By Naomi Freundlich and Maggie Mahar
This year the rhetoric around health care reform reached historic levels. Barely a week went by without pundits dissecting some new fact, policy detail or wording change implicit in the various reform plans emerging from Congress. The result was a barrage of media reports, often conflicting, that heralded the demise or success of reform on a regular basis. Twisted facts, reactionary politics and just plain scare tactics have been pervasive.
\Below, “The 10 Most Destructive Lies about Health Care Reform in 2009” and “ The Ten Most Constructive Insights, Suggestions and Questions.”
Heath Care Reform: The 10 Most Destructive Lies
1.) Seniors and the disabled "will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care."
Sarah Palin made these comments on her Facebook page, responding to a provision in the House health care bill that would provide compensation to doctors who consult with patients about end-of-life care. The lie quickly spread—repeated at town hall meetings, tea parties, on Fox TV and throughout the Conservative blogosphere.
2) “You lie!” Joe Wilson’s angry shout-out to President Obama in the middle of his speech before the joint session of Congress made headlines this fall. Wilson was responding to Obama’s promise that health reform will not include coverage for illegal immigrants.
3)"President Obama . . . wants to mandate circumcision." (Rush Limbaugh)
4) “Despite public statements by Pres. Barack Obama that ‘no federal dollars will be used to fund abortion,’ all of the major bills under consideration would put the federal government into the business of subsidizing elective abortion on a massive scale.” Minnesota Citizens Concerned for Life
“The Kennedy bill would result in the greatest expansion of abortion since Roe v. Wade.” according to National Right to Life Legislative Director Douglas Johnson
This charge, made by Conservative groups like the Family Research Council (which ran an ad with a distraught older man telling his wife that Medicare won’t pay for his back surgery because the government is spending too much on abortions) helped fuel opposition to reform.
5) “I have a message for you–You’re gonna die sooner!”
Dec. 1 2009 Senator Tom Coburn (R-OK) on the floor of the Senate warning senior citizens. Coburn was speaking about proposed Medicare cuts that could total billions of dollars. In fact, savings would come from removing the waste and over-treatment that plague the program.
6) “Health care reform will mean women won’t be able to get mammograms…”
Carly Fiorina, candidate for U.S. Senate from California made this statement during a weekly Republican address. She exploits her experience as a breast cancer survivor to make her case against health reform:
“Will a bureaucrat determine that my life isn’t worth saving?,” she asked before suggesting that the Senate health care bill would allow the Task Force to ration cancer treatments.
7) The Department of Veterans Affairs has "a manual out there telling our veterans stuff like, 'Are you really of value to your community?' You know, encouraging them to commit suicide." (Michael Steele)
8) "Take your AARP card, cut it in half and send it back. They've betrayed you," McCain told seniors after the group endorsed Medicare cuts. The Senator proposed an amendment that would “strip” the cuts from legislation—even though he had no intention of voting for the bill anyway.
9) “Obamacare Could Kill You” David Catron, writing in The Spectator, warns that a Federal Health Board will be used to make life and death decisions based on cost-effectiveness – deciding, for example when a drug’s expense has become too high to justify giving it to dying cancer patients.
10) A data-storing microchip "would be implanted in the majority of people who opt to become covered by the public health care option." (chain e-mail that found its way into the blogosphere)
Health Care: The 10 Most Constructive Insights, Suggestions and Questions
1) Maybe Washington Post columnists should have term-limits? County Fair, November 22, 2009, Jamison Foser
2 ) The greatest threat to America’s fiscal health is not Social Security,” President Barack Obama said in a March speech at the White House. “It’s not the investments that we’ve made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation’s balance sheet is the skyrocketing cost of health care. It’s not even close.”
3) “Having Scott lead the charge against healthcare reform is like tapping Bernie Madoff to campaign against tighter securities regulation.” Christopher, Hayes, writing in the Nation,” commenting on Rick Scott, the founder of Conservatives for Patients Rights who is best known as the former CEO of Columbia/HCA, the for-profit hospital chain that was forced to pay $1.7 billion to settle the largest health care fraud lawsuit in history.
