We should not be making policy for a country of 300 million people based on one person's or even a few persons' experiences. I feel much sympathy for Ms Smith and her family as a fellow human being. I accept her testimony as the "truth" of her experience as Prof Warren titles this post. But it is not the "whole truth" of healthcare finance and administration in America. Ignoring the value of statistics and economic analysis, often omitted from this thread for reasons obscure to me, there was no presentation at the hearing of other persons' perspectives in the health care world - e.g., doctors who deal with Medicare. They would have quite a few health care horror stories to tell, believe me, like procedures that are "covered" but for which the reimbursement amount is zero. A brilliant strategy for the bureaucrats who can tell legislators that "yes, the procedure is covered" and show how "yes, we are keeping costs under control." Doesn't work too well for doctors and patients though. There was no discussion of whether a different health care system could solve Ms Smith's family's problem and how much it would cost - for example, in a state run program, would her husband have been treated at the distant Mayo Clinic, as he was in real life? No assessment of how much it would cost to give everyone in the US equal treatment and how it would be funded and then to decide if anyone is going to propose such a plan and if not whether we should put on testimony about a problem that is not going to be solved. There is also the very hard question to pose, but policymakers should pose it, to be honest with us as opposed to being liked by us: Ms Smith's testimony culminates at the point where she has to move in with a child because they are broke. The hard question is, at what point do we as a society say an individual / family can shift their costs to everyone else or conversely, what contribution does each individual/family have to make to those costs? If exhaustion of personal means is not required, what is the point we'll select, what are the principles to decide that and what is the cost of that decision?

I don't know the answers to these questions but I do know they need to be confronted to make intelligent policy and they aren't being confronted openly. Rather, political objectives (which I am not unsupportive of), empathy and rhetoric are controlling the agendas and that is likely to lead to bad policy.

Elizabeth... in all of your very good posts about middle class debt on this sight, you haven't yet called for the obvious solution -- a repeal of last year's bankruptcy reform and a turn back towards making lenders take risk.

Medical bankruptcies became more of an issue after the bankrucpty reform (supported by current Democratic candidate Joe Biden) was enacted into law.

Isn't the first step to undo what was done by congress and Bush last year?

thosethingswesay.blogspot.com

You are so right. In fact, I think this logic should be extended to other areas where public funds are put to use. For example, when my neighbor's house is burning why should my tax dollars fund the fire department to put the fire out when maybe he hasn't upgraded his electrical wiring? Or maybe they left the coffee percolator on? Same with the public school system. Why should my money go to fund kids who need special education? Their parents probably let them watch too much tv and eat too much sugar. It's an outrage.

I could go on and on, but you get the drift.

Ain't gonna happen with the filibuster-happy GOP, for all intents and purposes, still in charge of the Senate's legislative agenda. And Mr. Veto waiting in the Oval Office to pick off anything good and decent that might escape the chambers of congress.

We'd need 67 votes to overcome that, not including Biden, Nelson, Carper, Johnson, who will assuredly oppose such a repeal. So basically, we need 71 Democrats in the Senate. :)

Oh, and 287 votes (2/3) to override a veto in the in the House.

Right.

Next idea...

Someone's been questioning the data of Steffie W and David H? I only wish more people would do so!

Of course I don't want to defend the 2005 bankruptcy law. And I have great sympathy for Donna S.

But Steff&D's most famous claim, that administrative costs are the main culprit in health care overpricing, this I've long found questionable.

In fact I believe that the best analysts of health care have found that every sector in the US health care industry, whether hospitals, doctors, high tech, or pharmaceuticals, every sector deserves a goodly share of the blame for excessive health costs.

But too many concerned Americans have not had acess to the analyses of careful health policy specialists, and they have not known on their own how they could question S&D's well-meaning arguments.

And so, for want of questioning, the quality of debate about health care has been, I fear, diminished.

The Massachusetts model bears watching. Universal coverage in other states like WA and TN have not been successful. VT arguably has everyone covered, but they also have some of the highest tax rates in the nation to pay the bill that keeps going higher.

