Recent advice from an independent panel analyzing the benefits of mammography screening for breast cancer has ignited a furor of conflicting opinions. The panel suggested that recommendations for screening be limited to women between the ages of 50 and 74. Women from 40 to 49 were advised to consult their physicians so as to decide for or against screening based on their individual risks and preferences. Evidence for a screening benefit in women age 75 or older was absent, and biennial rather than annual screening was recommended for the 50-74 age group. No evidence was found for the benefits of breast self examination.
For reasons cited below, the panel's advice appears to represent a prudent and thoughtful response to available data, but this has done nothing to halt the intense and sometimes acrimonious debate within the media and the medical community.
The controversy has raged around the advice to avoid recommending routine mammography for women age 40-49, a reversal of previous standard policy. Contrary to some media reports, the panel did not advise against screening for this age group, but only against making this a routine practice rather than a matter of individual choice. The debate also took on political overtones, based on accusations that the altered recommendations were motivated by a desire to save money at the cost of women's health. Further fueling the intensity of debate were testimonials from many women whose cancers were detected by mammography and who are now cancer-free, claiming that mammography saved their lives. Since it is impossible to know how any of these women would have fared in the absence of mammography, their anecdotal evidence is uninformative and will not be addressed here further.
Does mammography save lives? It is striking how greatly the certainty of expressed opinions exceeds the certainty of evidence, but enough evidence exists to justify tentative conclusions. A number of randomized, controlled studies have shown modest reductions in death from breast cancer among women screened by mammography, with the reductions (typically about 20 percent) greatest within the 50-74 age bracket. Even within this group, however, the benefits are not dramatic - typically, more than one thousand women must be screened over 10 years to avert one breast cancer death. This benefit, which appears to be real, must be balanced against the downside risks. These include unnecessary anxiety among large numbers of women from the experience of being tested, the additional anxiety from repeat exams when an initial exam is inconclusive, and still further stress from false positives. In addition, false positives lead to unnecessary surgery or radiation, and even some mammographically detected breast cancers that are correctly diagnosed can result in unnecessary treatment, because a fraction of these appear to disappear spontaneously and would never have surfaced in the absence of a mammogram. Finally, mammography itself exposes women to radiation, although at a danger level too low to offset the gain resulting from cancer detection.
Although the above evidence tells us that mammography reduces a woman's risk of dying from breast cancer, it does not answer a larger question - if a woman routinely receives mammography screening, is she likely to live longer than if she doesn't?
Death from breast cancer in a screened population is known as "disease specific mortality". Death rates overall are referred to as "all cause mortality". Do reductions in disease-specific mortality translate into reductions in all-cause mortality?
The evidence is conflicting, but in aggregate suggests that over the entire age span contemplated for screening, the answer is no - women who are screened will not live longer, on a statistical average, than comparable women who are not screened. In contrast, within the 50-69 year old age bracket, reductions in breast cancer disease-specific mortality do appear to be accompanied by small reductions in all-cause mortality as well.
The overall benefit for women age 50 to 69, combined with a lack of clear evidence for an overall mortality reduction outside of that age bracket, supports the panel advice recommending routine screening starting only at age 50, with younger women encouraged to consult with their physicians before making a choice.
A relevant study quantifying some of these conclusions can be found at
http://findarticles.com/p/articles/mi_m0689/is_6_51/ai_87914467/
]]>Last night, as I sat watching a TV documentary while breaking news stories scrolled across the screen, I was jolted by one of the headlines - 12 American soldiers had been shot to death by one of their own at Fort Hood, Texas.
The first question that entered my mind, bar none other, was this - Was the killer a Muslim?
A second question immediately followed - If so, was he acting out of hatred toward America that expressed itself in the murder of these American soldiers?
We now know the definitive answer to the first question - Yes.
We have at this early point a tentative answer to the second - Probably yes in the sense that his feelings about America as an entity expressed themselves in his actions against individual Americans.
I would have wished both answers to be different, but I was not surprised that are what they are.
Why is this a "dilemma?
That word signifies a choice between two (or more) conflicting alternatives, wherein either choice is unsatisfying. In deciding how I should feel, or how our society should act in response to Fort Hood, I believe little conflict would exist if either of the following were clearly true.
1. Most American Muslims harbor a smoldering anti-American anger that would find satisfaction in the killing of Americans - not merely the inevitable combat deaths in wars they might oppose (an opposition not limited to Muslims), but the deaths of any Americans who in any sense represented their country. The soldiers who died were killed in a just cause, and their deaths should be celebrated.
2. There are extremist fanatics within all ethnic groups in America. The act of Nidal Hasan might just as easily have been perpetrated by a Christian, a Jew, a black, a white, a man, a woman - no group, certainly not Muslims, is disproportionately inclined to perpetrate or support this type of evil deed.
