Keep in Mind

I have another rant on health insurance in the works, but in the meantime, take a look at what Joshua Holland writes at AlterNet. As we clamor for “single payer” — and I’ve done as much clamoring as anyone, I suspect — keep in mind that very few of the nations with national health care have pure “single payer” systems. Most of them, including France, have systems in which a private health insurance market still functions, I suppose for people who want the hospital suite with gold-plated bathroom fixtures. Whatever.

Anyway, Holland argues there should not be a war between single payer and public option advocates.

The Roller Coaster

I honestly don’t know what’s going on in Congress with health care reform. Here is Ezra Klein’s latest and Brian Beutler’s latest. The sticking point at the moment appears to be financing.

At The Guardian, Rose Ann DeMoro writes that the government sure as hell had better do something. If you want to be thoroughly depressed, however, read the comments to the article, in which American dittoheads tell Europeans how much better the U.S. system is to theirs. It’s embarrassing.

However, see also P.M. Carpenter, “Healthcare Reform and the Lure of Despair.”

I’ve been among the guiltiest of prejudgers of coming health-care legislation, essentially, or even explicitly, on occasion, declaring a robust public option doomed before birth. I now question the wisdom of that prejudgment, although, obviously, it may well prove to have been deadly accurate.

The chief cause of my self-questioning is not some pollyanish, utopian epiphany that has befallen my brain. Rather, it has been the overwhelming totality of like-mindedly negative prejudgments I’ve repeatedly encountered from around the Web.

And they’re downright depressing — premature tossings in of the towels; emotional declarations of it’s all over before it’s actually over; black, foreboding, self-righteous brayings of I told you so, again, before there’s even anything of substance on the Congressional table for us to be told about.

These are the Sarah Palins of online progressivism: the whiners, the quitters, the inactive activists, the incurably discontented voices of departure from Washington’s camp of Valley Forge before the first snowflake descends. And I’m embarrassed and ashamed to confess that too often I have had one foot in the retreating camp.

Normally I’d be with P.M. on this, but right now I’m feeling pretty bleak about it all. I still say if there’s no public option, they might as well not bother. And the public option still seems like an uphill struggle.

Ir-rationing Health Care

There are a number of treatments for early-stage, slow-growth prostate cancer. These treatments range from “watchful waiting” — not treating the cancer at all, but just keeping an eye on it — to surgical removal of the prostate gland, to high-tech proton radiation therapy using a proton accelerator. The costs for the various treatments range from a few thousand dollars to hundreds of thousands of dollars.

However, there is little evidence that the more expensive treatments are any more effective than the cheap ones, including watchful waiting. Indeed, for an older patient, watchful waiting makes sense, as there is a high probability he will die of other natural causes before the prostate cancer becomes a problem for him. On the other hand, younger patients, meaning men under the age of 65, might benefit from more aggressive treatment. But which more aggressive treatment?

At the New York Times, David Leonhardt interviews some prostate cancer specialists and finds there is widespread skepticism that the new, expensive, state-of-the-art treatments work any better than older, less expensive treatments.

“No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, “We’re not sure how good any of these treatments are.” When I asked Dr. Daniella Perlroth of Stanford University, who has studied the data, what she would recommend to a family member, she paused. Then she said, “Watchful waiting.”

Naturally, the health care industry is pushing the more expensive treatments.

And in our current fee-for-service medical system — in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients — you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data. A new proton treatment center will open Wednesday in Oklahoma City, and others are being planned in Chicago, South Florida and elsewhere. The country is paying at least several billion more dollars for prostate treatment than is medically justified — and the bill is rising rapidly.

This takes us back to the issue of private insurance companies. Or, should I say, the the medical-industrial complex, which includes private insurance companies? I’ve ranted for years that our system is very good at one thing — creating profitable health care products. Medical treatments that make somebody a lot of money somehow get paid for. But any part of the health care system that can’t be made profitable is allowed to rot.

So, there are billion-dollar investments being made to build prostate cancer proton treatment centers that may or may not be any more successful than older radiation therapies that doctors have been using for years. Or, more successful than doing nothing at all, for that matter.

Meanwhile, just as one example, the nation’s emergency rooms are crumbling into decay. Emergency rooms do not make a profit. They have very high overhead because they have to be ready for, well, emergencies. And many people who use emergency rooms can’t pay the bills. So many hospitals are closing or cutting back or downsizing emergency rooms.

