Obama on health care: With an eye and an ear to history; with heart to those who hurt

August 16, 2009

Did you catch Obama’s op-ed in the New York Times yesterday?

OUR nation is now engaged in a great debate about the future of health care in America.

Of what famous speech does that line remind you?

Obama is looking to past presidents’ efforts to push legislation, too — learning from the failures and hoping not to repeat (think Wilson and the campaign to ratify the Treaty of Versailles), learning from successes and hoping to expand (think of Lyndon Johnson and the creation of grants to college students).

Mostly, Obama’s hoping to give a boost to health care reform efforts slowed by the vicious, false rumor campaign against it.

See what Obama himself wrote, below the fold.

Read the rest of this entry »

Republican death trip

August 14, 2009

Senate Finance Committee members said yesterday they would strip out of the health care discussion any mention of helping older Americans or others with terminal diseases make adequate plans with, for example, durable powers of attorney and living wills.

Newt Gingrich and others on the wackaloon right have made the topic toxic, despite it’s having been urged by Republicans, to ensure privacy and individual rights near the end of death.

And so, also, we bid farewell to morality, reason and backbone among Republicans nationally.

Two pieces you should read:

  1. “Republican Death Trip,” Paul Krugman’s column today in the the New York Times
  2. “Sarah Palin’s death panels,” at former Labor Sec. Robert Reich’s blog

Refusing to be shouted down, on rants against health care reform

August 13, 2009

People who just know they’re right, damn the facts, irritate me; I’m allergic to unnecessary bull excrement.

Here, at The Elephant’s Child, I scratched the itch a bit.

The post from Elephant’s Child is answered, ad seriatum.  (I wrote this on the fly, and I may have missed a statistic here or there; if I find errors, I’ll correct ’em.)  EC’s responses are indented:

Remember that this thread starts out with your savaging a program to support child abuse prevention programs.

We will have to agree to disagree. The federal government runs the Indian Health Service which is a disgrace and a tragedy.

Private health care on the Navajo, Hopi, Pine Ridge and other major reservations is [essentially] non-existent. Yes, the IHS is inadequate by any rational standards. It’s also underfunded, and a key problem is that many enrolled members of tribes lack other health insurance.

The federal program may be a wreck, but it’s 1000% better than the private alternative, which in that case is nothing at all.

And this is what I fear: Without government intervention, Indians are left to die from easily preventable and easily treatable diseases. Without government intervention, 50 million other Americans are left to die from easily preventable and easily treatable diseases, and 150 million more have limited access.

For reasons I cannot fathom, you favor letting the people die rather than fixing things. Surely you’re not making that decision on the basis of any rational system of rationing, are you? I don’t think the poor and unemployed “deserve to die.” Talk about death panels!

They run Medicare, which is going broke from waste, fraud and abuse.

Absolutely false. Medicare has problems from rapid inflation by the private sector and other causes. But it is NOT “going broke from waste, fraud and abuse” by any measure. Compared to private health care, Medicare is purer than distilled water.

They run Medicaid, ditto.

Ditto. Medicaid has problems from overuse because too many people lack private insurance. Waste, fraud and abuse are significantly reduced from private systems.

Which leads me to wonder why you favor a system that is going broke from inflation, waste, fraud and abuse. The denialism runs strong in you.
(No — it’s going broke mainly from uncontrolled inflation — but if you can make wild unsubstantianted charges, I can at least point out that your favored position is worse.)

And they run the VA, which has some bright spots and poor care in general, at least according to vets.

And what does the private insurance system do for vets? Any injury due to war is excluded from coverage.

Again, you choose no coverage over some coverage. Whose side are you on? Not the vets’ side, it appears.

Our current health care system is the best in the world. We have better outcomes for the major diseases, and most people are satisfied with their health insurance and happy with their care.

Except for heart and lung disease, where Canada, France and England lay it all over us, on an epidemiological basis. Their systems do a lot fewer major procedures because there is much less heart disease, and problems are discovered earlier and treated much more effectively and cheaply.