Here's the problem - both of the above statements are false in my estimation. Like non-Muslims, most Muslims are good people committed to the democratic values of the society we all share. A minority of Muslims are not, and this minority is disproportionately large within the Muslim community compared with Americans in general. Any individual Muslim is unlikely to be a threat to the rest of us, but more likely to be a threat than someone of different ethnicity. If any reader disagrees with my assessment, I will concede that I can't prove it, but I would argue it to be plausible enough for us to pursue its implications. If any reader wishes to argue that the killings at Fort Hood are a justifiable response to grievances, real or imagined, I will choose not to argue the point, and proceed under the assumption that most others will disagree. My dilemma, and perhaps the enormously troubling American dilemma we face from this violent act is - how can we confront, both effectively and with fairness, an American community that does not deserve to be stereotyped, but which poses a threat we can't ignore? Pretending the threat is non-existent won't cause it to disappear. Exaggerating or exploiting it to demonize Muslims in general would not only be unfair, but would aggravate the threat.
Anyone expecting an easy answer beyond that of avoiding extremes is likely to be disappointed. My own sense, however, is that the most effective responses must of necessity come from within the Muslim community rather than be imposed on it from without. Based on history, I'm not terribly optimistic. Minorities in general (religious, national, racial, occupational - e.g., the police), faced with unjustifiable actions by one of their own, tend often to adopt a defensive attitude - they quickly condemn the acts and announce that those acts are unrepresentative of their community as a whole. What I would hope to see, but can't demand, is a response by the current Muslim community that transcends the ritualistic responses of other groups faced in the past with similar disapproval from society. Would it not be a powerful, even transformative moment in group responses, if a leader arose to say the following: "We as a community did not commit this act, but we are responsible for ensuring that it never happens again. For those outside who say it was heinous, we will say it louder than you. It is our good name that is at stake, and we are committed to rooting out any of those among us who would bring this disgrace to us again at any future time. If we fail, we deserve to be judged harshly, but we will not fail"?
Will that happen? I would like to think so, but it would be likely only if American Muslims are better than everybody else, and I'm afraid they're just like the rest of us.
]]>An off-year election was held yesterday in the 23rd Congressional District of New York to replace an incumbent who had left to accept another position. Because of important ramifications for the political scene nationally in the near future, I would like to summarize the results here for those who may have missed them from other sources and were unaware of the election and its outcome.
The 23rd District, in upstate New York, has been a reliable bastion for only one party since the Civil War (although district boundaries have changed over time). That result was not expected to change, because the incumbent was replaced by a well-liked candidate from the same party. This expectation was upended, however, by a movement launched by activists outraged by what they perceived to be a breach of faith by leaders who in their eyes had betrayed core principles for which they had fought. Seeing the moderate stance of the nominee as a rejection of the basic values they had labored hard to promote, they introduced their own candidate into the race. This conflict between mainstream moderation on one hand and a purer form of political consistency attracted national attention. Many prestigious figures spoke out in support of the purists, denounced the original nominee in incendiary terms, and poured millions of dollars into the campaign against her., As a consequence, she faded in the polls, and as the center of gravity shifted further and further toward the purists, she withdrew, leaving the field to her more radical replacement. The polls predicted a victory for this strategy.
The electorate, however, decided otherwise. Rejecting the attempt to push the party they otherwise favored in the direction of greater ideological purity, they handed a victory to the opposition. A district that had been in the hands of one party for more than a century is now represented by the other side.
Many analysts interpreted these results as a rejection of extremism, and as a self destructive act that threatened to marginalize the importance of a major political party and forfeit its opportunity to influence important national policies. The activists themselves, however, disagree. They believe that although their efforts might cost their party seat after seat, and might appear to drive the country in the direction opposite to their wishes, they should extend this same effort to future and larger contests. In their view, if enough of the centrist elements are routed from the scene, the principles the activists espouse will ultimately prevail.
I believe the above is a complete description of the results of yesterday's election in upstate New York. I've attempted to include all the relevant details. I don't think I've left out any item of importance, but if I've overlooked something, I'll try to supply the missing information.
]]>WASHINGTON -- A Republican congresswoman said Monday that people have more to fear from Democratic health care legislation than from terrorists.
Rep. Virginia Foxx of North Carolina made the comments in a speech on the House floor Monday.
"I believe that the greatest fear that we all should have ... to our freedom comes from this room, this very room, and what may happen later this week in terms of a tax increase bill masquerading as a health care bill," she said. "I believe we have more to fear from the potential of that bill passing than we do from any terrorist right now in any country."
The Democratic-controlled House is expected to vote later this week on the sweeping health care overhaul legislation that would extend coverage to millions of the uninsured. Foxx said it was scary because it would raise taxes, increase the power of federal bureaucrats and force people to buy government-mandated coverage -- among other things.
The Democratic National Committee denounced her comments.
