Quote of the Week: Do You Agree or Disagree?

From a review of The Truth About Health Care, by David Mechanic. The review is written by Rob Cunningham and appears in Health Affairs, September/October 2007.

“At some point we as a nation will have to decide whether we wish to design our health care system primarily to satisfy those who profit form it or to protect the health and welfare of all Americans.” Mechanic speculates that “anything is possible if the public begins to appreciate how little it gets for what it really pays.” But even as reform begins to rise again on the political agenda, the preponderance of the evidence in this book says that a majority of American prefer pluralism and individual liberty to the tedious business of working together . . .”

IF YOU’D LIKE TO COMMENT ON THIS POST, PLEASE CLICK HERE TO E-MAIL MAGGIE WITH YOUR THOUGHTS.

Thoughts on SCHIP

For a discussion of SCHIP,  and how easy it is for children to be dropped from the rolls, see my blog on The Guardian here.

Clinton and Edwards Open a Back Door

For a discussion of Clinton’s and Edwards’ health care plans, see my post on The Health Care Blog here.

Comment on Class and Health

(To see the original post on Class and health, click here.  To add your comment, scroll down and click on “Contact” on the left-hand side of the page.)

From Alan Abrams (a.k.a. Alan_A at the hpscleansing.com/group community forums)

I just read Maggie Mahar's health blog after linking to it from an agonist.org blog on universal health care. I then read Maggie Mahar's blog [post] on "Class and Health."  thus this quote:

"And yet, and yet . . . Schroeder sees reason for "cautious optimism." Although we trail behind other countries, we are healthier than we once were. We have reduced smoking ratse, homicide rates and motor-vehicle accidents. Vaccines and cardiovascular drugs have improved medical care. But progress in other areas will require "political action," Schroeder declares, "starting with relentless measurement of and focus on actual health status and the actions that could improve it. Inaction means acceptance of America's poor health status."

Healthier than we once were? Really?  Are…smoking, homicide rates, and motor-vehicle accidents adequate measures of the overall improving general health of Americans?

What about these:

• 58 Million Overweight; 40 Million Obese; 3 Million morbidly Obese
• Eight out of 10 over 25's Overweight
• 78% of American's not meeting basic activity level recommendations
• 25% completely Sedentary
• 76% increase in Type II diabetes in adults 30-40 yrs old since 1990

Comment on Class and Health

(To see the original post on Class and health, click here.  To add your comment, scroll down and click on “Contact” on the left-hand side of the page.)

Maggie,

A couple of thoughts on this.

First, Americans who work in physically demanding and/or dangerous jobs such as coal mining, steel manufacturing, auto manufacturing, etc. do not live as long, on average, as the population overall despite comparatively good wages and benefits.  I don't think countries like Iceland and Switzerland have nearly as many people relative to their populations working in these jobs as the U.S. does.  Japanese people in the U.S. also live longer than most people.  I suspect that it's due to a combination of diet and genetics. However, as they are here longer and adopt a more westernized lifestyle and diet, they probably don't live as long as Japanese people in Japan with comparable socioeconomic status do.

Second, regarding social inequality, I think our system, does, to a large extent, reflect our more entrepreneurial culture.  While reasonable people can differ about how much taxes should be raised on higher income people to both reduce inequality and raise money for worthwhile public priorities, I think it is important to remember that there could also be economic costs. In Western Europe and Canada, the total tax burden on middle and upper income people generally exceeds 50% of gross income.  It's expensive to sustain a welfare state with a generous social safety net.  I think, at the end of the day, those countries, which embraced socialism decades ago, are trading less inequality and more economic security for less economic growth and less opportunity, especially for its younger people. 

Class and Health

When compared to other developed countries, the U.S. ranks near the bottom on most standard measures of health. Many people assume that this is because the U.S. is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland. But while it is true that within the U.S. there are enormous disparities by race and ethnic group, even when comparisons are limited to white Americans our performance is “dismal” observes Dr. Steven Schroeder in a lecture  published in the New England Journal of Medicine yesterday.

Why? It’s not the lack of universal access to healthcare" says Schroeder, though that’s important. And it’s not just that we don’t exercise enough and eat too much—though that is a major cause. But there is one factor undermining the nation’s health that we just don’t like to talk about in polite society: Class. When it comes to health, class matters.

Schroeder, who is the Distinguished Professor of Health and Health Care at the University of California San Francisco (UCSF) underlines how poorly even white Americans stack up when compared to the citizens of other countries by pointing to maternal mortality as one measure of health. When you look at “all races” you find that in the U.S. 9.9 out of 100,000 women die during childbirth.  Focus solely on white women, and the number is still high—7.2 deaths out of 100,000 –especially when compared to Switzerland where only 1.4 women out of 100,000 die while giving birth.

Statistics on infant mortality reveal the same pattern: among “all races” 6.8 American children who were born alive die during infancy; limit the analysis to “whites only” and 5.7 infants die—compared to just 2.7 out of 1,000 in Iceland. .) When researchers compare maternal mortality and infant mortality in white America to rates of death in the 29 other OECD countries, white America ranks close to the bottom third in both categories.

