ago, but it has become pertinent again along with these pieces written by Gary Rotstein, health reporter for the Pittsburgh Post-Gazette:

End-of-life questions often go unasked

Disabled worry lives not valued

So now, they are bookmarked in the blog.

UPDATE: two recent op-eds in the Pittsburgh Post Gazette of note:

The last days of our lives: Our health-care system needs to provide better, more thoughtful end-of-life care.
Wednesday, August 26, 2009
By Dr. Robert Arnold and Nancy Zionts

Sunday Forum: Forget the euthanasia talk -- end-of-life care is needed
It's time to debunk the misconceptions about provisions in the health-care reform bill, says RAFAEL J. SCIULLO
Sunday, August 23, 2009

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George Lakoff: The PolicySpeak Disaster for Health Care

George Lakoff: The PolicySpeak Disaster for Health Care:

The narrative is simple:
Insurance company plans have failed to care for our people. They profit from denying care. Americans care about one another. An American plan is both the moral and practical alternative to provide care for our people.

The insurance companies are doing their worst, spreading lies in an attempt to maintain their profits and keep Americans from getting the care they so desperately need. You, our citizens, must be the heroes. Stand up, and speak up, for an American plan.
As for language, the term 'public option' is boring. Yes, it is public, and yes, it is an option, but it does not get to the moral and inspiring idea. Call it the American Plan, because that's what it really is.
The American Plan. Health care is a patriotic issue. It is what your countrymen are engaged in because Americans care about each other. The right wing understands this well. It's got conservative veterans at Town Hall meeting shouting things like, 'I fought for this country in Vietnam, and I'm fight for it here.' Progressives should be stressing the patriotic nature of having our nation guaranteeing care for our people.
A Health Care Emergency. Americans are suffering and dying because of the failure of insurance company health care. 50 million have no insurance at all, and millions of those who do are denied necessary care or lose their insurance. We can't wait any longer. It's an emergency. We have to act now to end the suffering and death.
Doctor-Patient care. This is what the public plan is really about. Call it that. You have said it, buried in PolicySpeak. Use the slogan. Repeat it. Have every spokesperson repeat it.
Coverage is not care. You think you're insured. You very well may not be, because insurance companies make money by denying you care.
Deny you care... Use the words. That's what all the paperwork and administrative costs of insurance companies are about - denying you care if they can.
Insurance company profit-based plans. The bottom line is the bottom line for insurance companies. Say it.

Private Taxation. Insurance companies have the power to tax and they tax the public mightily. When 20% - 30% of payments do not go to health care, but to denying care and profiting from it, that constitutes a tax on the 96% of voters that
have health care. But the tax does not go to benefit those who are taxed; it
benefits managers and investors. And the people taxed have no representation.
Insurance company health care is a huge example of taxation without representation. And you can't vote out the people who have taxed you. The American Plan offers an alternative to private taxation.
Is it time for progressive tea parties at insurance company offices?

Doctors care; insurance companies don't. A public plan aims to put care back into the hands of doctors.
Insurance company bureaucrats. Obama mentions them, but there is no consistent uproar about them. The term needs to come into common parlance.

Insurance companies ration care. Say it and ask the right questions: Have you ever had to wait more than a week for an authorization? Have you ever had an authorization turned down? Have you had to wait months to see a specialist? Does
you primary care physician have to rush you through? Have your out-of-pocket
costs gone up? Ask these questions. You know the answers. It's because insurance
companies have been rationing care. Say it.
Insurance companies are inefficient and wasteful. A large chunk of your health care dollar is not going for health care when you buy from insurance companies.
Insurance companies govern your lives. They have more power over you than even governments have. They make life and death decisions. And they are accountable only to profit, not to citizens.

The health care failure is an insurance company failure. Why keep a failing system? Augment it. Give an alternative.

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Friday, August 21, 2009

Health care reform: What is costly overuse, what is humane?

Health care reform: What is costly overuse, what is humane?:

This is the piece Betsy McCaughey read from on The Daily Show last night, regarding EOL care and the horrors of HR 3200.

"My problem, as a physician who has practiced medicine for decades, is that I just can't predict with certainty what is end-of-life care, nor can I determine for another individual the meaning of 'quality of life.'"

Well that's the whole point, isn't it? It s not the physicians choice it is the patient's choice, the patient's wishes that count. It is entirely the point of advance care planning and advance directives that it is up to the patient to decide what he or she wants. Our responsibility a physicians is to give them the best information that we can, imperfect as it is, and help them come to decisions that best reflect their wishes and goals.

And, no, we cannot predict with certainty when a person is exactly at the end of life - and I suspect that this author and Ms. M. would only except a definition of end of life as minutes away - but I do have a wealth of experience to go on, and I think it is unprofessional to allow families to cling to miracle scenarios for survival.

And here's another gem:
"I would be loath to talk a person on dialysis or in a wheelchair from a stroke into forgoing antibiotics for a pneumonia that may itself be treatable."

Well, so would I, because that is not the role of a physician, is it? Jeebus. Jude the Obtuse.

Ms. M. read this part:
"These and other provisions of the health choices act frankly scare me. As a physician, I took an oath long ago to put my patient's interests above all else, but provisions in the bill have a quality of coerciveness that make me wonder if I can fulfill my oath."

You have a higher duty to be honest with your patients and not blow smoke up their rears, telling them that this next chemo, this next procedure, this next indignity, is always worth it.

As I'm putting together this post, it infuriates me to consider countering this stupid, stupid, stupid, uninformed, heartless, obtuse rhetoric yet again.