Yes, the U.S. does a lot more heart transplants, easily by double. The problem is we have nearly quadruple the need for heart transplants. Heart disease is often preventable, almost always treatable, well before heart transplant time. It’s cheaper and better for the patient if we treat heart disease before it progresses to cripple the victim.

Yeah, we do more transplants. The tragedy you don’t name is that we need to do them.

We pay more for it in general because we can afford it.

Have you discussed this with small businesses? We can’t “afford” to pay double what every body else pays. These incredible expenses broke Chrysler and General Motors. The cost keeps small businesses from creating plans for employees.

Worse, that $6,000 per capita includes spending for the 50 million people excluded from easy access. We pay double for services, and we pay for a lot that we don’t get. Talk about waste!

Our system spends nearly 25% of every “health care” dollar in insurance administration, mostly designed to keep the minority of uninsured from getting care at all.

Don’t tell me we should spend hundreds of billions of dollars to bar the doctors’ offices doors, and then claim any system is more wasteful. There is no more wasteful system possible, and it’s a moral imperative that we fix it.

We pay double because the system is broken. We can’t afford it.

Medical care has been transformed in recent years with CT scans, MRIs and all sorts of new drugs and treatments that have saved and extended life. That’s expensive, but worth it.

Mostly unavailable to about half of Americans. Insurance plans pay for surgery that costs six to eight times a CAT scan, because it doesn’t like “expensive technology” without justification. If a CAT scan discovers no problem requiring surgery, insurance won’t pay. “Doctor error.” So doctors don’t use the technology as it could best be used.

But when that heart disease that could have been prevented ends up in the surgery theatre, Katy bar the doors on expenses!

The health care bill before Congress is estimated by the CBO to cost $1.2 trillion over the next ten years, and another trillion over the 2nd decade. Health care costs will increase by 8% a year while revenues increase at only 5%.

Without it, health care costs will continue to rise at nearly twice that rate, 15% annually.

Don’t look now, but the lousy bill you don’t like is better than the catastrophe you’re defending.

Yes, I did read the bill. Medicare was estimated by the CBO to cost $12 billion by 1990. By 1990, it cost $110 billion.

Why? Do you know?

Medicare was expanded because it worked so well. Plus, it turns out there was a much greater need than anyone had projected.

In 1994, health care inflation was estimated to run about 8% annually if the Clinton plan didn’t get passed. Instead it ran closer to 16%.

The problem you cite is doubled in private insurance. Don’t tell me you don’t like waste and then propose to double the waste.

Waste is waste whether it’s government-run or private business run, and it hammers costs either way. Greater waste hammers us more greatly.

Government-run health care will cost vastly more than private insurance ever cost.

That’s not so for programs in either Medicaid or Medicare, compared to comparable coverage offered by private companies. The record, in every other nation AND in the U.S., is that government-run systems are cheaper. Especially where government simply takes over the payment, and not the delivery (leaving private health care providers as private health care providers), government systems are vastly less expensive.

This is why the insurance companies started to squawk about how unfair it would be for the government to compete against them. Competition is the key to an effective free-enterprise system — we need to inject some into health care now.

Doctors will leave the profession — Some doctors have estimated that 20% of doctors will retire early.

Compared to the estimates of 30% of doctors are retiring early now, right? We’ve had a physician shortage for 40 years. Here in Texas nearly 20% of our counties have no physicians at all. There is a reauthorization for a 40-year-old program to encourage medical students to graduate and serve these populations — you called it “socialism.”

Or you didn’t know it was in the bill.

Either way, the sensible solution would be to pass the bill and get more doctors for less money to serve the underserved areas, thereby reducing the incredible expenses of health care and even greater expenses of delivering no health care to millions of Americans.

There is nothing whatsoever in the house bill that will reduce costs.

The single most important cost-saving step is to cover people who lack insurance. No program can reduce costs at all without that. That’s a key target in the bill.

