"You Can't Always Get What You Want"

Below, a guest post from reader Jim Jaffe, who is the health editor of CenterPolitics.com

he raises a good point: we cannot afford to give everyone every medical service or product that they—or even their doctor—might want. 

At the end of the article, I comment, highlighting where I agree with Jim’s argument, and noting where I disagree.

"You Can't Always Get What You Want"
By Jim Jaffe

The Obama administration wants to guarantee that all Americans can afford the medical care they need.  No one argues with that goal.  Unfortunately, no one agrees on a definition of need either.

Defining what we need is a difficult and delicate chore that won’t be advanced by the rhetorical food fights we enjoy on cable.  That’s what the failed managed care experiment of the l990s was all about.  It was also the basis of the complaint voiced by Harry and Louise when they shared their concerns about Clinton proposals a few years earlier.

Are Private Insurers Really Giving Up Much Ground?

Does Obama Have Enough Votes in the Senate?

Over at Health Care Pollicy and Marketplace Review  Bob Laszewski explains why the insurance industry has made a second concession to health care reform. In November, the industry said it was willing to cover everyone. Now, it has decided that it is willing to move toward charging everyone in a given community the same premium, regardless of pre-existing conditions. (Today if you have employer-based insurance, chances everyone in your company pays the same price for a particular plan, but if you are in the individual market, buying insurance on your own, insurers in most states are allowed to charge you more if you are sick or if you are old.)

Earlier this week, insurers sent a letter to Congress this week offering to phase in “community rating” as long as legislators enact “an effective, enforceable requirement that all Americans assume responsibility to obtain and maintain health insurance. Laszlewski translates: “as long as the federal government mandates that all men, women, and children in America have to be in the risk pool we’ll take the underwriting risk.”

Health, Education and the Welfare of the Nation: Part 2

Building on Success

The correlation between education, poverty and health is so tight that I sometimes think we need to address the three simultaneously. Often this just isn’t feasible. But there are places in our society where the three problems  come together in a way that invites a battle on all three fronts. Consider, for example, our nation’s poorest public schools.

In part 1 of this post, I talked about President Obama’s plan to rebuild our crumbling public education system. While the president’s blueprint defines an excellent beginning for the project,  Richard Kahlenberg, a senior fellow at the Century Foundation, points to one element that is missing: a program that would take poor children out of the ghetto, away from the environment that is undermining both their education and their health..

The notion of plucking children out of their neighborhood may seem elitist. Why not rebuild the schools in their neighborhoods?

The 111th Congress at Work

Nursing Homes, like deteriorating public schools, crumbling bridges and other pieces of our society’s essential infrastructure have been neglected for a long time.  Now, HeatlhBeat reader Gregory Pawelski reports that this year, Congress is finally give nursing homes the attention they badly need.  

“Last year,” he observes, “the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing on nursing homes—for the first time since 1977. One could say that this indicates a rather lackadaisical attitude on the part of Congress in regards to our senior and infirmed population. The last significant change in nursing home regulations was the Nursing Home Reform Act of 1987.”

Following that hearing, the House and Senate introduced the Nursing Home Transparency and Quality of Care Improvement Act of 2008.  But the 110th Congress adjourned before legislators had a chance to consider the legislation.

Health Care in Finland . . . Should We Tax “Gold-Plated” Employer-Based insurance? and More . . .

Check out Health Wonk Review, a round-up of some of the best health posts of the past two weeks.  The current edition is hosted by David Harlow of the Health Care Law Blog http://healthblawg.typepad.com/healthblawg/2009/03/health-wonk-review.html

And he highlights a number of intriguing and provocative blogs that are not widely known-- a measure of how many very good blogs are out there now--along with excellent  posts from favorites.

 

Among the featured posts:

 

On  Living the Scientific Life, “GirlScientist” offers an engaging and eye-opening  description of what it is like to find yourself in an ER in Finland. I hadn’t heard of this blog before, but I definitely recommend it. “GirlScientist” (a molecular biologist who studies evolution in birds) is a good writer, with a reporter’s eye for detail. I think you’ll enjoy her post.