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Wednesday, August 19, 2009

Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform | Video Cafe

Anthony Weiner Leaves Joe Scarborough Momentarily Speechless When Arguing for Health Care Reform Video Cafe:

"Isn't it amazing what a little clarity to your argument can bring you isn't it? Like arguing for real reform instead of the mushy middle. Anthony Weiner did a fantastic job on Morning Joe today and he actually left Scar speechless for a moment when trying to get him to answer just what the insurance industry does to benefit anyone. Of course Scarborough turned that around into 'You're arguing for a government takeover of health care' shortly afterwards, but he never could give any decent defense of why this country needs the insurance industry."

From Crooks and Liars, what a great video! An articulate advocate for Single Payer.

I'll ask the question again: What value do private insurers add to health care?

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Friday, August 14, 2009

Survival for $25,000 - TIME 1971

Survival for $25,000 - TIME:

This is an article about the trials and tribulations kidney failure patients faced before Medicare expanded in 1972 to cover kidney diseases theough its End Stage Renal Disease (ESRD) Program.

At 29, Don Shevlin was just two months away from taking his oral exams for a Ph.D. in English at U.C.L.A. Today, two years later, he has neither the degree nor any prospect of a teaching job. Says he: 'I see myself as perennially pauperized.'

Shevlin suffers from chronic kidney disease, an incurable type that necessitated the removal of the organ. Now, in order to prevent a fatal buildup of toxins in his blood, he must report to the university hospital three times a week for kidney dialysis, a six-hour cleansing process that enables him to survive until he can get a kidney transplant. Since his illness wiped out his small savings, Shevlin lives on welfare payments of $178 a month, while the State of California pays for most of the cost of his treatments —which amounts to $3,000 a month.

Shevlin's position is not unique. Nearly 5,000 Americans are currently undergoing regular kidney dialysis. Thousands more would choose such treatment if it were more widely available, but none can escape the gigantic cost of staying alive.

One of the questions I get asked is, "Aren't you worried that 'The Government' will take over and start cutting off care or rationing care?" Not under Democrats.

Medicare and the ESRD program are examples of America's liberal social justice tendencies accomplishing something.

Too bad kidneys aren't the only organs that go bad, or we'd already have universal health care.

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Dr. Alvin "Woody" Moss on West Virginia Public Radio

Below is a link to Dr. Moss’s interview with Beth Vorhees on WV Morning on health care reform and end-of-life care.

Link to listen--

Well done, Woody!

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KDKA Radio Interview #2

Mike Pintek of KDKA Radio Talks to Dr. Christopher Hughes About Health Care Reform
Yesterday, August 13, 2009, 6:33:00 PM

Part 1

Part 2

Part 3

Part 4

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Thursday, August 13, 2009

DrMatt: I'm worried about the death panels...seriously...

Over at DailyKos, DrMatt has collected a nice selection of anecdotes for my collection.

I have some more from Doctors for Amercia I'll try to post later today...

I will be on KDKA Radio Pittsburgh tonight (Thursday Aug 13) at 9 PM with conservative talker Mike Pintek.

You can listen live at


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Wednesday, August 12, 2009

IBD, Stephen Hawking and Nice

You have by now all read of the very funny folks at Investors Business Daily thought England's NHS was so awful that a poor soul like Stephen Hawking would be long dead had he to depend on those slugs in England for his care.

Just in case you missed it, here's the correction:

Editor's Note: This version corrects the original editorial which implied that physicist Stephen Hawking, a professor at the University of Cambridge, did not live in the UK.
But, enough hilarity. If you read the rest of IBD's editorial, you might notice their attack on England's National Institute for Health and Clinical Excellence (NICE), an arm of the NHS, for its ruthless analysis of the cost and effectiveness of drugs. The bastards!

Anyway, the editorial contains this sentence, "In March, NICE ruled against the use of two drugs, Lapatinib and Sutent, that prolong the life of those with certain forms of breast and stomach cancer." This is interestingly the exact same sentence that appeared in a WSJ op-ed on July 7th. But it's a beautiful sentence. Who can blame IBD?

IBD also has this gem: "The British are praised for spending half as much per capita on medical care. How they do it is another matter. The NICE people say that Britain cannot afford to spend $20,000 to extend a life by six months. So if care will cost $1 more, you get to curl up in a corner and die."

I can just see the clinicians and scientists at their final meeting, throwing patients under the bus for that dollar/pound. Bastards! The corollary to this, when you think about it, is the pharmaceutical company not lowering the price for the wonder drug by this apocryphal dollar. Bastards!

But what about these heartless beasts at NICE and these wonder drugs the British public is being denied.

From the NICE report on Lapatinab for breast cancer:

Clinical Benefit Rate
Using the independent assessment a greater proportion of subjects in the lapatinib + capecitabine group (29%) than in the capecitabine group (17%) achieved clinical benefit (odds ratio: 2.0, 95% CI: 1.2, 3.3, two-sided p-value: 0.008; cut-off date 3 April 2006). Using the investigator assessment of the clinical benefit response rate a greater proportion of subjects in the lapatinib+capecitabine group (37%) than in the capecitabine group (21%) achieved clinical benefit (two-sided p-value: 0.001).

Duration of Response
For subjects who responded to treatment, the median duration of response was 32.1 weeks in the lapatinib+capecitabine group and 30.6 weeks in the capecitabine group.

Get that? They are being denied a drug that increases the median duration of response by a staggering 1.5 weeks for the additional 12% who had some response to treatment!

The same paper included an analysis of a study on brain metastases that showed no significant difference in outcomes there, either.

Don't get me wrong. I am all for research and pushing the envelope. Continuing to study these drugs is fine, as long as all the appropriate ethical guidelines are followed, particularly with regards to real informed consent. But arguing on the basis of a study as described above that this should be placed into mainstream use is ridiculous.