The cheapest health care system is the one that delivers care appropriately, on a timely basis. We spend an inordinate amount of money in the last 6 months of patients’ lives — 50% by some estimates — because they lacked good health care that would have kept them more sentient and more ambulatory until death.

The most important thing we can do is move health care delivery from the old to the younger, from the hospital emergency room to the doctor’s office. We can only improve that if everyone has access to a doctor on a timely basis, for the delivery of simply preventive programs, for the delivery of early treatment of disease.

Government health care has failed in Massachusetts, failed in Hawaii, failed in Tennessee, failed in Oregon, and failed in Maine.
To cut costs, which the government will have to do, they will have no choice but to ration.

We ration health care now by cutting out one out of every seven people for no care at all (though we pay for it — they just don’t get it; the money goes to “insurance company administration” instead of health care delivery). We ration health care now by denying technology to most Americans. That rationing saves no money for the nation — it seems to double the cost.

In contrast, Medicare patients, in the biggest government-run program, are the single least-rationed group.

There will be rationing until we equalize access, which will require more doctors, more clinics, more nurses, less emergency room use and more doctor’s office visits. But that rationing now is draconian and cruel, based chiefly on whether one works for a company with a health plan or not.

That’s unfair and cruel. Worse, it multiplies the costs for everybody. (An enormous part of hospital charges to private insurance-covered people is to provide the pool of money for indigent care.) Multiplies, not “adds to.”

Non-fraudulent waste may be many times fraudulent waste. We need to stop it.

The first step is to cover everybody.

Both presidential health care advisers Ezekiel Emanuel MD, and Peter Orzag, his budget director,have pointed out extensively the high costs of end-of-life care and the need to cut back on those expenses.

Under the present system, yes. Emanuel’s paper in January talked about the rationing decisions made now, how unfair they are, and how they increase pain and suffering.

Damn straight we need to reduce those costs — to increase delivery of health care.

Don’t defend private rationing by pretending it doesn’t exist, or by pretending it’s more fair, when no study shows it is fair or cheap.

Pain pills for the older folks instead of hip replacements or motorized wheel chairs.

That’s what happens today, yes. Unless, of course, they’re on Medicare, the government run program. That’s why the advertising for carts for the immobile notes that the companies selling the carts will take care of Medicare paperwork.

God help you if you’re not on Medicare. Private insurance won’t.

All government-run health care programs ration care. Which they do because they will not do the things that would actually reduce the cost of health care, like tort reform, increasing free market competition, offer insurance across state lines, and offer medical savings accounts, high deductible policies.

Hold on — Medicare and Medicaid allow free market competition, offer insurance nationally (in contrast to private plans), and allow medical savings accounts (though that’s not a viable solution for the poor, unemployed, students and retired people).

Tort costs about 1% of health care — and to my view, it works well. I don’t think swimming pool companies should be able to suck the bowels out of children without paying for it.

We do have a tort problem with OB-GYN, but it is largely caused by the insurance companies’ refusal to defend good doctors. That’s not a tort reform issue.

You cite problems that exist now, problems that are subject to attack by H.R. 3200. We’re not going to get anything at all if yammering yahoos don’t stop fighting against all change.

Doing nothing is cruel and costly. If you want to make a case for adding something to H.R. 3200, make the case.

Defense of current incredible waste is not a rational, moral option.

All health care systems ration health care. Our system rations health care on income and geography, and age. Higher incomes, big-company-employed, urban locations, and higher ages get the care.

Is that smart? It’s not cheap.

I don’t think These all are proven to save costs, but the trial lawyers are second only to the Unions as financial support for Democrats.

Those figures aren’t accurate, or they demonstrate that political giving doesn’t have much effect.