4) “Most Americans would be delighted to have the quality of care found in places like Rochester, Minnesota, Seattle Washington, or Durham, North Carolina—all of which have world-class hospitals and costs that fall below the national average. If we brought the cost curve in the expensive places down to their level, Medicare’s problems (indeed, almost all the federal government’s budget problems for the next fifty years) would be solved. The difficulty is how to go about it.” Dr. Atul Gawnde
5) “If No Republicans Will Join, Why Should the Democrats Negotiate with . . . . Nobody?” asked Chris Matthews after grilling Republican Orrin Hatch on what it would take to get him to vote for health care reform.
“Would you sign on to any health reform bill this year?” Matthews queried. “Assume they dropped the public option and put in tort reform would you sign on? . . . or is this just a stupid negotiation? Are the Democrats just negotiating with themselves?”
6) “Name any stakeholder – hospital, physician, nurse, insurer, pharmaceutical manufacturer, supplier, even patients’ groups – every single one of them says, 'Oh, we need change! We need change!' But, when it comes to specifics, every single one of them demands to be kept whole or made better off.
“We are stuck in ‘the Tragedy of the Commons. The smart strategy for each person separately is not the best strategy for all people together. What is good for ‘me’ is not good for ‘us.’ Just like the villagers, health care stakeholders are eroding a common good by doing what makes sense for each of them, separately. In the short run, everyone wins. In the long term, everyone loses.” Dr. Donald Berwick, delivering the keynote address at Institute for Health Care I mprovement’s (IHI) 21st Annual National Forum on Quality and Improvement in Health Care,
7) Here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community has come to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers.” Dr. Atul Gawande, commenting on over-treatment in McAllen, Texas in “The Cost Conundrum.”
8) Over the past year, “the profit margin for health insurance companies was a modest 3.4 percent. Among the large, for-profit health insurers, profit margins line up with the industry as a whole: UnitedHealthGroup, the biggest health insurer, had a 4.1 percent profit margin over the past 12 months. WellPoint, the next biggest, had a 4 percent profit margin. Aetna, Cigna, and Humana came in below that.”
By contrast, “Pharmaceutical companies have a profit margin of 16.4 percent,” seventh highest of the 215 industries that Morningstar tracks. . . The big money isn’t in the insurance industry.”(Rick Newman, writing in U.S. News & World Report)
9) “An Independent Medicare advisory commission of doctors and medical experts charged with identifying waste can help encourage the adoption of common-sense best practices by doctors and medical professionals throughout the system — everything from reducing hospital infection rates to encouraging better coordination between teams of doctors.” President Obama, in a speech to Congress just after Labor Day
10) “Health Bill Alone Won't Stem Costs: White House” Reuters, reporting on White House Budget Director Peter Orszag’s comments on health care legislation. Orszag “indicated that other actions outside of Congress would still be needed to improve how medical care is delivered, including the Senate's proposed independent commission to oversee parts of Medicare.”
There is one other good that I believe can result from this legislation: the opportunity for us to see how this plays out, in the short run.
I believe it has been estimated by a reputable government agency, with no change, Social Security and Medicare, could consume 90% of federal expenditures by 2050.
So, with the legislation, at least we have a chance for positive change.
However, we need to see the law as changeable, flexible, so that what is not working can be improved upon.
We need abrupt change to get the process started.
Don Levit
Disingenuous Claims by HCR Bill Salespersons
Arvind Agrawal: Wed at 8:26pm
The disingenuous or false statements made by Team Obama and collaborating members of Congress, to transform the critique of the Bill into praise and gratitude by the public, are sickening and demoralizing. Their credibility can not be raised by constant repetition by increasing number of protagonists. Unfortunately many hosts who were challenging the falsehoods head on are doing so less and less, perhaps because they are getting tired and increasingly resigned to inevitability of a flawed bill. However this technique can not work because it will be very hard to create a collusion involving millions of progressives and independents. It is too bad that many defenders want to be trusted because of their eons of experience in the Washington scene, which has not even helped them develop enough intellectual honesty to recognize this basic concept. Some of the most egregious half truths going unchallenged are:
1) Subsidies and exchanges etc start in 8014, thus all this sobbing about 45k dying is at best crocodile tears. If true ED we should not be talking any other topic at all. Do you not want to see how can we stop these deaths immediately?