My other pet peeve about these types of treatments is the cruel, false hope given to so many patients as they are offered "the next" chemotherapy regimen, intensive care, and so on.

I also have no objection to choosing to continue these treatments to the bitter end, as long as one understands the choice. I often get patients on "salvage" chemotherapy, palliative chemotherapy or palliative radiation treatments who don't understand what those terms mean. Maybe they were too rattled when the discussion took place and simply don't remember. But my experience with these patients and their families is that the discussion never took place in earnest.

Being told that the cancer has come back or spread to your brain or whatever and that here's what we can do next is far different than having a really hard conversation about your prognosis and all of your options.

Maybe your options are 2 or 4 or 6 months with "salvage" chemo if things go well (or a much more abrupt end if they don't!) versus 1 or 3 or 5 months without, but at home, having your symptoms aggressively managed by a palliative care specialist and working with hospice for a peaceful dignified end. And more than likely the 2 or 4 or 6 months with aggressive treatment means a lot of that time spent in the hospital, dying in an intensive care unit, hooked up to life support until someone finally tells you, too late, the hard truth.

Let's not kid ourselves about this disturbing side of American medicine: our often mindless devotion to doing "everything" up until the nails are being hammered into the coffin is, more often than not, in stark contrast to doing "the best things" for our patients.

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AMNews: May 14, 2007. Battle over futile care erupts in Texas ... American Medical News

AMNews: May 14, 2007. Battle over futile care erupts in Texas ... American Medical News:

Disability rights and pro-life activists are pushing for changes in Texas law that would force physicians and hospitals to provide life-sustaining treatment indefinitely in medically futile cases.
Under an advance directives law hammered out by medical, disability and pro-life groups in 1999, the families or proxies of patients on life support have 10 days after hospital officials formally notify them that they plan to withdraw treatment to find another facility to care for the patient.
But the Terri Schiavo controversy and a number of heavily publicized cases in which Texas families scrambled to transfer their loved ones and sued hospitals to continue treatment have taken place since then. Bills now being considered in the Texas Legislature would eliminate that 10-day time limit. A measure in the 150-member House has garnered 80 co-sponsors.
The Texas Medical Assn. argues that these so-called treat-until-transfer bills would force doctors to continue treatment in cases when it's medically inappropriate and that further intervention inflicts pain on patients without any corresponding medical benefit.
The Texas law, which applies only to terminally ill patients with an irreversible condition who are unable to make their own health care decisions, is also unusual because it requires the hospital's ethics committee to review any medical futility case before the 10-day clock starts ticking. While hospitals in other states usually review any decision to withdraw care, such procedures are not legally required. Virginia is the only other state to place a time limit, 14 days, on how long an effort to transfer the patient must continue before life support is withdrawn.
Texas hospitals have used their state's advance directives law 27 times to withdraw treatment over family objections, said Robert L. Fine, MD, one of the 1999 law's architects.

Although, as the article points out, AMA ethics policy is consistent with this approach, I am surprised that it has ben used so often in Texas. But then, this is the death penalty state, and so, I suppose we shold not be surprised.

I can't see doing this, personally, but I can tell you that the irrationality of some families is impenetrable, and the strain on ICU staff - which should count for something - in engaging in what most of us would consider behavior tantamount to cruelty leads to early burnout of some very fine individuals for no benefit other than the acquiescence to this irrationality.

BTW, the law was not updated and stands as it was.

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The Associated Press: Long lines as free health care offered in LA area

The Associated Press: Long lines as free health care offered in LA area:

The Los Angeles event marks the first time Remote Area Medical has provided such medical care in a major urban area. The medical group typically serves patients in rural parts of the United States and travels to underdeveloped countries.

The piercing sound of teeth being drilled and scraped echoed up to the rafters where the Los Angeles Lakers once played to the roar of capacity crowds. Mobile health trucks provided other medical examinations, and tables full of donated eyeglasses were available to those who had eye examinations done.

Since 2000, The Forum has been owned by Faithful Central Bible Church, which donated the use of the facility for a week. The medical professionals volunteered their time and covered their own liability. Cash and services were donated by local hospitals, health systems and charitable groups.

Tennessee-based RAM's founder Stan Brock said he helps organize 30 to 40 such health care events a year, with a total of 567 events held to date, adding: 'We just wish we could do more.'

'This need has existed in this country for decades and decades,' said Brock. 'The people coming here are here because they are in pain.'
The event came at a time when the national debate over President Barack Obama's health reform plan has boiled over at town hall meetings, with opponents sometimes shouting down Democratic members of Congress who favor the program.
Rep. Maxine Waters, D-Calif., told a cheering crowd of volunteers and medical professionals at The Forum that she would continue to advocate for health care reform because 'we can do a better job of providing health care to those who desperately need it.

Let's see, 567 events times maybe 500 people each, how many anecdotes is that?

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Tuesday, August 11, 2009

A reality check on that Canadian "Brain Tumor" story

A reality check on a reality check:

Still, I found Holmes tale both compelling and troubling. So I decided to check a little further. On the Mayo Clinic's website, Shona Holmes is a success story. But it's somewhat different story than all the headlines might have implied. Holmes' 'brain tumour' was actually a Rathke's Cleft Cyst on her pituitary gland. To quote an American source, the John Wayne Cancer Center, 'Rathke's Cleft Cysts are not true tumors or neoplasms; instead they are benign cysts.'
There's no doubt Holmes had a problem that needed treatment, and she was given appointments with the appropriate specialists in Ontario. She chose not to wait the few months to see them. But it's a far cry from the life-or-death picture portrayed by Holmes on the TV ads or by McConnell in his attacks.
In Senator McConnell's home state of Kentucky, one out of three people under age 65 do not have any health insurance. They don't have to worry about wait times for hip or knee replacement or cancer surgery -- they can't get care. The median household income in Kentucky is $37,186 -- not quite enough for the $97,000 bill at the Mayo Clinic. CNN didn't mention that in its 'Reality Check.'"