Tort cases take up the slack where government regulation ends. Should we allow McDonald’s to keep burning old ladies almost to death? (I thought you were for reducing costs, no?) Unless you will allow the Ministry of Coffee Temperature to regulate every fast-food drive through, tort cases are real money savers in the long run. (It cost less than $2.00 to fix the Pinto’s gas tank so it wouldn’t explode on impact. How many lives should we have sacrificed instead? I thought you were for reducing pain and suffering.)

I know no Republican or Conservative who does not observe that Liberals want to guarantee equality of outcome.

But none of them can show anyone who actually proposes to do it, not since Lenin abandoned the idea in 1920. I know no Democrat or Liberal or Republican or Conservative who urges equality of outcome. I’ll wager you can’t name major players who do, if you can name anyone at all.

That’s the problem with a lot of Republicans and conservatives — they’re not even tilting at windmills, they’re tilting at wind. We need action to make things better.

You propose we stick with the most wasteful and inefficient health care program in the industrialized world, one guaranteed to bankrupt the nation, or collapse soon.

Better you should tilt at windmills.

It’s obvious in their legislation. All kids get vaccinated, they are required to be vaccinated before they can enter kindergarten, and help is available if they cannot afford it. Silly claim.

All kids getting vaccinated (religious exceptions honored), is a great idea, a high ideal, compassionate, money-saving and wise.

My brother had polio, and the complications killed him early. I’m partially deaf from measles, or maybe scarlet fever. I don’t think vaccinations are bad things at all. Back when we lost 1 out of 3 babies before their second birthdays to infectious disease, the nation was not better off.

Universal health coverage keeps a population healthy, learning and working. You don’t like it? Take a look at any nation where disease is rampant — like malaria in Uganda. The lack of simple preventive measures tends to cripple a nation’s economy and destabilize its government.

That’s not good.

I would challenge most of your claims, but there is no point. According to what I know to be true, you are vastly misinformed, but you probably think that of me. I simply do not have time to carry on pointless discussions.

Who was it who observed, it’s not what we don’t know, it’s what we know that isn’t true that gets us into trouble?


Don’t you be shouted down, either;  Share the facts, with the system of your choice:

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Republicans screw up again: “Death panels” amendment was a Republican’s doing — and there’s a logical explanation

August 13, 2009

Protesters like to complain that advocates don’t know what is in the health care bill, but day by day it becomes more and more obvious that it is the critics who don’t know what the bill proposes, or why.

Washington Post policy blogger Ezra Klein tracked down who put the “death panels” clause into health care reform bills being debated by the U.S. Senate.  (Yes, this demonstrates the value of the daily press, how they more thoroughly and accurately get the story than most bloggers do, or can. )

Turns out that it was a very conservative, Republican legislator from Georgia who put the amendment in the bill, for good and noble purposes.

So, all the sturm und drang about “death panels?”  It demonstrates that opponents of the bill don’t care what it actually does, or how beneficial it may be.  Like Napoleon at Waterloo, they think that they must win this fight at all costs, even if it brings down the nation.

Klein’s interview with Isaakson is below, in its entirety.

Is the Government Going to Euthanize your Grandmother? An Interview With Sen. Johnny Isakson.

I’ve seen the pain and suffering in families with a loved one with a traumatic brain injury or a crippling degenerative disease become incapacitated and be kept alive under very difficult circumstances when if they’d have had the chance to make the decision themself they’d have given another directive and I’ve seen the damage financially that’s been done to families and if there’s a way to prevent that by you giving advance directives it’s both for the sanity of the family and what savings the family has it’s the right decision, certainly more than turning it to the government or a trial lawyer.


U.S. Sen. Johnny Isaakson, R-Georgia - photo from Isaakson's office

Sarah Palin’s belief that the House health-care reform bill would create “death panels” might be particularly extreme, but she’s hardly the only person to wildly misunderstand the section of the bill ordering Medicare to cover voluntary end-of-life counseling sessions between doctors and their patients.