"It is outrageous that anyone would compare the action of terrorists to efforts to help American families get secure, stable and affordable health insurance," said DNC spokesman Brad Woodhouse.
Minority Leader John Boehner, R-Ohio, shrugged when asked about Foxx's comments and said lawmakers had their own opinions.
]]>A few weeks ago, an anguished blog on TPM recapitulated a news story from the Midwest. According to the news reports, two parents who believed in the power of faith healing watched their 11-year old daughter die from uncontrolled diabetes while they prayed for her recovery without seeking medical help.
The responses of commenters were extraordinary in their outrage at this act of parental negligence, in some cases expressing a fury that was almost palpable. One comment called the parental decision "premeditated murder" and demanded the severest penalty legally possible.
A recent Washington Post/ABC news poll reported that only 52 percent of parents polled said they would have their child vaccinated against the H1N1 influenza virus when the vaccine became available. Scaled to the larger population, that unwillingness translates into tens of millions of children at increased risk for serious illness and death. The H1N1 virus is unusual in that its threat to the elderly is less than that of seasonal flu, but its lethality in children is much higher. Already in the U.S., at least 96 and probably more children have died from H1N1 flu, and the epidemic is still growing -
On the other hand, the vaccine appears to be efficacious, based on antibody responses and parallels with similar flu vaccines - H1N1 Vaccination - as well as safe - Vaccine Safety - CDC and Vaccine Safety - WHO . It therefore appears that many more children may be condemned to death if current resistance to vaccination persists.
I hope it's clear that I use the term "condemned to death" metaphorically. I don't denounce the parents, who undoubtedly care deeply about their children's health. Rather, I would make the following point. Among these millions of reluctant parents, I expect there have been thousands or more who encountered the news story about the faith healing couple, and who reacted with the same outrage I described above. And yet, negligent deaths among children from faith healing in the U.S. are likely to be fewer - probably far fewer - than deaths from infectious diseases that would have been averted by vaccination. If they are not, faith healing is a far worse threat to this nation's health than most of us realize.
What is ironic, of course, is that if one asks either the faith healing believers or the vaccine rejectionists about their decisions, each expresses equal faith in the rational nature of their decisions, with the corresponding view that those who criticize are biased and closed-minded. Indeed, the choices are often justified on the basis of testimonial evidence - the paralytic who walked again after a faith healer touched him, or the child who died the day after vaccination - even though we also know that when the claims are subjected to rigorous scrutiny, none of the evidence supports the claims of efficacy for faith healing or excessive risk for vaccination.
The issue of vaccination in general is too broad to address here, except to say that the viral nature of Internet rumors combined with a natural suspicion of government and of authority figures tend to reinforce the understandable skepticism of individuals urged to take action for their own good. The H1N1 threat is severe enough, however, and the dangers to children great enough, to emphasize that in this case, the innocent will be destined to suffer, and on rare occasion to die, if well-intentioned but misguided suspicion of vaccination is not countered.
In that sense, the guilty parties may ultimately be less the well meaning but misinformed parent, and more those of us with some knowledge of public health who don't do our job. That means providing accurate information, but it also means treating the lay public with respect rather than an accusatory attitude, so that they respond favorably to our attempts at education. When I used the term "condemned to death" earlier, I emphasized that I did not mean it literally. But even as I reread what I wrote, I find it too willing to pin blame on others, particularly if we antagonize those whom we wish to convince. When it comes to condemning children to death, we must be careful that we're not the ones doing the condemning.
]]>All of us who post on TPM make mistakes, and most of us figure we have to live with them. If something we write is criticized, we might want to argue with the critics, we might concede the point, or we might just shut up and let others judge the merits of the disagreement. One thing we don't do is hide the evidence in order to pretend that the material we wrote was never written, or if it was, that the criticisms were never made. At least most of us don't do that. Whatever our mistakes, we don't descend to a level of dishonesty and moral cowardice that conceals those mistakes from the scrutiny of others after they've been committed - as though they never happened.
Recently, one regular TPM participant, Jacob Freeze, did that at least twice. Freeze, who goes by the TPM pseudonym of Rutabaga Ridgepole, wrote blog items that others criticized severely for perceived inaccuracies. Rather than defend his material, or concede error, Freeze/Ridgepole deleted both blogs along with the criticisms. In one case, the deleted items seem to have disappeared forever. In the second, the blog material reappeared, but without the criticisms. Instead, Freeze/Ridgepole substituted his own comments for the ones he deleted.
Readers will react to this with different degrees of concern, but at least some of us are likely to view these attempts to create a false impression as a breach of moral integrity unworthy of TPM. There are other things in the world more important than this, and so I hesitated before deciding this was worth mentioning. Was I only trying to express my own anger, because my criticisms were among those deleted in both instances, or was I hoping to help other TPM readers better judge what they read? I decided the answer was both. I also hesitated because unlike some, I don't look forward to the insults that are likely to fly when someone is criticized for character flaws, but I figured I could put up with them. If someone wants to point out my flaws, of which I have my share, I may dispute some of the criticisms, but I won't pretend no-one made them.