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The Health Care Blog: How to Rein in Medical Costs, RIGHT NOW

The Health Care Blog: How to Rein in Medical Costs, RIGHT NOW
From Dr. George Lundberg...

"So, what can we in the USA do RIGHT NOW to begin to cut health care costs?

An alliance of informed patients and physicians can widely apply recently learned comparative effectiveness science to big ticket items, saving vast sums while improving quality of care.

1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.

2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.

3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.

4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.

5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.

6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.

7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved."

My personal opinion is that all of these issues are not solely driven by economics, but just as often by being the path of least resisitance. It is generally easier to do the "next thing," rather than having difficult conversations about a CABG or intervention or chemo regimen or whatever, and the real risks and benefits to the patient in front of you. So rewarding patient care and outcomes and time spent or simply not rewarding so generously all of these procedures could go a long way as Dr. Lundberg suggests.

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Thursday, August 6, 2009

The Best Medical Care In The U.S.

The Best Medical Care In The U.S.:

Every day some 1,400 patients pass through the Buffalo VA's unprepossessing entrance, into what many might assume is a hellish health-care world,
understaffed, underfunded, and uncaring. They couldn't be more wrong. According to the nation's hospital-accreditation panel, the VA outpaces every other hospital in the Buffalo region. 'The care here is excellent,' says Roemer. 'I couldn't be happier, and my friends in the POW group I belong to all feel the same.'

Roemer seems to have stepped through the looking glass into an alternative universe, one where a nationwide health system that is run and financed by the federal government provides the best medical care in America. But it's true -- if you want to be sure of top-notch care, join the military. The 154 hospitals and 875 clinics run by the Veterans Affairs Dept. have been ranked best-in-class by a number of independent groups on a broad range of measures, from chronic care to heart disease
treatment to percentage of members who receive flu shots. It offers all the same services, and sometimes more, than private sector providers.

According to a Rand Corp. study, the VA system provides two-thirds of the care recommended by such standards bodies as the Agency for Healthcare Research & Quality. Far from perfect, granted -- but the nation's private-sector hospitals provide only 50%. And while studies show that 3% to 8% of the nation's prescriptions are filled erroneously, the VA's prescription accuracy rate is greater than 99.997%,
a level most hospitals only dream about. That's largely because the VA has by far the most advanced computerized medical-records system in the U.S. And for the past six years the VA has outranked private-sector hospitals on patient satisfaction...

read on...

When I talk about the VA, I always make this qualification: I know that they are struggling to deal with the epidemic of PTSD and the influx of Veterans from the past seven years, and they need the help of us as taxpayers. Go show IAVA that you care.

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AMA Conference Call on HC Reform

The AMA is doing regional conference calls on health care reform. The one for my region (PA, NY, MA, maybe others) was tonight. I gather it was the first one they've done so far, but they indicated they would be doing more.

On the call for the AMA were Immediate Pat president Nancy Nielsen, Jim Wilson, Political Education Programs Manager, and Richard Deem, Senior VP for Advocacy.

I was pretty pleased with the call and the positions that the AMA seems to be taking, so you may be pleasantly surprised.

The call started with some comments by Dr. Nielsen, then questions from the group (transcribed for the AMA reps, who read them to us), and a brief closing statement.

Dr. Nielsen opened with a discussion of HR 3200, presumably because of the push back the AMA has gotten from its more conservative members. HR 3200, in its original release addressed in positive ways, many of the AMA's highest priority goals. These included extended coverage for the uninsured, preserved choice of health insurance plans, fundamental Medicare reform including elimination of the SGR, encourages mangament of chronic diseases and coordination of care, increased payment to Primary Care Physicians with no reduction in fees to specialists.

The things in 3200 the AMA wants changed: addition of Medical liability reform; change in plan for public option fees to be 5% above medicare; and restrictions on physician ownership of hospitals.

Ammendments introduced so far include "modest" liability reforms (AMA speak for anything that is not "caps" on damage awards), including encouraging states to give incentive payments for certificate of merit and "early offer" programs, and she reaffirmed, essentially, that we're all about caps at the AMA. Also ammended, public plan participation by physicians will not be mandatory and public plan fees will be negotiable and not fixed to medicare rates.

Compromises still being sought include, in the Senate HELP committee: Public Plan similar to HB 3200; negotiated payments; the plan must be self sustaining, and compete on a "level playing field."

In the Senate Finance Committee, the bipartisan "Gang of 6" are seeking compromise legislation, but we have not seen an actual bill yet. But all indications are that this bill will NOT fix SGR (only another one year fix, then replay the annual ritual of rganized medicine fightinng to fix this again. The AMA wants to fix this with Senate FLOOR VOTE. Also concerning are possible penalties for PQRI non participation and that we may end up with co-ops rather than PO/PP. Dr. Nielsen preemptively addressed the question of why the AMA has postioned itself where it has re: HB 3200: We need insurance market reform because insurance is tenuous to the public, it is tied to jobs, it is limited by preexisting conditions and because we all pay for care given to uninsured anyway. Getting rid of SGR is a big deal for the AMA as is avoiding other financial penalties (such as with PQRI) and we do all have to be worried about costs.