Americans simply don't trust politicians enough to believe the promises that if we get everyone covered we will save money out of the deal. Real-world examples prove the opposite.

To what extent do you believe education and/or advertising are factors in personal health responsibility? Television, is, all too often, the babysitter that would appear to mold behavior as much as does school -- and health education is not that much of a factor in school.

For that matter, I do hope "physical education" has improved since I was in school, sometime during the Neolithic. With the exception of one year of high school I spent in Maryland, rather than New Jersey, physical education was a time where the varsity athletes took most of the time with the "coach", and there was no meaningful attempt to improve the conditioning or find good physical outlets for the remaining students.

You can appreciate my shock when entering the Towson, MD high school, to find a true physical education teacher, who explained that he believed he had a commitment to find at least one physical activity at which each student could do well -- and make it a habit. Even when going for standardized fitness techniques, he took a very active role in teaching conditioning and techniques. It wasn't that much of a surprise to get techniques for pacing in a medium-distance run, but I was fascinated how much care he took to make sure people did pushups and situps efficiently.

Depression is widespread in both adult and child populations, and is a disincentive both to physical activity and healthy eating. While overmedication certainly is a concern, the strongest evidence for efficacy of psychotropic drugs is in depressive disorders. Are these adequately treated?

Overmedication, I suspect, also is partially dependent on advertising. Given the amount of misinformation that gets through in direct-to-consumer prescription drug advertising, it's well, for my blood pressure, I don't watch much TV. Unfortunately, it takes a substantial amount of medical knowledge to catch the misleading in both prescription and over-the-counter advertising.

Watching the Weather Channel today, an innocent enough activity, just one random ad had me shaking my head. Benadryl was touted as "superior" to the "leading" antihistamine. While it is true that diphenhydramine (generically available Benadryl) often is more effective for allergy relief than second-generation antihistamines, diphenhydramine is significantly sedating in many people. Indeed, it's the most common ingredient in over-the-counter sleep aids. How many accidents, ranging from driving to kitchen knives, are caused by inadvertent sedation?

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

Don,

The fantasy of blaming the victim (your term "requiring personal responsibility") is the reason why my physician graduated from medical school with thirty years of student loans to pay off.

He would have preferred to focus on the practice of medicine and continued to get better at that. Instead he is focusing on training in how to run a business and how to deal with about 40 different insurance companies plus Medicare, Tricare, Tricare-for-Life (different from Tricare), and all the various business matters involving personnel, rent, purchase of his equipment, and so on. He was working for the medical school, but couldn't get paid enough to make a dent into his student loans.

Instead of practicing medicine as his primary focus, his job is to make a profit out of the practice of medicine. He's bright and capable, and will make a decent profit, but it has become his main focus. Medicine is just what he has to do to make that profit.

My dentist decided that he could no longer afford to take my dental insurance, and I can't afford his full prices, so we have parted company. He's not practicing dentistry. He is making a profit, through the practice of dentistry. It's a shame. He used to be a very good dentist.

You may have noticed the recent news articles on the study that shows that obesity - and weight reduction - are both contagious. That means that a large part of obesity is a group phenomenon.

Your "personal responsibility" cant means that those of us who want to work with groups to change the dynamics are prevented from doing so.

I am retired and have gained thirty pounds in the last ten years. No one in my neighborhood belongs to a health club, and I couldn't afford one anyway. There is a desperate need for city or county funded exercise programs ~in the neighborhoods~ and the leadership to get them started and get the local people into them.

Personal responsibility starts AFTER such programs are reasonably available to EVERYONE. The programs are a group effort, but you derail the initiation of such efforts when you demand "personal responsibility." Once the group effort creates the needed programs and they are up and running, THEN it's time for "personal responsibility."

So get the frack out of here with your efforts to kill group efforts before they have begun. You and your attitude of "I don't give a shit about anyone but myself and my family" are a major part of the problem. America doesn't need you.

Re: You may have noticed the recent news articles on the study that shows that obesity - and weight reduction - are both contagious.