Turn to life expectancy, and you find that white women in the U.S. can expect to live 80.5 years, only slightly longer than American women of all races (who average 80.1 years). Both groups lag far behind Japanese women (who, on average, clock 85.3 years). The gap between “all American men” (who live an average of 74.8  years) and white men in the U.S. (75.3 years) is wider—but not as wide as the gap between white men in the U.S. and men in Iceland (who live an average of 79.7 years).

“How can this be?” asks Schroeder. After all, as everyone knows, the U.S. spends far more on health care than any other nation in the world.

The answer is a stunner: the path “to better health does not generally depend on better health care,” says Schroeder. “Health is influenced by factors in five domains — genetics, social circumstances, environmental exposures, behavioral patterns, and health care. When it comes to reducing early deaths, medical care has a relatively minor role. Even if the entire U.S. population had access to excellent medical care — which it does not — only a small fraction of premature  deaths could be prevented.” [my emphasis]

A Healthcare System That Works

Medscape offers a window on one U.S. healthcare system that is working. It’s worth clicking here: http://www.medscape.com/viewarticle/503922?src=mp (free registration/log-in required) to find out more.

I should add that I have had very similar experiences with the same system. Why does it work better than most U.S.healthcare?

If you would like to comment, scroll down and click on “contact” (right under “Google search”) on the left-hand side of the page.

My response to Barry Carol’s comment on “If We Mandate Insurance Should Twenty-Somethings Pay Less?”

(To read my original post on whether 20-somethings should pay less, scroll down to Archives on the left-hand side of the page and click on “September 2007.” You will find my post about three-quarters of the way down the page)

Barry—

First, let me say that if we mandate insurance I very much doubt that it will cost $12,000 for a family of four. That number includes a private insurer’s profits and administrative costs (which can eat up as much as 20 percent of premiums) as well as a lot of waste in the form of redundant and unnecessary tests, over-priced drugs and devices and unproven treatments.  Politicians who talk about requiring everyone to buy insurance almost always stress that we have to rein in health care spending by refusing to pay exorbitant prices for drugs and devices (manufacturers need to give us the discounts that they give patients in other countries), and by rewarding efficient care—while penalizing providers who are less efficient. (For example, if a hospital has a very high rate of infections, the insurer might refuse to pay the cost of the extra treatment needed to treat the infection, forcing the hospital to absorb the cost. If this happened to often, the hospital administration would have to step down.)

Secondly, if we do mandate insurance, large employers would be required to continue to contribute as they do now, either by providing insurance for their employees or by contributing to a large fund to finance subsidies. So they would be paying a large chunk of the premiums for a family of four. In addition, any plan that calls for mandates also calls for subsidies for those who cannot afford to pay the full premium. For example, a median-income family earning $50,000 a year, before taxes, cannot afford to pay $8,000 a year for health insurance. That family would need a subsidy.

My Response to Barbara Rodin’s comment

(To see my original post on cutting back on healthcare spending, scroll down and click on “September 2007”under “Archives” on the left-hand side of the page. You will find my September 12 post a little more than halfway down the page.)

Barbara—

In some cases, patients can and should actively share in decision as to what kind of care they need. For instance, in the case of elective surgery like a knee implant,  the surgeon and  the patients should discuss the risks and benefits. How long will it take to convalesce? How much pain will the patient experience after surgery?  What can he or she expect in terms of improved function?
Is physical therapy an alternative to sugery? I’ll be writing more about “shared decision-making” for elective surgery in the future.

On the other hand, when it comes to picking a particular knee implant, this is a decision that you want your surgeon to make. Research shows that you are most likely to be satisfied with the outcome if your surgeon uses a device that he has used many times  in the past. Practice makes perfect.

Moreover, too often consumers are influenced by misleading advertising. See my post on “Bespoke Knees” below.  Often drug-makers and device-makers advertise a product “directly to the consumer” because they know they would have a hard time persuading physicians of their claims. They just don’t have the medical evidence to back up what they’re saying.

Bespoke Knees

Bloomberg recently announced that the Food & Drug Administration has bestowed its blessing on a new “gender-specific” knee implant. Manufactured by Smith & Nephew, the new knee is designed to fit the “unique anatomy” of a female. This is not the first knee- for- women-only. Last year the FDA approved a similar knee made by Zimmer Holdings, the company that takes credit for what it describes as a “bespoke knee” for women.

Will the new devices allow women to function better? "In theory, yes, but the evidence isn't there," Kimberly Templeton, an associate professor of orthopedic surgery at the University of Kansas Medical Center and a spokesperson for the American Academy of Orthopaedic Surgeons told U.S. New & World Report. Sheryl Conley, Zimmer's chief marketing officer explained seven studies now underway will look at patient satisfaction and range of motion. Preliminary data will be available in a year or so.

In the meantime, these couture knees for women are fetching twice as much as the plain-vanilla knees that, until recently, were used for both men and women. But this is not the FDA’s concern.