She also points out that we physicians are being dealt with very fairly in HB 3200: Hospitals are going to get cuts, home health gets cuts, as do others while physicians get $230 Billion (erasing SGR debt is part of this number, but also includes higher fees for PCPs including incentives for coordinating care and dealing with chronic care patients)

Why did AMA support HB 3200 so quickly? Dr. Nielsen said that early support means something and gives us more influence; we are working with leaders in both houses and they understand Medicare must be strong(!). The AMA did not "give away" support; it was negotiated and we got things: No mandatory participation in a public plan, more money.

She points out that ranting is not useful, quiet negotiation does and is working.


Q: Socialized medicine!!! Slippery Slope!!!! (I paraphrased here.)
A: NO: Americans will not tolerate it. Expanding coverage is not socialism.

Q: Will there be rationing under Medicare or under any public option.

Q: Wwhy support anything without "significant" liabilty reform?
A: We're still fighting!

Q: How does AMA support 3200: It's awful.
A: No, it isn't. SGR!

Q: Can we have physician council to guide HC?
A: AMA may be filling this role in guiding legislation, but not clear if tere would be a way to do some far reaching council.

Q: Anything restricting physician patient relationship?
A: The AMA is FIRM in that there can be no interference in care decisions. CER will never mandate what a doctor may offer to a patient. MC is easier to deal with than PHIs(!!!), she said, from her perspective as a primary are physician. Less hoops with MC! We also want best evidence! Mr. Deem: No penalties on PQRI in HB 3200

Q: How can we support bill we haven't seen? Aren't we being used/abused?
A: Physicinas are necessary in this debate. Congress has brought actors together and said we are all in this together and we have to do this. NN thinks we are participating, not being used and we believe we have influenced the process significantly, but perhaps not on CAPS.

Q: HB 3200 better PCP fees?
A: Yes; also increased coordination of care fees.

Q: Did you read 3200?
A: Yes. We have a team that does that and they analyzed it. I have read it as well.

BIG POINT HERE: She calls out the BS email about he facts of HB 3200 as "outrageous," and notes that the AMA has reviewed, and agrees with the rebuttal provided by

Q: Massachusetts seems to be working well except cost controls, what now?
A: We need to learn from MA; getting people in system but costs are big issue; bigger question is how do we come to grips with our responsibility as citizens and patients and physicians and insurers? MA has shortages in work force, nursing and derm and gen. surgeons; We don't need to wait for workforce to be online before we reform HC; lead time too long for physicinas in particular. Choice of doctors and insurers key.

Q: 70-83% of peopple are satisfied with coverage; maybe they won't be if we change things; maybe Congress will lower reimbursement after the bill passes?
A: We are all nervous; but we are also the unhappiest MDs in the world. Prez says you can keep what you have; AMA is concerned about this and we want to preserve choice.

Q: Will Public Plan crowd out private insurers?
A: Bill is written so choice to join PP is limited (to the uninsured, small businesses and some others) but this could change and we must be vigilant.

Q: Why should we trust this administration?
A: Trust but verify. This is about influence and we are critical to change. It is important for us to pay attention and focus on what we agree on, and not on divisive issues.
Mr Deem: Adminstration trying to fix/improve payment formula and did something about MD administered drugs that AMA has been asking for for 8 years and we are just now getting it.

Dr. Nielsen made the point here that Obama's example of non-indicated tonsillectomy example. She thinks that was Really Bad; we know it is not like that; they got big push back.
[CMHMD: I actually agree that he really mangled this one; "inartful" was the kind way to put it, I thought.]

Q: Will there be an independent body, such as an uber-MEDPAC or IMAC, that will rule the roost?
A: Dr. Nielsen expressed concern that there seem to be expenditure targets for physicians, but not for any of the othr big players. She indicated the many if not all of these issues are "in process," and the AMA is expressing our concerns.

Dr. Nielsen added that she thought a view expressed what she called a "minority view" of physicians is that an independent council would be better than dealing with congress. [CMHMD: I don't think this is a minority view. Many health policy big wigs think having Congress function as the "Board" for Medicare is a bad thing that needs fixed.]

Q: CBO score for Senate Bills?
A: We don't know when we'll get them.

Q: Other countries physicians' have less financial pressure coming out of training.
A: We agree and are working on it.

Q: What should physicians be doing now?
A: AMA is happy to help and reach out. Like this call. Hard to say what to do; gives example of tea baggersand cautions that physicians need to be rational and let people know we want to take care of patients without government interference and make sure uninsured get in system and don't saddle kids with crushing debt. Don't fall for labels and rhetoric.

Q: What happens to HSAs?
A: Mr. Deem: HSAs stay in so far. And we will push for that.

Q: Geographic variation?
A: AMA pushing for money for IOM study. Gypsy payment floor (?)

Closing, Dr. Neilsen: This is moving target. What's the difference between an echanges and a co-ops? Exchanges are like a mall to shop; co-op like a single store where owners are also customers.
[CMHMD: I'd call this mutual insurance, and it could be a good thing if well regulated.]

CMHMD final comments: I fouund this very encouraging. There was the expected conservative push back, but that's OK, Dr. Nielsen did a great job of keeping things focused on what are truly high goals for physicians: universal access and fairness in the system. She also stuck to the markers she must or get pummelled by the membeship on tort reform and "choice," but, hey, pretty good from where I'm sitting!

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Wednesday, August 5, 2009

Interviews with KDKA and PCNC for Doctors for America

I had a couple of interviews with conservative talk hosts here in Pittsburgh Monday night on the Pittsburgh Cable News Channel with Kevin Miller and Tuesday morning on KDKA radio with Mike Pintek as representative for Doctors for America on health care reform. I thought I'd share, and perhaps get a little constructive input.