2) Insure 31M (not 47M) by 2019, not exactly a crash program, is it? Why do they not point out that tax payer money will be squandered on high bone crushing premiums (and more than proportionately higher subsidies) which are projected to grow 111% by Ins Industry’s own estimates.
3) No clear description of what new alternatives, which provide the same cost lowering and competition as the Public Option, have been created and which were not present in Obama Campaign’s Health Care plans.
4)Ban the insurance denial based on pre-existing conditions. Bu the differential of older people with pre-existing conditions can be upto 300% in the Senate Bill and 200% in the House Bill. The same number is 20% in Vermont state regulation. At this number people higher than 400% poverty level will not find it affordable. For those eligible for subsidies, tax payer will be hit for obscenely high amounts.
I agree with Don — they really key part of this legislation is that it gets us started. Major adjustments will be needed, but we’re started. The other key part to me is the establishment of the principle that insurance underwriting by individual health history — denying coverage based upon past history — will not be allowed anymore.
Don, Chris and Facebook
Don– I agree that this has to remain very fluid and flexible.
I remain concerned that conservatives in Congress will make that impossible, blocking every attempt to cut Medicare spending, for example.
This is why it is so impt. that the Rockefeller amendment that would strenghten the Medicare Commission passes. . .
But I also see no alternative to passing this bill. And with luck,
it will get the process started.
Much depends on who is elected to Congress in 2010–and whether the Democrats win in 2012.
Chris–
Yes, this legislation seems to make two very important statements : 1) society has an obligation to provide insurance for everyone and 2) insurers cannot shun the sick–or gouge them.
Younger Americans will all be in teh same pool, whether they are -sick or heatlhy.
I’m hoping that there is no turning back from those principles.
If so, this is a start.
But . . conservatives could still repeal all or part of this legilsation before 2014.
Once people realize that when folks with pre-existing conditions are in the pool, premiums rise for everyone, they will Not be happy. (Most people haven’t figured this out.)
It’s only if you live in one of the very few states that have community rating and guaranteed issue that you realize how much insuring the sick increases premiums.
And if we don’t stiffen the mandates, premiums will be much higher, because a great many young, healthy people won’t buy insurance. They’ll pay the modest penalty. . . .
Finally, would feel much better if this was going to roll out in 2013, making it more
difficult for conservatives to repeal it if they win the election in 2012.
Facebook–
This reform could not be rolled out as quickly as some hope because the logictics are going to be very complicated.
At least we’re moving to protect the most vulnerable immediately– children with pre-existing conditions.
But even if we could give insurance to everyone who is now uninsured tomorrow, that won’t help them much unless
a) it is comprehensive insurance that they can afford to use and
b) there are doctors and nuress available to provide the care.
What people need is health CARE not health INSURANCE.
Making sure that the insurance transaltes into high qualify, affordable care won’t be easy.
The insurers have to be regulated; subsidies have to make it affordable (rigiht now even some who receive subsidies won’t be able to afford to actually use the insurance because co-pays will be too high.).
Before trying to give everyone insurance, we need to bring down the underlying cost of care.
Bottom line: you can’t flip a switch and make a totally irrational, fragmented and wildly over-priced health care system suddenly rational and affordable.
That said, I agree that charging older people 3 times as much is tantamount to charging for pre-existing condtitions.
And secondly, I agree that we shouldn’t wait until 2014; that we should be able to roll out reform by 2013.
Finally, I would point out that the notion that 45,000 die each year Because They Don’t Have Insurance is a number made up out of whole cloth.
Uninsured people die each year. But we have no way of knowing what would have hpapened to them if they had insurance. Insurance doesn’t say your life. Excellent care might save your life–and it might not.
According to Dr. Steve Schroder having access to health care (or not) is only a 10% factor in whether or not you die prematurely of a treatable disease.
Poverty, and all of the problems that correlate with porvery is a 40% factor.
If we wanted to do something to really help people between now and 2014, we would launch a war on poverty, focusing on education, nutrition, housing, public health . . . .