The study showed nothing of the sort. There is no microbe that causes obseity being passed from person to person like the flu. What the study showed is that overweight people tend to have overweight friends, and vis versa. This is an example of social sorting, not contagion. You don't become overweight by associating with overweight people, rather if you are already overweight you tend to get along better and feel more comfortable with other overweight people.

Actually, far from needing to overturn the law, which would require a supermajority, the House Judiciary Committee may have the right idea by simply defunding the US Trustee's office. The UST is charged with bringing Motions to Dismiss based on the income-level presumption in the new law, as well as auditing debtors that it suspect may be committing "fraud." Last week, the Committee slashed the funds in the budget for the UST, specifically stating that it was concerned it was spending too much time pursuing frivolous motions.

If the UST is prevented from bringing Motions to Dismiss based on budgetary concerns, and since no one else is authorized under the law to do so, the new law will have no teeth. It would be effectively repealed.

Have you looked at provider compensation versus financing of medical education? There are multiple problems here: providers going into practice under heavy debt load, plus a pressure to go into specialties highly compensated by procedure rather than time. There's rather little incentive to go into primary care, especially with the huge administrative costs of primary care practice.

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

The "policy debate" boils down to one fundamental question: In this country, do we, or do we not have a moral obligation to provide health care to our citizens? Other western nations believe that government's duty to the common good requires it; our Constitution acknowledges government's duty to the "welfare" of its people--not to mention our treasury:

The United States spent an average of $6,102 per person on health care in 2004 (the latest year for which figures are available), according to the Organization for Economic Cooperation and Development. Canada spent $3,165 per person, France $3,159, Australia $3,120 and Britain a mere $2,508.

Life expectancy in the United States was lower than in each of these other countries and infant mortality was higher. Looking at the numbers another way, the Kaiser Family Foundation determined earlier this year that health care spending accounts for 15.2 percent of the U.S. economy.

By contrast, health care spending represents 9.9 percent of Canada's gross domestic product, 10.4 percent of France's, 9.2 percent of Australia's and just 7.8 percent of Britain's.

And again, the citizens of these countries on average live longer than we do.

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/07/25/BU44R6ES62.DTL

They also have shorter wait times for care, including for cancer:

A Commonwealth Fund study of six highly industrialized countries, the U.S., and five nations with national health systems, Britain, Germany, Australia, New Zealand, and Canada, found waiting times were worse in the U.S. than in all the other countries except Canada. And, most of the Canadian data so widely reported by the U.S. media is out of date, and misleading, according to PNHP and CNA/NNOC.

In Canada, there are no waits for emergency surgeries, and the median time for non-emergency elective surgery has been dropping as a result of public pressure and increased funding so that it is now equal to or better than the U.S. in most areas, the organizations say. Statistics Canada's latest figures show that median wait times for elective surgery in Canada is now three weeks.

"There are significant differences between the U.S. and Canada, too," said Burger. "In Canada, no one is denied care because of cost, because their treatment or test was not 'pre-approved' or because they have a pre-existing condition."

"Furthermore, when a service problem emerges in Canada, prompt analysis and resource deployment is mobilized to resolve the problem," noted PNHP's Young. "In the U.S., the situation only worsens each year, hence we are presently in an enormous crisis. That's why we a need a single payer system, such as HR 676 which is now before Congress, that can respond to new demands."

http://www.medicalnewstoday.com/articles/76295.php

http://www.tnr.com/doc.mhtml?i=w072307&s=cohn72707

The infant mortality rate in this country is staggering. Bush gets all of his medical care paid for by taxpayers--but he threatens to veto the SCHIP for poor children whose parents cannot afford or get private insurance? That's unconscionable.

Why have Americans allowed themselves to be treated with such contempt by criminals and profiteers? It's patently absurd. The French smoke more, drink more and eat more fattening food--yet they have full national health care, and they live longer, French doctors don't spend their time fighting with "care" managers; they just do what they love--provide medical treatment. And, they make a very nice living doing it.

Britons have national health care and pay only 40% of what what we do. It isn't one or two personal anecdotes of suffering--it is a huge wave of suffering in America. And, the reason is because we have been propagandized into believing that "capitalism" requires the sacrifice of our loved ones on the alter of "free market" theology. I mean, really...it just boggles the mind. The Republicon Party doesn't even believe children deserve protection--Bush plans to veto the SChip funding.