I have to say that I thought both hosts were fair to me, though the television host seemed to try to bait me into peripheral discussions [He is a moon landing skeptic, for instance!] while the radio host was more focused on getting detailed information out of me, which I appreciated.

The issues that seem to be the most concerning to conservatives, or at least get them the most stirred up, are those concerning the cost of the program and the impact on
the budget and, of course, taxes, the ceding of control of health care decisions, or rationing decisions, in their minds, to the dreaded government bureaucrats, and euthanasia. Believe it or not.

My response to the cost argument is the one you all know, that our current non-system costs way too much, far more than any other place on the planet, including the countries like
France and Germany who cover everyone, don't ration in any significant way, and have no longer waiting times than our own.

Skepticism abounds about drawing any lessons on health care reform from other nations, as the utter failure, in the conservative mind, of Canada and Britain, necessarily precludes us from learning anything at all from them. I did manage to point out that while both Canada and England have had problems with their systems due primarily to inadequate spending, they did manage to insure everyone. I also pointed out that in Britain, since the liberal Labor Party took over from the Conservative Thatcher/Major governments, things have improved significantly on the waiting times front.

They expressed concerns about the cost of the Public Option being thrown about of a trillion dollars or more. In the context of health care spending currently of 2.4 trillion, one trillion over ten years, or 0.1 trillion per year does not seem like much. On the other hand, we are in danger of putting a layer of something that should be good over top a heap of a messed up non-system. I specifically agreed that Obama's message that, if we were starting from scratch, single payer makes the most sense was true. “Government Bureaucrats!” Mr. Pintek played a clip of Barney Frank saying that if the public option were done well and performed well, it could very well lead to single payer. Mr. Pintek suggested that they were trying to be sneaky with this, but I suggested that if they were, this was not a very sneaky way to do it. But even if this was how it would turn out, where's the harm? If the public option proves to be so wildly popular that private insurers get crowded out and the public in the end decides that perhaps this is the best way to provide health care, isn't that a great thing? “Government Bureaucrats!”

So, rationing is next, and is always the real subtext of all of this. Both hosts were aware that insurance companies sometimes deny care, but neither seemed to consider that we
ration by income. I told both the story of a patient of mine who was a middle aged man, without insurance for quite a while. He'd had a cough for close to a year followed by an intermittently bloody cough for a couple months and then developed such difficulty breathing that he finally came to the emergency room and then into my ICU with respiratory failure. He had, by this time, metastatic lung cancer. I pointed out that while you can go to the emergency room for emergency care, the familiar canard of “they can just go to the emergency room,” rings hollow in nearly every basic health care situation. I paraphrased from a wonderful letter from the New York Times, and pointed out that ER's don't do cancer care nor manage asthma nor prenatal car nor diabetes and don't do any of the things we think of when we talk about every day health care needs.

But what about government bureaucrats rationing health care? They both seemed disbelieving that this did not seem to concern me terribly. I argued that we could be well served by a commission made up of physicians who used comparative effectiveness research and analyzed the benefits and costs of treatment to help guide us , rather than medical directors at private health insurers making these determinations.

I regret that we did not get to end of life issues on the PCNC show, but we did on KDKA. I was asked what I thought of the House Bill and what it would mean to us with respect to Advance Directives and forcing the elderly to forego treatment. I think that it will finally make decent payment available for physicians to do Advance Care Planning, which is the term for having discussions on what a patient's wishes are when they are at the end of their lives. This is a very good thing, something that physicians involved in EOL care have been advocating for for years because it is the right thing to do. I have EOL discussions with patients and families literally every day I spend in the ICU. Letting your family know what you want at the end of life is a great gift to them. I tell this to patients and families all the time and it is so true: these are agonizing decisions to make when you have not had these important discussions. If people think about this even for a minute, they will know it is true. I also pointed out that advance directives can go either way, and if you want every last treatment until they are nailing your coffin shut, you can specify that in your AD as well.

We took a few emails/calls on KDKA. The first was not so much supportive, as antagonistic to the host and the conservative listeners. Thanks, but no thanks for that email. The
second was from a nurse who wanted an “American” solution and seemed to resent my referring to France and germany, but in the end, seemed to agree that we needed reform and I think was OK with a
public option as a way to get there. I think it was at this point, Mr. Pintek caught me flat footed when he followed up and asked how Germany makes decisions on what is covered and what is not. I recalled that the benefits packages provide by the insurers there were standardized, but what I wasn't aware of was that they have a commission that does do cost benefit analysis on treatments before they are approved as benefits. This commission has been accused of dragging its feet on new treatments, but this likely reflects a bias among many physicians to not adopt treatments until the evidence is solid. This has actually been studied in the US, and Massachusetts, with Harvard and Mass General and some of the finest health care in the world has this same regional bias and are slow to adopt new treatments. I'll try to remember this for next time!

The last call was from a physician's spouse who had heard me speak about Medicare and what I consider its adequate reimbursement. The host had said he thought the reimbursement was low and that some doctors would not accept it. I pointed out that, depending upon where in the country you practice, Medicare may be your best payer (Nevada, Southeastern PA) or at least, as in the Pittsburgh area where we are, not too far off from private insurance plans. I also pointed out the cost
of $82K per physician annually to deal with insurers and billing.