One of the foremost advocates of expanding Medicare end-of-life planning coverage is Johnny Isakson, a Republican Senator from Georgia. He co-sponsored 2007’s Medicare End-of-Life Planning Act and proposed an amendment similar to the House bill’s Section 1233 during the Senate HELP Committee’s mark-up of its health care bill. I reached Sen. Isakson at his office this afternoon. He was befuddled that this had become a question of euthanasia, termed Palin’s interpretation “nuts,” and emphasized that all 50 states currently have some legislation allowing end-of-life directives. A transcript of our conversation follows.

Is this bill going to euthanize my grandmother? What are we talking about here?

In the health-care debate mark-up, one of the things I talked about was that the most money spent on anyone is spent usually in the last 60 days of life and that’s because an individual is not in a capacity to make decisions for themselves. So rather than getting into a situation where the government makes those decisions, if everyone had an end-of-life directive or what we call in Georgia “durable power of attorney,” you could instruct at a time of sound mind and body what you want to happen in an event where you were in difficult circumstances where you’re unable to make those decisions.

This has been an issue for 35 years. All 50 states now have either durable powers of attorney or end-of-life directives and it’s to protect children or a spouse from being put into a situation where they have to make a terrible decision as well as physicians from being put into a position where they have to practice defensive medicine because of the trial lawyers. It’s just better for an individual to be able to clearly delineate what they want done in various sets of circumstances at the end of their life.

How did this become a question of euthanasia?

I have no idea. I understand — and you have to check this out — I just had a phone call where someone said Sarah Palin’s web site had talked about the House bill having death panels on it where people would be euthanized. How someone could take an end of life directive or a living will as that is nuts. You’re putting the authority in the individual rather than the government. I don’t know how that got so mixed up.

You’re saying that this is not a question of government. It’s for individuals.

It empowers you to be able to make decisions at a difficult time rather than having the government making them for you.

The policy here as I understand it is that Medicare would cover a counseling session with your doctor on end-of-life options.

Correct. And it’s a voluntary deal.

It seems to me we’re having trouble conducting an adult conversation about death. We pay a lot of money not to face these questions. We prefer to experience the health-care system as something that just saves you, and if it doesn’t, something has gone wrong.

Over the last three-and-a-half decades, this legislation has been passed state-by-state, in part because of the tort issue and in part because of many other things. It’s important for an individual to make those determinations while they’re of sound mind and body rather than no one making those decisions at all. But this discussion has been going on for three decades.

And the only change we’d see is that individuals would have a counseling session with their doctor?

Uh-huh. When they become eligible for Medicare.

Are there other costs? Parts of it I’m missing?

No. The problem you got is that there’s so much swirling around about health care and people are taking bits and pieces out of this. This was thoroughly debated in the Senate committee. It’s voluntary. Every state in America has an end of life directive or durable power of attorney provision. For the peace of mind of your children and your spouse as well as the comfort of knowing the government won’t make these decisions, it’s a very popular thing. Just not everybody’s aware of it.

What got you interested in this subject?

I’ve seen the pain and suffering in families with a loved one with a traumatic brain injury or a crippling degenerative disease become incapacitated and be kept alive under very difficult circumstances when if they’d have had the chance to make the decision themself they’d have given another directive and I’ve seen the damage financially that’s been done to families and if there’s a way to prevent that by you giving advance directives it’s both for the sanity of the family and what savings the family has it’s the right decision, certainly more than turning it to the government or a trial lawyer.

Update, August 14: Time’s Swampland blog notes that the the Republicans passed exactly the same language in a bill signed into law by George W. Bush in 2003, the Medicare prescription drug bill — except that bill limited application only to the terminally ill.  That provision worked well in protecting the rights of patients in end-of-life scenarios, so it was determined to expand the plan.  42 Republican Senators voted for it then.

I’m sorry, did you say something?  I’m having difficulty hearing you with all these hypocrickets chirping away.

Share the facts:

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Palin proposes “death panels”

August 11, 2009

Isn’t that a fair headline?