(And the practice of using emergency rooms as default “free” clinics for the poor and uninsured not only adds to the burdens on emergency rooms; it is also probably the least cost-effective way anyone could think of to provide last-ditch health services to the poor and uninsured, which is another big reason our nations spends so much on health care.)

Anyway — it appears that if somebody is making money off a particular gizmo or course of treatment, the health insurance industry manages to find room in its heart to pay for it. However, the private insurance companies routinely refuse to cover people who have even minor “preexisting conditions” and drop customers whose ailments are money-losers.

Put another way, if current trends continue, the day will come when the medical-industrial complex will simply refuse to provide treatments that aren’t making a profit for some part of the medical-industrial complex. And consider that conservatives not only want to kill government-led health care reform; they want the private insurance and other parts of the health-care industry to be even more unregulated and unwatched than they are now, and the government “safety nets” to be dismantled, on the theory that the “free market” fairy will solve our problems, even though there is no place on earth in which 21st-century medical care is being delivered by a “free market” system.

Leonhardt’s interviews show us that when it comes to health care, “profitable” and “effective” do not necessarily find their way into the same ball park. Weirdly, “profitable” and “cost-effective” are not necessarily fellow-travelers, either. That’s because the medical-industrial complex does not make a profit from curing you; it makes a profit from what it call sell to you, whether it cures you or not. And if two treatments are shown by studies to be equally effective, the industry will push the one that provides the higher profit.

Let’s go back to our gentlemen with early-stage prostate cancer. “You have cancer” has got to be among the worst pieces of news anyone ever gets. “You have cancer, but let’s not treat it” doesn’t sound much better, and I understand why some patients would push their doctors into providing some kind of treatment. Leonhardt says a Swedish study on treatment effectiveness recommends removal of the prostate gland for men under age 65. Such surgery can result in sexual dysfunction, however, so I understand why men may want another option. So doctors say, well, there is this new proton-therapy treatment …

One of the reasons the medical-industrial complex gets away with scamming us is that doctors themselves often do not know which treatment is most effective. There is remarkably little effectiveness testing going on. “Drug and device makers have no reason to finance such trials, because insurers now pay for expensive treatments even if they aren’t more effective,” Leonhardt writes. So the doctors often have little else to go on but what the sales reps tell them. And some doctors are as keen to boost their revenue streams as anyone else in the complex.

A critical part of President Obama’s health care proposal is called “comparative effectiveness research (CER).” CER is not, as the Right claims, a plan that would allow the government to countermand a doctor’s decisions based on cost-effectiveness studies. The common claim on the Right that CER is about rationing is a lie. The point behind CER is to fund the kind of effectiveness testing that is not being done now and provide that information to doctors and patients, so that doctors and patients can make more informed decisions about what course of treatment to pursue. (See also what Dr. Howard Dean says about CER.)

Of course, if CER becomes government policy, all those billions of dollars being invested to build proton accelerators to treat prostate cancer might not bring much of a return, which brings me to my last point.

Whenever I publish something about health care I get comments claiming that the private, for-profit health care industry is always better than “the government,” all we need is tort reform, blah blah blah, or that government (as opposed to the health insurance industry?) shouldn’t be involved in health care decisions. I agree with the latter; the government shouldn’t be involved in health care decisions, but nobody is saying otherwise.

The mendacious anti-reform talking points repeated ad nauseam by the dittoheads of the Right are generated by a network of right-wing think tanks and other organizations that exist solely to influence public opinion. This network is very good at getting their propaganda uncritically parroted throughout mass media and the Internet, repeated over and over until it becomes “common knowledge.” And in many cases the deep pockets funding those think tanks are also heavily invested in the medical-industrial complex. And round and round it goes …

Lies and the Lying Liars, Etc.

Last week in “Restating the Obvious” I quoted Erick Erickson of RedState:

Jay Rockefeller, Ted Kennedy, Barack Obama, and a host of liberal writers admit that the government will determine whether or not to treat you based on whether the government thinks the cost/benefit analysis makes sense.

And I asked if anyone knew were Erickson got such an off-the-wall idea. Well, I stumbled across the “source” yesterday. Harold P of Democracy for America says the righties are scrambling what’s called “comparative effectiveness research (CER).”