What should anyone else do? Josh Marshall may want to revisit guidelines for deleting posts, but that's up to him. My suggestions to other TPM participants are the following:
1. If it happens again, call attention to it, and refrain from discussing the topic of the blog until Freeze allows all views to remain available.
2. If you write a lengthy comment on one of his blogs, save a copy to your hard drive as a backup, so that if he pretends it never happened, you'll be able to show others that it did.
]]>"We hold these truths to be self evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness." - The Declaration of Independence, 1776
As the debate intensifies over society's obligation to make adequate healthcare available to all its members, many Progressives embrace the notion that the unalienable right to life inevitably implies the right of all Americans to the healthcare needed to save lives and avert suffering.
Others disagree, invoking the established principle that no one can claim an unlimited right to infringe on the freedoms or well-being of others.
"Natural law states that people have rights to life, liberty and the pursuit of happiness. A good is something you work for and earn. It might be a need, like food, but more "goods" seem to be becoming "rights" in our culture, and this has troubling consequences. It might seem harmless enough to decide that people have a right to things like education, employment, housing or healthcare. But if we look a little further into the consequences, we can see that the workings of the community and economy are thrown wildly off balance when people accept those ideas.
First of all, other people must pay for things like healthcare. Those people have bills to pay and families to support, just as you do. If there is a "right" to healthcare, you must force the providers of those goods, or others, to serve you." - Ron Paul
Who is correct? Is there an unlimited right to adequate healthcare? Is there a right to healthcare, but limited by a requirement that your "right" not impose burdens on others? Or is healthcare not a right at all, but simply a privilege - a gift we may choose to bestow on others as a token of our generosity?
Because these questions involve fundamental differences in social philosophy and individual temperament, I expect them to remain as intractable in the realm of current policy disputes as they are contentious. My own perspective, therefore, is that the right to healthcare is an issue best left unresolved.
In support of this position, let me quote next from a document that also refrains from suggesting that any human has a "right" to demand a service from another human, but rather rephrases the question in terms of what humans must demand of themselves.
It is from Matthew 25. "The King" refers to Jesus, and I must preface this citation by disclosing that although I am not a Christian, I find the spiritual dimensions of what follows too fundamental not to be shared beyond the confines of a particular belief system.
"Then the King will say...'for I was hungry and you gave me food. I was thirsty and you gave me drink. I was a stranger and you welcomed me...
I was naked and you clothed me. I was sick and you visited me. I was in prison and you came to me.'
Then the righteous will answer him, 'Lord, when did we see thee hungry and feed thee, or thirsty and give thee drink?
And when did we see thee sick or in prison and visit thee?'
And the King will answer them, 'Truly, I say to you, as you did it to one of the least of these my brethren, you did it to me'"
Now, I find it striking that nowhere in the above passage does God refer to the right of the hungry to demand food, nor the right of the sick to demand care. God says instead, "No, they are not demanding food from you, nor are they the ones demanding care from you - I am the one who demands it."
Whether this is the literal God of Christianity, or the essential humanity within us that is our own form of divinity, it is a power that imposes the obligation to care not from outside but from within. And for some of us at least, who hear our own inner voices louder than the shouts of outside demanders, it is a power that must be obeyed.
Not all may hear voices equally loud, but we can ask all to listen for them. And so, I suggest that if friends or colleagues are reluctant to concede another's right to impose healthcare expenses on them, it might be wise to agree. Instead, you can ask what it means if they impose that same obligation on themselves. Would they see that as a relationship with their God in which, as the document goes, "as you did it to one of the least of these my brethren, you did it to me", or do they think they would merely be doing God a favor?
]]>During his recent speech to Congress, President Obama asserted that proposed healthcare reform legislation excluded illegal immigrants from insurance coverage. Representative Joe Wilson (R., S. Carolina) shouted "You Lie", and gained instant notoriety in the media. Who was right - the President who claimed the illegals were excluded, or Representative Wilson, who claimed they were covered.
To this nation's enduring shame, the President was right and Wilson was wrong. We are now committing ourselves to punishing illegals with the threat of illness, pain, suffering, and death.
I understand the political forces that have imposed this obscenity on healthcare reformers. I am convinced that in their hearts, they would wish to extend to illegals the compassion we owe to all human beings. I understand that their first priority must be to achieve desperately needed reforms of a healthcare system spiraling toward catastrophe. I understand all that in my head, but at a deeper level, it is something I truly don't understand. What have we become as a nation when the greed for political advantage forces us to forfeit our basic humanity? Is it worth it for the winners of that concession to have scored such a decisive victory over kindness? Is it worth it for those who made the concessions to sacrifice the victims for the sake of others? Sadly, the answer to the latter question is probably yes.