Maggie – I find most of your points persuasive, but I must disagree with your conclusion that there is no clear evidence that lack of insurance is responsible for up to 45,000 deaths annually in the U.S. The Harvard study estimates the number as between about 35,000 and 45,000 deaths attributable to the lack of insurance AFTER correction for confounding variables such as income, smoking, alcohol, obesity, and a variety of other factors that exert their own effects. The numbers cited in the study therefore do not appear to be contaminated by these confounding factors. These are estimates, of course, and as in other epidemiologic studies, can never yield evidence for causality as conclusively as would be possible in a controlled experiment, but it is unlikely they are very far off. The study, in fact, suggests reasons why they may underestimate the true effects, and so until better data emerges, they should serve as a valuable guideline.
The link to the study is
http://pnhp.org/excessdeaths/health-insurance-and-mortality-in-US-adults.pdf
Agree that neither of the bills does much to control costs which is the ultimate issue that we all must confront.
Politicians though will be the last to use the inevitable “R” (rationing) word. Because right now it is poltical suicide to even imply that ANY treatments would/should be reduced or denied.(even though some actually do direct harm)
The big elephant in the room which we are beginning to dance around remains the death and dying issue.
We need a serious sober national dialogue on this issue to begin to grow up and to fix US health care.
Dr. Rick Lippin
Southampton,Pa
Fred–
According to the Institute of Medicine 18,000, not 45,000 Americans die each year because they don’t have insurance. And IOM makes it clear that this is an “estimate.” See http://www.kff.org/uninsured/upload/the-uninsured-and-their-access-to-health-care-fact-sheet-6.pdf
Neither IOM –nor the Kaiser Family Foundation, which quotes IOM, has a reason to low-ball how many people die becuase they don’t have insurance.
Unfortunately, the Harvard study is affected by the PHNP bias. Wollhandler, et. al. are single-payer advocates (PNHP is the physician organization for single payer folks and its members are adamant that single-payer is the ONLY solution to our healh care problems. They insist that Insurers ARE THE PROBLEM.
(I’ve talked to physicians who originally joined PNHP, and then left because “they’re Stalinists.”
PNHP is convinced that if we just eliminated the private insurance system, we would have an affordable system.
Unfortuantely, they often exaggerate the numbers–how much insurance adds to the cost of care–and how many people die because they dont’ have insurance.
They’re not very interested in how many people die prematurely just because they are poor becaue that doeson’t support their thesis that if we just had Single-Payer the problem of premature death in the U.S. would be solved.
Here’s the problem: it’s very, very difficult to adjust for all of the variables and determine whether lack of insurance was the “cause” of death–or whether some combination of poverty, lack of insurance, etc., was the cause. (2/3 of the uninsured are poor).
We do know that the uninsured are more likely to die if they are in a traumatic accident–or if they have cancer– than the well-insured.
This is becuause not having insurance can delay treatment.
This is because private hospitals will often transfer an uninsured patient (say, an accident victim) to a public hospital, saying that they don’t have room.
This is because the uninsured often wind up at public hosptials that have fewer resources than private hospitals–fewer nurses, tests take longer, residents maybe working unsupervised, etc. etc.
For example, Harlem hospital using many fewer resources when treating a Medicare patient than NYU Medical Center does when treating a very similar patient.
In addition, because so many of the uninsured are poor they are usually not well-educated and may have difficulty communicating with doctors.
Finally, because many of the uninsured are African-American or Latino, doctors and nurses treat them differently, are less likely to give them pain-killers, etc. (Pain actually can kill.)
Meanwhile, the poor die 6 years earlier than wealthy Americans for a number of reasons that have to do with the environment they grew up in, poor nutrition, fewer opportunitites to excercise, etc.
In addition, poor Americans insured under Medicaid don’t live as long as Americans who are insured by Medicare or private insurance.
Care under Medicaid tends to be sub-par. The patient has insurance, but is likely to be treated in a separate part of an academic medical center that is staffed by residents working with fewer resrouces than the doctors “upstairs” who see the patients who have private insurance.