What is CER? Dr. Howard Dean explains:

At issue is something called “Comparative Effectiveness Research” which basically means giving your doctor access to the latest research on what treatments and therapies work and which don’t. This also helps doctors know which treatments are more expensive than others, and helps both patients and doctors decide if there is a cheaper treatment that is just as effective. As a doctor and the husband of a doctor, I know how important it is to have solid scientific research to make critical decisions for my patients.

This research will help doctors choose the best treatment for their patients’ situation and help them make more informed choices rather than risk prescribing less effective or even potentially harmful treatments.

Essentially, in order to control costs and provide patients with better care as we reform health care, the Federal Government will fund and disseminate research that evaluates the effectiveness of different treatments and medicines. This research will give doctors and patients better choices, and most importantly better health care for their money.

This is a common sense idea that should have been put in place a long ago.

Naturally, the Right is against it. Igor Volsky wrote for Think Progress on June 19:

During yesterday’s mark-up of the HELP Committee’s ‘Affordable Health Choices Act,’ Sens. Tom Coburn (R-OK), Pat Roberts (R-KS), Mike Enzi (R-WY) and Orrin Hatch (R-UT) introduced multiple amendments preventing the government from using the results of comparative effectiveness research (CER).

Of course they did. What else would you expect?

Responding to the Republican charges, Sen. Barbara Mikulski (D-MD) pointed out that existing language already prevented the new comparative effectiveness council from using the research to make coverage decisions. …

…The government isn’t mandating that doctors adopt the results of CER and it is not rationing care. Each patient has his or her unique needs and the ultimate decision for how to proceed should be left to the doctor and the patient. Currently, approximately one-third of all treatments have never been proven to produce better outcomes; CER would provide doctors with unbiased information about the most effective treatments, help doctors and patients make better informed decisions, and improve the quality of care.

(It seems to me that one of the results of CER might be that doctors do less over-treating and over-prescribing, which the Right has complained about for years. The Right’s complaints are in the context of scare stories about out-of-control malpractice litigation, charging that fear of lawsuits causes doctors to over-treat and over-test, thus running up the cost of medicine. However, this is a charge I’ve been looking into lately, and the “defensive medicine” claim appears to be mostly myth, albeit a myth many doctors believe. Over the past couple of decades several states have passed stringent “tort reform” laws that have drastically reduced the number of lawsuits filed in those states. And guess what? Doctors continue to order as many tests and as many treatments as they did before. But that’s another post.)

So how did the fevered imaginations of righties turn CER into rationing? You can trace that back to a column written in February by Betsy McCaughey. As Harold P at Democracy for America explains, McCaughey’s article is grossly inaccurate. But it established the conflation of CER with rationing, and the Right won’t let go of it.

Paul Krugman:

How bad is it? Let me count the ways.

  1. Politicians who rail against wasteful government spending are taking action to prevent the government from reining in … wasteful spending.
  2. Politicians who warn that the burden of entitlements is killing the federal budget are stepping in to block … the single most painless route to reducing the growth of entitlements.
  3. They’re doing it in the name of avoiding “rationing of health care” … but they’re specifically addressing taxpayer-funded care. If you want to go out and buy a medically useless treatment, Medicare won’t stop you.
  4. These same politicians are, of course, opposed to efforts to expand coverage. In other words, it’s evil for government to “ration care” by only paying for things that work; it is, however, perfectly OK, indeed virtuous, to ration care by refusing to pay for any care at all.

See also Ezra Klein

Restating the Obvious

There’s more commentary today on health insurance rescissions. Many are angry, but I’m not seeing anyone else state the obvious — the CEO’s insistence that they can’t stop recissions and make a profit; the implicit acknowledgment that they can’t insure people with preexisting conditions and make a profit; amounts to a confession that the private health insurance industry cannot solve the health care crisis. The “free market” is inadequate to the task of paying for modern health care.

And see Digby — the CEOs of the 23 top health insurance companies received $14.9 billion in compensation over a five year-period. You can provide a lot of health care for $14.9 billion.

What are the righties saying? So far the only reaction I’ve seen is from Erick Erickson of RedState. Taking his comments in reverse —

More damning, the White House cannot think of a single example of a single-payer system in the world that works.

Apparently White House spokesman Robert Gibbs was caught inexcusably flat-footed on a question about which single-payer system in the world “works.” I can answer that, but first let’s turn the question around — name a single nation in which 21st-century health care is being delivered by a “free market” system, at all.