Privatization is Profitization. Big Insurance is making OBSCENE PROFITS off the suffering and bankrupting of Americans at their most vulnerable level. It is immoral, depraved and criminal--and absurd. Our government is colluding in the murder of at least 18,000 Americans every year because we--as a people--have been propagandized by profiteering liars.

You may be willing to die so CEOs can live well in their palatial mansions while I suffer and die horribly and bankrupt my family in the process. But I am not. National Health Coverage in America is the only public policy there is now.

i don't believe France has literally thousands of foreigners crossing their border every day without their consent. Their immigrant problems are 2nd and 3rd generation now. Their immigrants also have legal status and protection -- ours don't.

Do you believe Americans would accept longer wait times to see a provider as they do in many other countries with lower overall health spending?

The best news in this area is that the Administration is making the mistake of indicting Michael Moore for going to Cuba. This will keep him in the news and therefore help him keep drawing public attention to the problems people are having with their health insurance. This will get a lot more attention form the media than any congressional hearing. The more publicity this issue gets, the better.

But America's immigrants assimilate (even our illegal ones) more easily than Europepan ones do. All in all I would rather have America's immigration problem than France's
As for wait times, can we bury that old chesnut? Americans already have long wait times in some cases. Nor do European wait times involve access to primary care physicians or urgent care. Emergencies are handled promptly and routien care is readily available. European wait times involve access to specialists (in non emergency situations) and for elective procedures-- and you have significant wait in the US in those cases too. Now it is true that wait times in Canada can be significantly longer (overall) than in the US, but Canada is an outlier in this regard, probably due to its low population density and vast distances between population centers. Average wait times in Western Europe overall are not significantly greater than in the US. Moreover since a shift to universal healthcare or even outright single payor would not change the number of physicians (specialists, PCPs, etc) or healthcare centers (hospitals, clinics etc) it's hard to see why we would suddenly have longer wait times, given that neither supply nor demand would change.

well, I lost about 70lbs and that was noticed by my coworkers; one of them got a personal trainer (starting to look like a body builder), another is now doing an hour a day on his treadmill at home (lost 25 lbs), etc...

people are materialistic, we all know that; based on what I've ssen, my coworkers know firsthand that I lost 70lbs in a year and they wanted the same thing.

the medical industry, for all the good it does, can be a bad group to hang out with! they transform the weight gain issue into a medical problem that requires expensive diets, nutritional counseling, stomach stapling, etc...

my coworkers saw that elbow grease could work, pursued it themselves-- a few fit ones more diligently, and got good results.

To boldly go...

[That's unconscionable.] Yes it is. And incredibly even a large fraction of the GOP supports the expansion.

if citizens demand that their government stays solvent, shouldn't the government expect the same of its citizens?

as the boomers retire, I don't think that taxes can be raised high enough to support cost of living adjustments, health care, public pensions, failed private pensions, etc...

retirees will have to figure out how to remain a productive part of the economy or their quality of living will tank. I recently read that "the eldery's quality of life will be based on how well the elderly take care of themselves!"

it's a unique opportunity for sure! and I don't blame Bush because I think he's simply supporting bi-partisan policy expectations on the issue.

To boldly go...

Re: It's not a given that everyone can jump into an exercise program.

And what about people for whom exercize simply does not work, as a weight loss technique? Three years ago my partner and I shared a car. Since his job was farther away than mine (and most at night) he dropped me off at work in the morning with my bike and I rode home at the end of my day (I had very good reasons involving traffic dangers, grooming and hygiene, etc for not riding to work in the morning). I also went out two or three nights a week and danced like a fiend for two or three hours. And I rode a lot for pleasure too. I have no doubt that all the exercize was very good for me, benefiting my cardiovascular system enormously. But: I lost all of five pounds. (I was not obese but was overweight). I can easily see someone who really wants to lose weight in that situation just giving up in despair.