Meanwhile, the poor cancer patient is likely to be less healthy to begin with simply because of the amoutn of stress in his life.
What role does stress play in determining which cancer patients survive and which don’t? We don’t know.
How does one separate all of these factors say how many Americans die “because they don’t have insurance.”
Clearly, it’s a very subjective process and, unlike IOM and Kaiser, PNHP has an axe to grind and a long history of playing wtih the numbers.
Dr. Rick–
I agree that while the bill opens to door to let Medicare begin to control costs it doesn’t guarantee cost control.
But I would say the elephant in the middle of the room is not “death” but rather “over-traeatment.”
Too many people think that some huge percentage of our health care dollars are spent in the final six months of life when people are dying.
The fact is 80% of our health care dollars are spent on people with chronic diseases–diabetes, heart disease cancer, arthiritis, depression, etc.
These “chronic” diseases are, by definition, long-term diseases.
And while we don’t “manage” them very well (with early low-tech interventoin) we do over treat them (with aggressive care– bypasses, angioplasties, chemo, knee surgery when the patient has arthritis (and surgery won’t help); radiation and surgery for eaarly stage prostate cancer (when we have no evidence that these treatments extend lives) and “screening” for heart disease and cancer.
Certainly our American fear of death makes patients perfectly willing to go along with being overtreated, but I don’t think we want to focus the debate on end-of-life care.
IF we just focused on the overtreatment listed abovev, and put more emphasis on low-tech preventive care, we could save billions without getting into the moral and religous quagmire surrounding the issue of whether or not we shoudl “do everything possible”.
That question should, I think, be left up to the patient himself or herlself, in consultation with a palliative care specialist who explains the options honestly, and helps the patients sort out his or her feelings, fears and hopes.
If at all possible, the patient, not the patient’s family, should be making the decision.
Maggie – We can probably agree that many thousands of deaths annually are attributable to lack of insurance. Whether it’s 18,000 (the IOM report) or 35,000-45,000 (the Harvard study), it’s a tragically large number.
The Harvard study referenced the earlier IOM report, while indicating it was based mainly on data that were 20 years old, and so the 18,000 figure does appear to be outdated. The larger figure is based on what I perceive to be a rigorously performed epidemiologic analysis, and while I agree with you that confounding factors, including income, can only be adjusted for but not made to disappear, it’s hard for me to imagine that the 35,000-45,000 figure for deaths attributable to insurance lack is very accurate.
Even the lower figure from the earlier report would be an imperative to do what the current reform packages are proposing to accomplish, albeit incompletely – provide adequate insurance to the uninsured.
Finally, I totally agree with you that poverty as a contributor to ill health and premature deaths is a national disgrace that must be addressed in its own right.
Re my just-posted comment, I meant to say that it’s hard to imagine that the Harvard study’s figure of 35,000-45,000 excess deaths due to insurance lack is very far from accurate.
The true numbers may be slightly higher or lower, but probably not greatly different from the cited estimates.
Fred–
In 2009, Health Affairs published an article explaning how PNHP distorted the facts to arrive at 45,000.
Btw– I wish you would trust me when I report explain numbers. I’ve spent so many years doing this, as a reporter,
both covering Wall Street and covering health care.
You can almost “smell” bad numbers. The case they make is too good to be true– or too bad to be true. It’s surprising. And the folks publishing the numbers have an agenda.
PNHP’s numbers cannot be trusted. Period.
They are adept at creating what looks like a very sophisticated study– but they fudge in many ways to get the results they want.
In 2009, Health Affairs printed an article explaining how the PNHP study exaggerates.
Here is what John Goodman explains in the Health Affairs piece:
“Physicians for a National Health Program (PNHP) has just repeated the exercise (with all its methodological sins) and boosted the tally to a 40% increase in the probability of dying for the uninsured. [note to Fred a 40% increase in unlikely–especially since, as Dr. Atul Gawande recently pointed out, we haven’t seen huge advances in the past 20 years. The huge advances came in the 60’s, 70’s and into the 80s. )
Goodman continues;
“That produces a whopping 45,000 premature deaths every year — almost as bad as the Vietnam War. And, yes, we get a state-by-state breakdown. There will be 5,302 deaths attributed to uninsurance in California this year. There will be 75 in Wyoming, etc., etc. There is even a minute-by-minute tally: “The Institute of Medicine, using older studies, estimated that one American dies every 30 minutes from lack of health insurance,” says David Himmelstein, one of the authors. “Now one dies every 12 minutes.”