{Cricket Chirps}

The United States is the only industrialized democracy that pretends to have a “free market” system, although in fact a large part of our health care costs are being paid by government, anyway. And the World Health Organization says ranks the U.S. at #37, behind Costa Rica, in terms of quality and fairness of our system.

In other words, there are 36 nations with some form of government-paid national health care system, several of which are single-payer, that are doing a better job than we’re doing in delivering health care.

Erickson also says,

Jay Rockefeller, Ted Kennedy, Barack Obama, and a host of liberal writers admit that the government will determine whether or not to treat you based on whether the government thinks the cost/benefit analysis makes sense.

Does anyone have any idea where Erickson got that idea? I’ve seen no such admission, and of course Erickson doesn’t provide a link.

Life as a Preexisting Condition

The must-read new story today is by Lisa Girion of the Los Angeles Times. In “Health insurers refuse to limit rescission of coverage,” we find the clearest case yet why the private health care industry will never, ever, not in a million years, come even close to solving the health care crisis.

In a nutshell — yesterday three big insurance company executives — WellPoint Inc., UnitedHealth Group and Assurant Inc. — told the House Subcommittee on Oversight and Investigations that their business models depended on being able to cancel the health insurance policies of customers who cost them too much money. An investigation by the Committee had found that over a five-year period, these companies had canceled the coverage of more than 20,000 people in order to avoid paying more than $300 million in medical claims.

One of the execs claimed the rescissions — industry jargon for canceling coverage — were necessary to protect the companies from fraud. People lie about preexisting conditions on their applications, he said, and this drove up the cost of insurance for everyone else. I’ll come back to this point in a moment.

In practice, this means insurers target people with high-cost conditions such as breast cancer and lymphoma and direct employees to examine patients’ paperwork for any pretense to cancel coverage. People with innocent mistakes and inadvertent omissions; people who were unaware of a preexisting condition at the time they filled out the application because the symptoms hadn’t developed yet; people whose preexisting conditions were minor and had nothing whatsoever to do with the disease costing the insurer money — such people found themselves dumped out of the health care system at their time of greatest need.

A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne.

The sister of an Illinois man who died of lymphoma said his policy was rescinded for the failure to report a possible aneurysm and gallstones that his physician noted in his chart but did not discuss with him.

Karen Tumulty at Time presents several other heart-breaking, and outrageous, examples.

Of course, you might remember that Michael Moore documented this practice quite nicely in Sicko. We all knew this was going on. Members of the House Committee feigned surprise.

But I want to go back to the part about rejecting people with preexisting conditions. Who above the age of 40 does not have a preexisting condition? For that matter, what percentage of young adults freshly cut loose from their parents’ policies find they cannot obtain insurance because they failed to get through childhood without a preexisting condition?

The insurance companies are saying they can’t make a profit unless they deny coverage to people with preexisting conditions. How is this not an admission the private health insurance industry is a big, fat FAIL?

Righties just love to tell us that the reason health insurance is so expensive in some states, like New York, is that those states have (Cue: “Fortuna, Imperatrix Mundi (O Fortuna)”) regulations. And what are those regulations? Chief among them are provisions that limit the insurers’ abilities to deny coverage to people with preexisting condtions.

So, in many states, a middle-aged person with no serious health problems who was once prescribed Lipitor for high cholesterol would be unable to obtain health insurance at any price. In New York, this person can get insurance. Yes, it’s so expensive most people can’t afford it, but it’s obtainable for those who can pay for it.

What this says to me is that relying on a private insurance industry to pay for health care costs is unworkable. A private insurance industry simply cannot do the job of paying for health care, because the only way a private company can make a profit is to deny coverage to people who are actually sick so that they don’t have to pay those bills.

My next question is, how obvious does this have to get before people see it?

I’m sure some people do lie on their insurance applications in order to obtain coverage. But in most industrialized democracies, this wouldn’t even be an issue. You’re a citizen, you get health care. Whether you once had acne treatments or took Lipitor or had a gallstone or even had a life-threatening disease, you get health care. Because the purpose of the health care system in most countries is delivering health care, not making a profit.

And for those worried about the cost to government of providing health care to sick people, let me present this handy chart:


This chart was adapted from a Canadian site calling for health care reform in Canada. The Canadian system has its problems, but I suspect seeing the mess we’re in persuades many Canadians to leave well enough alone. At least Canadians can get health care.