The only real solution I see, after reading all the proposals for getting medical help for everyone, is that we start realizing that we are creating the problem ourselves. why can't we help those in need out of our own pockets? Are we too selfish? Is our thirst for "things" more important than someone else's life or death? When people suffer medical catastrophes, we should be stepping up and helping these families. If we took care of each other, we wouldn't need the government to do it. When the government does it, it comes with a greater cost both short and long term. Universal healthcare should really be universal generosity and caring for your neighbors. We are all 30 to 90 days from being in trouble ourselves if we haven't properly prepared. Even if we have, there are going to be situations where we can't do it alone.

Jim Anderson

The Truth About Credit

Facebook Profile

You don't have to be Bill Gates. If a community pulls together, it doesn't take much sacrifice. A lot can be accomplished in large numbers.

if I hear this "Just depend on private charity" riff one more time I am going to vomit!

I'm sorry, but this statement clearly reveals selfishness and immaturity. You never get something for nothing.  Relying on government to solve our problems forgets about the costs of doing so.  You lose personal freedoms, liberties, and economic opportunity.  These are principles that this country was founded on.  I'm sure that isn't a reflection on you.

Jim Anderson

The Truth About Credit

Facebook Profile

Re: If a community pulls together

Are you living in some parallel universe? If not then put down the crack pipe, dude! Most communities do not have enough money to fund medical care for their members. Do you know nothing about "income stratification"? Only a very small number of people in this country have the kind of money you are talking about. The churches? Don't be stupid! Even the Roman Catholic Church, the richest church in the world, would be bankrupt by year's end if it tried to pay for everyone's healthcare.
Do you have any idea what kind of money we are talking about here?
Moreover, every other First World country on Earth has universal healthcare-- and guess what -- IT WORKS!!! Why shouldn't we have that too? What the hell are you afriad of? Your idea is as brain-dead as if you suggested we should just all sit around and pray for a miracles when we get sick instead of availing ourselves of modern medicine.
And maybe I'm "immature and selfish" (though someone like you who opposes universal healthcare is a far better candidate for selfish than I am!), but yes, I am sick to death of egomaniacal oligarchs like you who would rather let people than have healthcare for everyone for some sort of stupid idleogical perfectionist nonsense.
Flat out, you and your snake oil do not belong on any sort of progressive blog. Go find a nice rightwing site to haunt.

Pretty strong words for someone who makes anonymous posts. (empty profile and refuse email contact.) We all have a right to an opinion, but I don't think personal attacks accomplish anything. Sorry if you took what I said personally. I just don't believe another government program is going to work. Everytime we look to the government for help, we increase taxes. When we increase taxes, we increase poverty and we surrender more liberties. I simply disagree with your assessment.

Jim Anderson

The Truth About Credit

Facebook Profile

The running guru, Jim Fixx, died of a heart attack at 52

it would be interesting to know how much stress Jim put himself under? I was eating too much bad stuff mostly because of stress and there's no doubt that some of my weight loss was attributable to becoming "more relaxed" and "less stressed out."

i.e., my blood pressure dropped from 140/90 to 115/72 over the year-- that's something that I monitor at home now.

Public articles I've seen don't indicate if he had had routine lipid...

you might want to search for "space doc" on google and see what that guy has to say about cholesteral! given your cracker jack knowledge about medicine, it would be interesting to hear what you think of his statemtent that drugs like lipator do nothing. His claim-- if I remember it right, was that 50% of the people who have heart attacks don't have high cholesteral.

because of that knowledge, I tend to pay a lot of attention to the glycemic index of foods since some experts claim that insulin tolerance is associated with heart attacks.

so, to answer another question that someone asked me in this thread, "how can I lose weight without a lot of exercise?," I'd have to say, based on my reading-- and my own experience, look into glycemic dieting! essentially, I only do half the aerobics that I used to; however, I now walk a lot, ocassionaly rollerblade and loosely follow a glycemic diet.

I used to exercise around 180 heart beats/minute on my elliptical because researchers didn't seem to agree on the pros and cons of "high heart rate" exercise. These days, however, my heart is much stronger and stays in the normal range.