Illegal immigration confronts us with daunting challenges. These must be addressed - to some extent with more secure borders, and to a greater extent by enforcement of laws against fraudulent employment. Enforcement requires penalties, but the death penalty should not be the enforcement mechanism, even if only a few die for lack of timely care, nor should unnecessarily severe or prolonged illness be the penalty for those who recover spontaneously or reach the hospital ER before it's too late. Is there not something in the Constitution about cruel and unusual punishment?
I remain hopeful. I hope, and at some level I believe, that if we today can blithely ignore employment regulations so as to enjoy the benefits of cheap labor by illegals, we might find ways to circumvent healthcare regulations that leave the same laborers uncovered by insurance - including insurance they would pay for to the extent possible.
It is not that we are asking taxpayers to cover all their healthcare costs at our expense. We do that for some individuals, but we wouldn't for the illegals. We do it for felons imprisoned for murder, rape, armed robbery, child molestation, and other crimes. If they fall ill, they go to the prison hospital and are treated as a gift from the taxpayer. But they are in this country legally, and that makes all the difference. They are Americans.
On most occasions, being American is something to be proud of.
Not this time.
]]>The question as to whether a public option is important deserves rigorous scrutiny, but must be distinguished from a second question - is the public option essential?
The differences are not inconsequential. If robust reform is achievable with or without a public option, enormous effort and enthusiasm will now be justified to ensure the passage of reform legislation as a transformative change for the better in American healthcare. If, on the other hand, reform without a public option would be almost worthless, as some have suggested, little enthusiasm would be justified, and little would likely ensue.
There are "in-between" scenarios involving non-profit cooperatives, a "triggered" public option, or a public option as a pilot program in selected regions. Indeed, one of these may eventually emerge as a component of reform bills, but for the sake of clarity, I wish to consider only the stark alternatives - a public option or reform without it.
Here, I will make the argument that if other reform objectives are met, a public option as an additional component would be important, but far from essential. I hope others will offer their perspectives indicating why they agree or disagree. I also hope, however, that those opinions will be documented by evidence, so that we might all end up better informed. In the end, the public option is a policy rather than a religion, and its value must be decided on the basis of evidence rather than faith.
Let me start with the obvious - a public option would reduce the costs of health insurance premiums. To an important degree, however, the value of a public option depends on the extent and magnitude of that reduction. At this point, I would like to lay out, in two parts, what I consider relevant evidence. The first part concerns the level of impact that might be anticipated from a public option per se, and the second the impact of other reforms independent of the public option.
EVIDENCE BEARING ON THE POTENTIAL IMPACT OF A PUBLIC OPTION:
1. The cost of existing public insurance (e.g. Medicare) has been rising at rates similar to private insurance (about 8-9% per year).
2. Of the U.S. total healthcare expenses (almost twice that of most other industrialized democracies), private insurance profits account for less than 2%, and insurance company administrative costs about 6%. If all profits were eliminated, and administrative costs reduced to levels in other countries such as Canada, total healthcare costs would fall by only 3-4 percent. (Note that the above estimates are obtained by multiplying estimated reductions in private insurer costs by about 36% , which is their contribution to the total healthcare bill).
3. Almost all the excess healthcare costs (including excess administrative costs) reside within healthcare itself, due to duplicate or unnecessary facilities, tests, procedures, and specialty referrals based on a fee for service paradigm that encourages excess. Compared with these, insurance excesses are rather minor.
None of the above evidence refutes the conclusion that savings achievable with a public option are meaningful, but provides less reason to conclude that their impact will address more than a small fraction of the healthcare challenge. Among challenges not addressed are the abuses inherent in the insurance system independent of overall costs, and the huge excesses in healthcare outside of the insurance system. Let's look at how these might be addressed. Much of what follows is encompassed within proposed legislation, and much is already operative already in other nations with successful healthcare programs - some with dominant public insurance components and others that rely primarily on strong regulation of private insurers.
OTHER PROPOSED REFORMS WITH SIGNICANT POTENTIAL IMPACT
1. All individuals must be accepted by insurers, with no exclusions for illness or pre-existing conditions.
2. There can be no discriminatory rates for illness or pre-existing conditions, and only small differences for age.
3. No insurer can withdraw coverage from an individual who pays the premiums.
4. There can be no annual or lifetime caps on coverage.
5. All insurance plans must offer at least a minimum essential benefits package.
6. There will be limits on copays, and no copays for routine checkups (preventive care).
7. All individuals will be insured (with waivers in exceptional circumstances or with tax penalties for refusing insurance).
8. Low income individuals will receive government subsidies to render insurance premiums affordable.
Each of the above addresses inequities, but not cost containment. The following is a critical component of proposed reforms that directly addresses costs.