I had also pointed out that most doctors support some form of national health insurance, particularly PCPs and even a majority of general surgeons, but not some specialists like radiologists, anesthesiologists, and surgical specialists. I think she was a little peeved by that, because that's what she started her comment with. She said that many doctors won't take Medicare, and especially when they go to national meetings she hears this from people around the country. I have heard this before, even from fellow Doctors for America physicians telling me what they hear from colleagues. But if you look at what Medicare actually pays us, the regional variation is very small, with the exception of Alaska (the physicians of Alaska owe fromer Sen. Stephens for that). So whether Medicare fees look like a pittance to you or not has more to do with what your private insurers are paying you than what medicare is paying you. So, certainly physicians will look at a $150 fee from a private plan and a $100 fee from Medicare and conclude that Medicare may not be worthwhile. That is not unreasonable, but when you factor in the cost of dealing with private insurers, $82K per doc or about 14% of overhead, maybe Medicare is subsidizing the private plans! Anyway, I wish I'd had the presence of mind to ask what her husband's specialty was!

Things I didn't get to squeeze in but will try to next time:

  • "It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein." Teddy Roosevelt, “Man in the Arena” The Sorbonne, Paris, France, 1910

  • Public
    opinion favors not only the public option, but national health insurance
    of some kind. And they are willing to pay more in taxes for it, even if this is phrased in such a misleading way in every polling I've ever seen.

  • England's NICE, by analyzing cost of care in the context of benefits to patients has led to price reductions from pharmaceutical companies in order to meet their cutoff. And NICE can be pressured if it is felt to be making unwise recommendations.

  • Having an independent commission running Medicare, rather than Congress, might be quite an improvement.

  • If we do manage to get to a German or French style system, which party would be more likely to demand cost cutting resulting in longer waiting times and rationing of care?

  • I was asked about Massachusetts and demurred because I really don't know enough to comment intelligently. I wish I had referred them to the PNHP site, as they have lots of information and intelligent critiques of what's going on there.

And things to add from your comments will go here:

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Tuesday, August 4, 2009

Health Care in Germany

Health Care in Germany:

This is from a British source, The Institute for the Study of Civil Society

First, Germans are free to visit any doctor they like. They may either walk in off the street, or ring for an appointment that will invariably be booked for the same morning or afternoon. Consumers can and do penalise bad service. Our recent study of German consumers commonly produced reactions like this: 'I saw a long queue, so hopped on the tube and went to a different practice'; 'she was rather ill-tempered so I never went back'; 'the facilities were drab, so I went to a different one next to my office'; 'I felt rushed at his practice so didn't go back'.

Second, Germans do not have to see a GP before visiting a private specialist. GPs do act as gatekeepers to German hospitals, but about half of all specialists practice outside the hospitals. German hospitals provide few out-patient services. Instead, there are a large number of independent clinics, invariably with the most sophisticated diagnostic equipment. Most Germans have a favourite GP, although many maintain a relationship with more than one - just in case - but if they need to see a specialist they would not waste time seeing a GP first.

Third, there are plenty of specialists. Germany has 2.3 practising specialists for every 1,000 people, compared with only 1.5 in the UK.

What problems are there in Germany? The German media is not excited by the subject. There are no patients lying on trolleys in A&E. Germany suffers no real rationing. Yes, problems occur from time to time. Just at the moment, there is a shortage of nurses, and many Germans feel that care is expensive, but serious complaints are few. Nevertheless, reform is in the air. Since January 2004 members of the statutory insurance plan have had to pay 10 euros per quarter to see a GP.

The reforms also saw the introduction of charges for non-prescription drugs, and an end to free treatments such as health farm visits and to free taxi rides to hospital. This is expected to allow for a reduction in premiums from an average of 14 to 13 per cent of annual gross wages.

German satisfaction rates in 1996, the latest Eurobarometer survey, showed that the German are far more satisfied with their system than we are with the NHS. About 11 per cent of Germans said they were 'very or fairly dissatisfied', compared with 41% per cent here. And when asked whether their system needed 'fundamental
changes' or a 'complete rebuild' 19 per cent of Germans said 'yes', compared with 56 per cent of Britons.

Does the German healthcare system deliver an acceptable standard of care for serious illness to all members of society? Do the poorest in society benefit from a higher standard of healthcare provision than those in the UK? The answer to both of these questions is an emphatic, 'yes'.

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Monday, August 3, 2009

HEALTH REFORM: Poll Shows Hopes, Not Just Fears for Reform | New America Blogs

HEALTH REFORM: Poll Shows Hopes, Not Just Fears for Reform New America Blogs:

The poll doesn't indicate that Americans would prefer not to have health reform. In fact, the data shows just the opposite. When asked what they though would happen if 'the government did NOT create a system of providing health care for all Americans,' a solid majority of people were 'very' or 'somewhat' concerned that the number of uninsured people in the U.S. would keep increasing, that they themselves might be uninsured at some point and that the cost of their own health care would go up.

To us, the poll doesn't indicate support is falling apart for health reform -- it does mean that uncertainty is on the rise. This is understandable, as a lot of details are still being hashed out and even members of Congress have difficulty quickly grasping all the complexities of the policy options being discussed right now. That's why it will be important for advocates of reform, including the President, to explain it clearly (and repeatedly) in the coming weeks. Shift the focus from the scary unknown to the known -- that the current system is broken, and it's time to fix it. Because there's a lot in it for all of us.

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450,000 Doctors Demand: ‘Heal Health Care Now’ -- Media Center -- American Academy of Family Physicians

450,000 Doctors Demand: ‘Heal Health Care Now’ -- Media Center -- American Academy of Family Physicians:

Today marks the launch of “Heal Health Care Now.” This Web-based initiative ( consists of several elements, including a provocative video of family doctors speaking in support of the health system reform legislation Congress is debating currently. The video culminates with a call to action encouraging viewers to let their legislators know they stand behind nearly half a million doctors to support reform. The Web site also provides a quick and easy tool that encourages viewers to contact their legislators directly.