 

Over at GoozNews, the always excellent Merrill Goozner suggests that we need an  Annals of Negative Results---- more news about drugs that failed in clinical trials, so that other researchers can learn from the failures. 

 

At Health Access Weblog Beth Capell questions the idea of taxing “gold-plated” health benefits that employees receive from their employers. She points out that the most valuable benefits tend to

offer insurance plans with relatively low-deductibles and co-pays—in other words, insurance plans that employees can actually afford to use. Do we really want to discourage employers from offering good insurance by taxing their employees’ “gold-plated” benefits ?

 

 Probably not. I would prefer taxing employer-based health benefits based, not on the value of the benefits, but on the employee’s income.  If a median-income family earning $55,000 is lucky enough to have good health benefits, I wouldn’t want to tax them, not in this recession.

 

 On the other hand, if a family earning $175,000 receives benefits worth $14,000—and if, like 15 percent of all “better paid workers” in the U.S.--  the employee pays nothing toward the premium ( while the employer lays out the full $14,0000)  it seems fair to tax the $14,000 as part of the employees’ total compensation.  The taxes paid could be used to subsidize healthcare for workers whose employers do not offer health insurance.

 

At BNET Healthcare David Hamilton throws a spotlight on Massachusetts, where many patients are finding it very difficult to make an appointment with a primary care doctor. Ironically, this is in part because the state’s heroic effort to provide universal access has sent more patients into the marketplace, looking for care. Meanwhile, the number of medical students training for primary care has been shrinking nation-wide, and thanks to low pay and poor working conditions, primary care physicians have been retiring early.

 

Hamilton points out that the Obama administration is doing what it can, “rushing out new federal funds to rescue Medicaid programs and public clinics across the U.S.”

 

Finally, at the Disease Management Care Blog Jaan Sidorov points to the high cost of out-patient care—all of those one-day surgeries that may not be necessary. . .     

To find these outstanding posts, and others, go to http://healthblawg.typepad.com/healthblawg/2009/03/health-wonk-review.html

Why Obama Should Stand Firm on a Public-Section Insurance Option Part 2

( * Please note parts 1 and 2 of this piece were posted simultaneously. This is part 2-- part 1, which you really should read first-- is right below)

Conservatives often argue that it just isn’t fair to force private health insurers to compete against a government plan because . . .

Well, to be perfectly candid, they know that most for-profit insurers would lose. They don’t put it that way, of course. They argue that the government plan would enjoy “unfair advantages.” It wouldn’t’ have to pay profits to shareholders, for instance, and it wouldn’t have to pay seven-figure salaries to its secretaries. It also wouldn’t have lay out hundreds of millions to advertise –or to lobby Congress.

But have the private insurers’ apologists considered the possibility that private insurers pay their executives too much? Maybe you don’t have to ante up $11 million to attract a good man. (I know you can get a good woman for less.) Perhaps for-profit insurers squander money on needlessly lavish advertising. Maybe these companies shouldn’t be spending quite so much trying to grease the palms of our elected officials.

Why Obama Should Stand Firm on a Public-Sector Insurance Option Part I

Many Republicans in Congress are dead-set against including public sector health insurance--some call it “Medicare for All”-- as a choice under National Health Reform.

The resistance is so strong that this could be the deal-breaker that prevents President Obama from gathering the Senate votes he needs to pass his plan for universal coverage this year. Nevertheless, if we want to provide sustainable, affordable, safe and effective healthcare for all, many say that the public sector option is essential. At the recent Healthcare Summit, President Obama put it this way: “The thinking on the public option has been that it gives consumers more choices and it helps keep the private sector honest, because there's some competition out there.” I agree.

Tuesday, the Institute for America’s Future released a report that makes that argument by taking a close look at what happened in Massachusetts. (You’ll find the brief on the Campaign for America’s Future website . In the past I have suggested that Massachusetts’ health care plan would serve as the canary in the coal mine for healthcare reform. These days, the canary isn’t singing a happy tune.

A Guest Post: What the Doctor Ordered

This post was written by Pat S,  a recently retired physician who practiced in the Midwest for 30 years.  He has worked for both private practices and for large multispecialty groups, spending about half of his career in each setting.