She must be proposing them — they don’t show up in the health care bill before Congress.

Update: Over at Le-gal Ins-ur-rec-tion, Cornell Law prof William A. Jacobson dug out an article by Rahm Emanuel’s brother Ezekial, a respected bioethicist at the National Institutes of Health, and suggests strongly that Palin is just contributing to the the debate.  In the paper (at Lancet, subscription required, but access to this paper is free because it’s so important), Dr. Emanuel and others discuss how to allocate health care resources to provide the greatest healing among many competing, worthy patients, when resources cannot be allocated to all of the worthy patients.  Jacobson said:

Put together the concepts of prognosis and age, and Dr. Emanuel’s proposal reasonably could be construed as advocating the withholding of some level of medical treatment (probably not basic care, but likely expensive advanced care) to a baby born with Down Syndrome. You may not like this implication, but it is Dr. Emanuel’s implication not Palin’s.

Jacobson misses the greater point here, the part the sticks in the craw of those of us who have lived with these issues for 20 years, or 30 or 40:  Dr. Emanuel’s paper discusses how to improve the current system of allocation of resources.

We aren’t debating whether to have “death panels.”  The discussion is on how to make them work more equitably, and how to expand health care resources to make the need for such decisions less frequent. Palin’s point is to defend unfair death panels used often.  She doesn’t know that, and Jacobson should realize that and not defend it.

Here’s the summary at Lancet:

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

He’s working to make the death panels more fair, more accurate, more beneficial.  Palin suggests we should leave the current system in place where Palin’s death panels, though working hard, often are unfair and inaccurate, and waste resources.

In the present system, resources generally are allocated first on the basis of who has money.  De facto, the system writes off to death anyone with a serious disease who is poor.  “Poor” in this case doesn’t mean destitute.  An annual income of $60,000 would put one into the category of “poor” I’m talking about here.

Jacobson said:

These critics, however, didn’t take the time to find out to what Palin was referring when she used the term “level of productivity in society” as being the basis for determining access to medical care. If the critics, who hold themselves in the highest of intellectual esteem, had bothered to do something other than react, they would have realized that the approach to health care to which Palin was referring was none other than that espoused by key Obama health care adviser Dr. Ezekial Emanuel (brother of Chief of Staff Rahm Emanuel).

I took the time to find out.  I knew in advance.  I’ve sat through hours of legislative hearings on this issue.  In my opinion, Sarah Palin is still a carbuncle on the face of this debate.  Her calling these panels “death panels” is designed to obfuscate the issues and deny the debate Jacobson says we need to have.  She’s providing heat for cheap political gain, not light.  She’s defending death, not life.

Shame on her.  Jacobson should know better, too.  I can all but guarantee that Palin didn’t read Dr. Emanuel’s paper, and didn’t consider the issues at all.  I’ll wager she does not know that hospitals in her state make these decisions regularly.

Under Palin’s way, death panels already exist. Death panels make decisions on life or death every day, and the poor and uninsured are at the bottom of the scale of who gets to live, top of the list of who gets to die.  Uninsured people often get shut out of the process, allocated pain and death from the start, because they lack insurance.

H.R. 3200 doesn’t do much to change this equation, the authors and legislators hoping to avoid cyanide politics like Palin plays; instead the bill encourages programs to help patients be on the “live if I want to live” side of the equation.  These encouraged programs should be bread and butter to legal clinics at most law schools, by the way — great help to the poor in anticipating what to do in life-threatening emergencies.  (I mention that because Jacobson is a clinical law professor — I don’t know which end of the legal clinics he works in, but he should know better anyway.)

We’ve already got the debate, and we already know that Palin’s trying to poison the well and fog up the lecturn, so that health care resources are misallocated.  In reality, this leads to more unnecessary and preventable deaths.

Yes, let’s have the debate:  Palin’s wrong to stand with unfair death decisions.  She’s had her say, and she should be held accountable.

Agree or disagree, invite others to join the discussion:

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