Also today, organizations representing 450,000 doctors signed and delivered a joint letter indicating their support of health care reform to Sen. Harry Reid (D-Nev.) and his colleagues in the U.S. Senate. The American Academy of Family Physicians along with the American College of Physicians, the American Osteopathic Association, the American Medical Student Association, Doctors for America and the National Physicians Alliance signed the letter which reads in part, “We are confident that the reforms being proposed will allow us to provide better quality care to our patients, while preserving patient choice of plan and doctor.”

Two national nonpartisan health care organizations — the AAFP and the Herndon Alliance — developed the online “Heal Health Care Now” initiative in a strategic effort to counter some of the most potent anti-reform arguments with the most trusted spokespersons — front-line family doctors. The AAFP represents more than 94,000 family physicians and medical students. The Herndon Alliance is a nationwide coalition of more than 200 minority, faith, labor, advocacy, business, and health-care provider organizations, including the American Nurses Association, the American Academy of Pediatrics, the AARP, the Mayo Clinic and Families USA.

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Facts About Healthcare Costs - National Coalition on Health Care

NCHC Facts About Healthcare - Health Insurance Costs:

In 2008, total national health expenditures were expected to rise 6.9 percent -- two times the rate of inflation.1 Total spending was $2.4 TRILLION in 2007, or $7900 per person. Total health care spending represented 17 percent of the gross domestic product (GDP).

U.S. health care spending is expected to increase at similar levels for the next decade reaching $4.3 TRILLION in 2017, or 20 percent of GDP.1

In 2008, employer health insurance premiums increased by 5.0 percent – two times the rate of inflation. The annual premium for an employer health plan covering a family of four averaged nearly $12,700. The annual premium for single coverage averaged over $4,700.2


National Health Care Spending

In 2008, health care spending in the United States reached $2.4 trillion, and was projected to reach $3.1 trillion in 2012.1 Health care spending is projected to reach $4.3 trillion by 2016.1
Health care spending is 4.3 times the amount spent on national defense.3

In 2008, the United States will spend 17 percent of its gross domestic product (GDP) on health care. It is projected that the percentage will reach 20 percent by 2017.1

Although nearly 46 million Americans are uninsured, the United States spends more on health care than other industrialized nations, and those countries provide health insurance to all their citizens.3

Health care spending accounted for 10.9 percent of the GDP in Switzerland, 10.7 percent in Germany, 9.7 percent in Canada and 9.5 percent in France, according to the Organization for Economic Cooperation and Development.4

Employer and Employee Health Insurance Costs

Premiums for employer-based health insurance rose by 5.0 percent in 2008. In 2007, small employers saw their premiums, on average, increase 5.5 percent. Firms with less than 24 workers, experienced an increase of 6.8 percent.2

The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $12,700 in 2008. Workers contributed nearly $3,400, or 12 percent more than they did in 2007.2 The annual premiums for family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker ($10,712).

Workers are now paying $1,600 more in premiums annually for family coverage than they did in 1999.2

Since 1999, employment-based health insurance premiums have increased 120 percent, compared to cumulative inflation of 44 percent and cumulative wage growth of 29 percent during the same period.2

Health insurance expenses are the fastest growing cost component for employers. Unless something changes dramatically, health insurance costs will overtake profits by the end of 2008.5

According to the Kaiser Family Foundation and the Health Research and Educational Trust, premiums for employer-sponsored health insurance in the United States have been rising four times faster on average than workers’ earnings since 1999.2

The average employee contribution to company-provided health insurance has increased more than 120 percent since 2000. Average out-of-pocket costs for deductibles, co-payments for medications, and co-insurance for physician and hospital visits rose 115 percent during the same period.6

The percentage of Americans under age 65 whose family-level, out-of-pocket spending for health care, including health insurance, that exceeds $2,000 a year, rose from 37.3 percent in 1996 to 43.1 percent in 2003 – a 16 percent increase.7

The Impact of Rising Health Care Costs

National surveys show that the primary reason people are uninsured is the high cost of health insurance coverage.2

Economists have found that rising health care costs correlate to drops in health insurance coverage.8

A recent study by Harvard University researchers found that the average out-of-pocket medical debt for those who filed for bankruptcy was $12,000. The study noted that 68 percent of those who filed for bankruptcy had health insurance. In addition, the study found that 50 percent of all bankruptcy filings were partly the result of medical expenses.9 Every 30 seconds in the United States someone files for bankruptcy in the aftermath of a serious health problem.

A new survey shows that more than 25 percent said that housing problems resulted from medical debt, including the inability to make rent or mortgage payments and the development of bad credit ratings.10

About 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs. 11

A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses.12

Retiring elderly couples will need $250,000 in savings just to pay for the most basic medical coverage.13 Many experts believe that this figure is conservative and that $300,000 may be a more realistic number.

According to a recent report, the United States has $480 billion in excess spending each year in comparison to Western European nations that have universal health insurance coverage. The costs are mainly associated with excess administrative costs and poorer quality of care.14

The United States spends six times more per capita on the administration of the health care system than its peer Western European nations.14

Acrobat version with references is here.

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Saturday, August 1, 2009

Presentation for Medicare 44th Anniversary

I gave a presentation in Avalon, PA on the occasion of the 44th Anniversary of Medicare, Thusday July 30, for Organizing for America. Thanks to everyone who came and were so kinly receptive to the talk, and of course to Terry, Al, Peter and Sylus for organizing things!

'>The slides are here.

The references in the slides are all on this blog somewhere, just search in the upper left hand corner to find them.

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