9. Minimum limits can be set on insurer medical loss ratios. These are the percentage of premium dollars that must be spent on medical care rather than profits or administrative costs. Many states already have established minimums (e.g., 70-80%). HR3200, for example, doesn't specify a figure, but allows this to be set in the future by the insurance commissioner or other authority, whereas the Senate HELP Committee bill sets the minimum at 85%. If this is set high enough, it would preclude excessive profiteering or insurer administrative inefficiency even in the absence of a public option. Note that this minimum can be set for each type of insurance (e.g. employer-based group insurance as opposed to individual coverage), so that insurers could be prevented from using a high ratio in one group to offset a low one in another group.
Assuming all these other reforms, many of which already operate in other nations, are implemented in adequate fashion, would the absence of a public option constitute a seriously damaging omission, or merely a moderate disadvantage in a program that is otherwise an enormous step forward?
To summarize the foregoing in another manner - if all individuals have adequate insurance (subsidized for affordability when necessary), and if insurers are required by law to spend the large majority of premium dollars on medical services rather than administration or profits, would not premium costs without a public option be only marginally higher than costs achievable with that option? Would not the percentage figures set for minimum medical loss ratios offer comparable opportunities to constrain costs, and deserve far more attention than the debate has focused on them?
My answer to the question I raise in the last paragraph is a tentative "maybe but not necessarily". Here is why.
To reverse the unsustainable trajectory of high and rising costs within healthcare itself requires major restructuring to incentivize elimination of unnecessary services, and to reward quality rather than quantity of the services delivered. Proposed legislation begins to address this issue with demonstration projects testing alternative healthcare delivery mechanisms, incentives to increase primary care, and funding for comparative effectiveness research to develop guidelines helping physicians decide what works and what doesn't (or may even be harmful). Among the alternative delivery mechanisms are accountable care organizations (ACOs) that receive payments in exchange for providing necessary care as an integrated package rather than uncoordinated services from providers acting without reference to each other. This mechanism rewards good outcomes but penalizes unnecessary expenditures, and can thus reduce costs.
Let us consider a community with a few large, well-established hospitals and provider networks, and an upstart ACO with few patient subscribers to date. Let us assume that it can afford to charge as little as $7000 annually for patients whom the established providers would charge $10,000 due to duplication and inefficiency. We will also assume private insurers must spend 80% of premiums on medical services, and can keep 20% for profit and overhead. If they spend $10,000 in paying the established providers, they can therefore keep $2,500, whereas if they pay the ACO $7,000, they keep only $1,750. As long as the ACO is too small to attract many patients away from the established institutions, it benefits the insurers to cover patients these institutions serve rather than ACO patients, simply passing the extra costs on to subscribers. In the long run, a growing ACO would provide formidable competition to the establishment and a major attraction to insurers, but private insurers tend to respond to short term demands from investors. In contrast, a public option, particularly with startup subsidization by the government, could in theory invest in a contract with the ACO with the goal of helping it grow to a point where it replaces more expensive providers for many patients.
To what extent would this scenario play out with a real world public option? I doubt that anyone can predict the answer with accuracy, nor is it fair to claim that only a public option would enable ACOs to grow and eventually serve as major cost reduction mechanisms. It is these uncertainties that make it difficult to judge the eventual importance of a public option independent of its short term ability to achieve minor cost reductions beyond those achievable by a robust reform program lacking a public option. The additional benefits might ultimately prove substantial, but they might equally prove trivial if healthcare costs can be constrained via comparative effectiveness research and the natural growth of ACOs or other alternative provider mechanisms. To me, the uncertainty is a signal that I should refrain from excessively dogmatic claims. Even so, I would argue that proposed reforms outside of a public option will represent major advances toward the eventual goal of high quality affordable healthcare for all, and do not deserve to be belittled. It would be truly unfair the characterize them as "worthless". My personal enthusiasm for them will remain high, even as I hope they may be supplemented by a public option in its strongest form. The likelihood that a public option would be less critical for robust reform than other reform options in no way detracts from the firm conclusion it would be important.
In asking for the views of others, I would again urge them also to refrain from dogmatic assertions of belief, and instead document all claims with the most persuasive evidence they can muster.
]]>
"Look", not "sound"?
His own skills and the suggestions from his advisors will undoubtedly permit him to deliver a speech in an effective manner. What I'm wondering is whether this occasion might not also be an appropriate opportunity to emphasize visual rather than exclusively auditory means of communicating content.
As I understand it, Obama will tell the country that healthcare reform entails a set of essential changes. It seems to me this type of listing lends itself to visuals - in big, bold print, and kept in view for at least a minute each to ensure their retention in the memory of the national audience.