I believe the only way we’ve got a shot at lowering per-capita cost while delivering health care to everyone is to kick the insurance companies out of the picture altogether and going to a purely public system. At least a public health insurance plan would be a step in that direction.

Regarding the recently released CBO estimate of $100 trillion over ten years — see Extra Klein for why the CBO estimate is deeply flawed. See also “The Bright Side of the CBO Snafu.”

Steve McMahon Is So Wrong

I caught the segment in the video below on Hardball yesterday. If you don’t want to watch, it’s a discussion among Tweety, Democratic strategist Steve McMahon and Republican strategist Todd Harris. McMahon thinks the Democratic Party should cut the public insurance option from the health care reform package and pass a “compromise” bill without it.

McMahon thinks the health care package won’t pass with the public insurance option but could pass without it. He thinks it’s better for Congress to pass something it can call “health care reform” now rather than have the whole effort defeated because of the public insurance option. We have a window of opportunity to pass a health care reform bill, he says, and if we miss this window and pass nothing there may not be another chance for years.

My thinking is just the opposite. If Congress passes a bill without the public insurance option, it will confirm the darkest beliefs of Americans about government being irrelevant to their lives. I sincerely believe that the rest of the legislation might make some marginal improvements in the system. It might make a tangible difference for a few people. But it would do nothing that will make a big, tangible difference in the lives of most American citizens.

So if they pass this bill without the public insurance option, there will be a big whoop-dee-doo in media about how now everybody’s got health care reform. And the days and weeks and months will go by, and most people won’t notice that anything has changed.

This is, I think, the absolute worst thing that Congress could do. It would be better to let the whole thing be defeated, then go to the American people and say, look, we tried to get you this meaningful reform, but Republicans and Blue Dog Democrats blocked it. And, yeah, that’s a lame excuse. But I think rank and file Dems, and many Independents, are sick to death of these pathetic tweaks that Washington mistakes for accomplishments but which don’t make any real difference in the lives of Americans.

In the long run, whether a bill was passed with bipartisan support or not will mean absolutely nothing. If a bill passes that really does relieve many of our fears of losing our insurance and being dumped out of the health care system altogether, that bill will be very popular. Before long, politicians who didn’t support it will pretend that they did. There’s your bipartisan support.

On the other hand, a “compromise” bill passed with everyone in Congress holding hands and singing “Koom By Ya,” but which does not make a tangible difference in peoples’ lives, won’t mean a bucket of warm spit by the time the next elections roll around.

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Why the AMA Is Selling Us Out

We shouldn’t be surprised that the American Medical Association has come out against government-sponsored insurance plan. The AMA these days has many concerns other than medicine. It is a main proponent of “tort reform,” a vast right-wing conspiracy to enhance corporate profits by denying citizens’ 7th Amendment rights to sue for damages in court.

Although it still pretends to be the voice of American physicians, in fact it has been losing membership steadily for the past several years. The most recent information I could find says that about a third of American physicians are members. It has struggled financially with dwindling membership dues.

The AMA and the American Council of Engineering Companies are co-founders of the American Tort Reform Association (ATRA), which has turned into an umbrella group of special interests and astroturf organizations pushing for tort reform legislation. The ties of “tort reform” to the Right, via Karl Rove, are legendary.

Take, for example, the organization Citizens Against Lawsuit Abuse (CALA), which has chapters in several states actively pushing “tort reform” to state legislatures. According to SourceWatch, CALA is an astroturf organization commissioned by the Philip Morris tobacco company in 1995, and Philip Morris continues to fund and direct CALA through ATRA. SourceWatch says,

A “privileged and confidential” Philip Morris (PM) tort reform budget from 1995shows that PM spent over $16 million to instigate tort reform during that year alone, and that PM paid an international public relations firm called APCO & Associates (now known as APCO Worldwide) almost $1 million in 1995 to implement tort reform efforts behind the scenes.

ATRA promotes CALA on its website (scroll to bottom) as

… citizen activists fed up with the high cost and injustice in our legal system. They work actively within their communities to urge individual responsibility, safety, and to chronicle abuses of the legal system and to fight for civil justice reform.

Yeah, right.

It is ironic that the AMA, which 20 years ago stood up to the tobacco industry by calling for a ban on tobacco ads, is now in bed with it. They’re shacked up in a shabby off-the interstate motel hoping no one finds them, but they’re in bed just the same.