Doctors play a critical role in any potential health care reform.  Although they have very little impact on attempts to broaden access to health care, they are central to efforts to improve the lagging quality of US health care and to address the issue of the cost of medical care in the 21st century.

Our national health care bill now runs over $2.5 trillion a year, consuming 17% of GDP. The cost of health care threatens to overwhelm the economy, and ultimately, as President Obama has noted, undermine any economic recovery. Unless we change the way we practice medicine, the adoption of new policies to improve health care access through universal insurance and improve benefits in both private and public programs will make our financial problem even worse, since greater access will lead to increased spending as new people enter the market for medical services.

If we imagine a long train of carloads of cash from both government and private sources entering the healthcare market, it is doctors who have their hand on the throttle.  Most medical spending occurs because of orders written by doctors: tests ordered by doctors, hospital admissions carried out by doctors, procedures recommended and performed by doctors, and drugs and other treatments prescribed by doctors.  When it comes reducing health care costs and improving the health of most Americans, doctors have greater power than anyone.

A New Team at the FDA -- Sharfstein's Critics

Over the week-end, when I heard that President Obama had selected Margaret  Hamburg as FDA commissioner and Joshua Sharfstein as deputy commissioner, I began Googling “Sharfstein.”  I already had read about Hamburg and I knew the former New York City health commissioner has earned very high marks. 

But I didn’t know much about Sharfstein. So my heart sank when I read this in the “Comment” section of yesterday’s Guardian: “Although Dr Margaret Hamburg, the nominee for commissioner, boasts significant experience in government and is highly thought of in the public health community, her new deputy, Dr. Joshua Sharfstein, is an inconceivably poor choice.”

Reportedly, Sharfstein is going to be the point man regulating drugs and devices. Meanwhile Hamburg  will ovesee food safety and tobacco—if the agency wins some control over the substance. (According to the Wall Street Journal, a bill that puts tobacco under FDA regulation seems poised for passage next session).  Given how the FDA’s work will be divided, Sharfstein’s appointment becomes extremely important. Indeed,  the “Comment” in the Guardian notes: “from the vantage point of industry and patients, this would make Sharfstein a far more influential figure than his nominal boss – but without requiring confirmation by the Senate.” Here they seem to be implying that the Obama administration is trying to slip a weak candidate past the Senate.

But then the article’s authors, Jeff Stier and Henry Miller set out to explain why they object to Sharfstein. And at this point, I begin to smile.They portray Pharma as an industry that has been bullied, by the government and the press: “The new FDA leadership must  confront a trend that has become popular – especially among members of Congress and the media – of vilifying drug companies, and even alleging that regulators have become too cosy with industry.”  Imagine that.

Health, Education and the Welfare of the Nation

We know that health, education and poverty are linked. This is why, at one time, the U.S had a Secretary of Health, Education and Welfare. Restoring that cabinet post might go a long way toward inspiring discussion about how to approach all three simultaneously. By viewing them as separate problems, we “see” only one part of the elephant. With that in mind, I have decided that, from time to time, HealthBeat should look at ideas for educational reform.

The facts about the connection between education and health are grim. A year ago the Congressional Budget Office (CBO) issued a report titled “Growing Disparities in Life Expectancy” which revealed that “the gap in life expectancy at age 25 between individuals with a high school education or less and individuals with any college education increased by about 30 percent” from 1990 to 2000. The gap widened because of increases in life expectancy for the better educated group,” the report notes. “Life expectancy for those with less education did not increase over that period.”

People with less education also are m ore likely to suffer from the disease many of us dread most, the scourge we call “Alzheimer’s.” A 2008 study published in the medical journal Neurology  reveals those with at least 15 year of education have a “cognitive reserve” of extra neural connections, which allows their brain to handle more plaques and tangles without showing Alzheimer symptoms. Conversely, according to a 2007 study from Finland, “people who don't finish high school are at a higher risk of developing dementia and Alzheimer's disease compared to people with more education regardless of lifestyle choices and [other] characteristics.”