Just some examples. "AMERICA MUST KEEP WHAT IS GOOD ABOUT OUR HEALTHCARE AND CHANGE WHAT NEEDS TO BE FIXED. HERE ARE THE CHANGES THAT CONGRESS MUST MAKE TO GUARANTEE HIGH QUALITY, EFFECTIVE HEALTHCARE FOR ALL OUR CITIZENS:"
slide 1: NO AMERICAN WILL BE DENIED HEALTH INSURANCE
(while the slide is up, the President discusses "cherry picking" and "pre-existing conditions, and the following slides will also be accompanied by relevant talking points)
slide 2: NO AMERICAN WILL BE CHARGED UNAFFORDABLE RATES FOR BEING SICK
slide 3: EVERY AMERICAN INSURANCE PLAN WILL COVER BASIC MEDICAL NEEDS
slide 4: NO INSURANCE COVERAGE WILL EVER RUN OUT OR BE TAKEN AWAY TO SAVE THE INSURER MONEY
slide 5: AMERICANS MUST BE GUARANTEED AFFORDABLE COVERAGE BY REQUIRING COMPETITION
(Here, of course, is where the public option will be discussed. From media reporting, I judge it unlikely that Obama will threaten to veto a reform package without a public option, but he can make the point that a public option is the only sure means of guaranteeing effective competition in areas where insurer monopolies and weak bargaining leverage for subscribers render coverage unaffordable - mainly, those who must purchase individual coverage, or small businesses with meager bargaining power. He can point out that large employers can already negotiate favorable rates, and that no proposal in Congress would add a public option to the mix for those employers, or attempt to eliminate insurers for those employers.
slide 6: HOSPITALS AND DOCTORS MUST BE REWARDED FOR PROVIDING BETTER HEALTH
(this is the place to discuss changes that reward providers for outcome rather than unnecessary tests and procedures that raise costs but don' t help patients, or may even harm them (e.g., unnecessary radiation exposure from routine CT scans when they don't confer any benefit)
Finally, at some point, these might be reiterated in a summary slide:
NO AMERICAN WILL BE DENIED HEALTH INSURANCE
NO AMERICAN WILL BE CHARGED UNAFFORDABLE RATES FOR BEING SICK:
EVERY AMERICAN INSURANCE PLAN WILL COVER BASIC MEDICAL NEEDS
NO INSURANCE COVERAGE WILL EVER RUN OUT OR BE TAKEN AWAY TO SAVE THE INSURER MONEY
AMERICANS MUST BE GUARANTEED AFFORDABLE COVERAGE BY REQUIRING COMPETITION
HOSPITALS AND DOCTORS MUST BE REWARDED FOR PROVIDING BETTER HEALTH
Ross Perot once did something like this, and it went over well. Maybe if done on a grander scale, in front of Congress, the effect could be even more compelling. It would also lend itself to recapitulation in the print media, YouTube, and the Evening News on TV,
Just a thought.
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The URL is http://www.youtube.com/watch?v=g1ZFNOAL-Tg
I hope people will check it out, rate it and/or comment on it, and tell your friends so that it might achieve a little bit of attention as an aid to reform efforts.
Thanks.
Fred
]]>I hope some of you will check it out, and if you like it, tell your friends to spread the word. If you or they have YouTube accounts, you can rate it (5 stars, I hope) and rave about it in the comments section. My name doesn't appear, so I don't have personal fame and fortune riding on it, but I'm just hoping to add a little bit of additional weight to our side of the communications battle. The more viewers any pro-reform videos draw (even simple-minded ones), the greater the effect, because viewership on YouTube tends to be self-enhancing.
The URL is http://www.youtube.com/watch?v=Gopzproty7w
Next week, I hope to put up a longer and more serious personal statement based on my familiarity with some aspects of the healthcare system.
Thanks to all.
Fred
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Some posts (and maybe some people) are attention grabbers. A few days ago, a post appeared that garnered 43 recommends and dozens of comments. It was mildly interesting. It probably inspired a few readers to philosophize about societal values, but in truth, I didn't think it was very enlightening. It provided little substantive insight into matters that currently roil the political waters. In my view, it was more entertaining than informative. Is something of that nature really worth so much attention?
Who wrote this attention grabber? I did. I was bemused, I suppose, and pleased with all the attention, but I didn't delude myself into thinking the post deserved it. In the past two days, however, I have posted twice on a matter of transcendent importance for America's future - healthcare. In each case, I felt compelled to offer information that had been lacking from discussion here. I did so not only because healthcare is important, but because it is a topic on which the large majority of TPMers are seriously under-informed. I find this true of some hoping to learn, but even more of others who appear less interested in additional knowledge than in demonizing Sarah Palin's "death panels" or vilifying town hall rowdies, while at the same time castigating reform opponents for their unwillingness to find out the actual facts.
The two posts received 2-3 comments and 1-2 recommends, and each disappeared quickly from the TPM sidebar.