The reason why I stick to a glycemic diet is because I recently had my fat/muscle percentages checked and my body fat was optimal! That information amazed me because, in 2005, I had 240 lbs on a 5'10" frame!

One of the harder things to talk about is the difference between "a diet" and "a diet." i.e. while most people diet to loose weight, I will be dieting until I die because my diet is the foundation of the way I eat.

I got into all of this because I became scared of becoming diabetic-- I knew that drinking half a gallon of cherry coke every day at dinner was bad for me; now, I mostly drink water and consume much less soda. I also order the "kids meal" at the restaurants I visit like Culvers, Famous Daves and I mostly eat the "happy hour pizza" at Old Chicago.

To boldly go...

the main reason why I found the "space doc" website to begin was that my father could tell when my mother was taking her statins; she became quite depressed and nippy. now she takes a fat blocker to reduce her cholesteral.

It's been a while since I went through his website but one of his points was that statins reduced swelling, or something, so it wasn't the removal of cholesteral that reduced the risk but a side effect.

while it might not be peer reviewed-- at least in my mother's case, the described symptoms sounded familiar. her doctor rallied against the notion that statins could ever be harmful and maintained that they were as safe as water. thus, I lost some respet for doctors because I saw my mother's condition and I saw a doctor who denied what he could see.

Now that she is off statins, she's back to normal.

To boldly go...

It's been a while since I went through his website but one of his points was that statins reduced swelling, or something, so it wasn't the removal of cholesteral that reduced the risk but a side effect.

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

Every country's system is different, and, both in Canada and the US, there are further differences at the provincial/state level. Friends in Ontario seem to get much faster care than those in British Columbia, and I can easily believe Nova Scotia doesn't get a high level. In Massachusetts, I am able to get coverage when I'd be uninsurable in Virginia.

Every system has some sort of rationing and utilization review mechanism. In the US, these mechanisms include initial underwriting as well as micromanagement (sometimes as decent case management) of individual cases. The German multipayor system, closely regulated and with a government safety net, doesn't demand preapproval for a wide range of treatments. Instead, they look at (usually) quarterly cost per provider, and investigate the overall practices of the very costly ones.

It may well turn out that a costly provider had to deal with an epidemic, or had a particularly sick set of patients. In some of those cases, the costs are justified. When they are high, the first attempt is to assist in becoming more efficient, not to drum the clinician out of the contracted system.

Every system makes different policy choices. Canada has made a general policy of wide access to basic services, as opposed to unlimited access to specialty care. Frankly, I was surprised how aggressive the palliative oncology was for a relative of a friend in BC, which was also in an outlying area where primary practitioners and internists got general guidance from a remote oncologist.

Attention is paid to capital expense. For some time, there was no CT or MRI capability in Kamloops, the 6th largest population center in BC. First, they got a CT, the speed of which can be crucial in emergency medicine. They began getting visits from a mobile MRI, but I believe they have their own. The justification came from, in part, it having a resort area with a large number of athletic injuries. [for the record, I have no desire to take up skiing. I figure that I can fall down well enough without help].

Lithotripsy still requires a 5-hour minimum drive to the university hospital in Vancouver. A number of laboratory tests are sent there, but most people would be surprised how many specialized lab tests are sent out in the US, even by major hospitals.

Canada has done original work in lowering the cost of primary practice. For example, in almost any US emergency room, ankle injuries are X-rayed [see my reference above to my great skill in falling down, with resulting ankle injuries]. X-rays are likely to affect treatment, however, only if there is a fracture that may need surgical reduction, or at least realignment. The Ottawa Ankle Rules are now a worldwide standard of care, reducing the cost and radiation hazard of unneeded X-rays. Indeed, while many CT scans are absolutely justified, there is much more recognition that they expose patients to enough radiation to increase cancer risk. Where possible, ultrasound should be used, which has no radiation hazard and actually may be faster and more available to check for internal bleeding. MRI also has no radiation hazard, but certain contrast media put kidneys at risk. High-tech diagnostics and interventions can be enormously valuable, but also, in the US, can be profit centers.

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]