Why did these two posts command so little attention? I believe it is because they would have demanded from readers some actual attention - some focused, concentrated effort spent on digesting data in a way that left them far better informed, but which also compelled them to alter their perspective on this entire topic. No longer would they see the debate as a conflict between simple right answers and simple wrong ones, but rather as a complex and alarming set of challenges that elude simple solutions. Readers would not necessarily have found that I disagreed with their healthcare reform goals, but they would have realized that those goals fall far short of what reality demands. They would have become less eager to castigate some members of Congress who are struggling to come to terms with that reality in their search to negotiate reform legislation that will endure in the long term.
Both posts were similar. The link to the more recent one is
http://tpmcafe.talkingpointsmemo.com/talk/blogs/fredmoolten/2009/08/medicare-for-none.phpI do hope some will be willing to visit it. It is not I who deserves the attention, but the material that's to be found there. I've already tried twice to sell this stuff, and I'm now trying for a third time.
Is that acceptable, or is it too much badgering? I appreciate the thoughtful comments most of you offer, and I hope most of you will appreciate the depth of my conviction that we need to do healthcare reform right, and that doing it right means knowing the critical evidence rather than just the talking points. To a few others among you who have complained that I lecture too much, who would call me an attention-grabber (ain't so), and who would tell me I patronize you as though you were children rather than show you the respect you know you deserve, I would say that's fine as long as you spell my name right.
But if you don't click on the link and pay attention to what you find there - shame on you.
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They are mistaken. Regardless of whether a single payer system, a public option, or a non-profit cooperative arrangement is enacted, or no option at all, the most probable outcome we face is Medicare For None. An equally probable accompaniment will be a private insurance network that is affordable by none.
Despite the prevailing rhetoric, insurance reform is only one facet of a far more daunting challenge. Insurance inequities aside, healthcare itself is broken and is hurtling towards bankruptcy. The culprit is an unmanaged and chaotic system of duplicate or unnecessary facilities, tests, and procedures driven by a fee for service paradigm that encourages excess. As technology has advanced to offer an ever increasing choice of these various services, some quite expensive, healthcare costs have escalated to levels that devour more and more of our nation's total economy.
However desirable it might be to curtail unjustifiable costs imposed by private insurers, these are not responsible for the escalation. The evidence for this conclusion resides in the observation that the cost of public insurance - Medicare and Medicaid - is rising faster than overall health system costs. In small part, this disproportion reflects changing demographics, but a more important reason is that Medicare (and Medicaid in most states) are very good insurance programs that offer extensive benefits. Medicare beneficiaries thus enjoy access to a widening array of services, some useful, some useless, and some harmful - the good, the bad, and the ugly. An ineluctable principle arises from this observation - in the absence of system reform, insurance reform might make healthcare more equitable, but it will also drive it closer to economic ruin.
The sobering data can be found at
Those data, I believe, should be scrutinized, digested, and then confronted with unsparing honesty. Current reform proposals have failed that test in that they include only vague half measures and pilot programs aimed at system change, involving comparative medicine, fee for value rather than fee for service, bundling, and the like, but these are small-scale, and lack authority to mandate any needed changes. They are only a tiny step forward while the entire system is racing backward toward oblivion.
In the current debate atmosphere, reform opponents have warned seniors that they may be about to lose Medicare benefits. Reform advocates have denounced the warnings as scare tactics. It is the wrong message for advocates to send. Rather, they should be telling seniors and everyone else something very different - "Be afraid. Be very afraid."
]]>Much current healthcare reform debate centers around proposals to extend health insurance to almost all Americans so as to allow them access to care that might spare them from serious illness, death, or financial devastation. Insurance reform is necessary, but it is not sufficient to reverse the current descent of American healthcare into unaffordable chaos. The greater part of the threat lies elsewhere. It is the elephant in the living room that legislators find difficult to mention because it is so daunting to fix. It is the healthcare system itself - a disorganized morass of duplicate or unnecessary facilities, tests, and treatments based on a fee for service paradigm that encourages excess and discourages attempts to reduce waste and inefficiency.
For anyone who doubts that fixing healthcare itself will ultimately be more important than fixing the insurance system, however much it needs fixing, I highly recommend the sobering analysis at the following site, which deserves careful and objective scrutiny -
http://www.concordcoalition.org/issue-briefs/2009/0521/long-range-forecasts-health-care-costs-ominous-and-maybe-even-optimisticIf the level of healthcare discussion were commensurate with the magnitude of the dangers posed by each element of the problem, we might not necessarily want to see less discussion of insurance, but I believe we would need far more on what the insurers pay for. Indeed, if insurance coverage is extended, and healthcare excess is not curtailed, the problem will worsen rather than subside, because more and more people will be able to demand services that include both necessary ones and wasteful ones that threaten to bankrupt the system.
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