(Himmelstein is one of hte leaders of PNHP. They love dramatic sound bites like “one every 12 minutes.”)
Goodman points out that “As in the previous [studies done by others t]he researchers interviewed the uninsured only once — and never saw them again.
A Decade Later, the Researchers Assumed the Participants were Still Uninsured and, If they Died in the Interim, Lack of Insurance Was Blamed as One of the Causes.
Yet, Like Unemployment, Uninsurance Happens to Many People for Short Periods of Time. Most people who are uninsured regain insurance within one year. The authors of the PNHP study Did Not Track What Happened to the Insurance Status of the subjects over the Decade examined, what medical care they received Or Even the Causes of their Deaths.
Also, before you go into mourning too quickly, be aware that when former Director of the Congressional Budget Office (CBO) June O’Neill and her husband Dave used a similar approach, they found that the involuntarily uninsured (low-income people) were ONLY 3% More Likely to Die over a 14-Year Period than those with health insurance. There was no statistically significant effect on the “voluntarily uninsured” (higher-income people).
That’s not too surprising in light of a RAND study finding: Although people are receiving appropriate care a little better than half the time when they see doctors, the care they receive is not affected by whether they are insured or by the type of insurance they have. People who are uninsured, of course, may delay seeing a doctor in the first place — because of their lack of insurance. . . .”
Now, Goodman also has an axe to grind: he is opposed to single-payer and govt’ controlled insurance.
But he isn’t the only source who questions teh PNHP figures.
As Dr. Steve Schroeder, (who has an impeccable reputation as fair-minded ) pointed out in the Shattuck Lecure of two years ago (published in NEJM) access to health care– or lack of access to healthcare– is only a 10% factor in accounting for premature deaths.
Poverty is a 40% factor.
We all like to think that if we just gave everyone health insurance and they got health care, everyone would be much healthier.
Unfortunately, medicine isn’t all that it’s cracked up to be.
Even when detected early, many cancers are incurable.
Doctors haven’t found an answer to obesity: even if patients diet and excericse under medical supervision, very, very very few obese people are able to take weight off and keep it off.
It’s a very complicated disease.
Bariatric surgery is an “answer”–but the surgery kills some people; others never fully recover. It’s dangerous and a last ditch solution only for those who are morbidly obese.
Think of it this way: we spend far more on healht care than any other deveoped country. Americans undergo many more surgeries, take more tests, see more specialists etc. etc.
Yet we are not as healthy, overall, as most other populations. If healthcare was all that it is cracked up to be, we should be healier.
The reason we’re not: we tolerate much higher levels of poverty.
Maybe, one day, if we do manage to get nearly everyone “covered” by health insurance, we’ll finally admit that this is not the answer.
Healthcare helps (10%) — a war on poverty could domuch more (and did do much more from the 60’s into the 70s–when we began to lose interest in the poor.)
Maggie – Although we’ll continue to agree on the dangers of being uninsured, we may continue to disagree about the Harvard study estimates of up to 45,000 deaths annually attributable to lack of insurance. It’s not that we can be confident that the Harvard figures are extremely accurate, but I haven’t seen evidence to suggest that they seriously overestimate the higher death rates.
I’ve looked at several sites critical of the study, and the principal criticism has been that one of the sources only looked at insurance status at one point in time. However, if that weakens the accuracy of the data, it does it by underestimating rather than overestimating the mortality differences. This is because some individuals classified as uninsured might have been insured at another point, and the converse would be true for those classified as insured. This has the effect of making the two groups appear more alike than a pure population of insured or uninsured individuals would prove to be.
There may be other methodological flaws that significantly weaken the study’s conclusions, but I haven’t seen them clearly identified. I’d be interested in further analyses by epidemiological experts in this area if you or others can reference them. As someone who is not an expert epidemiologist, I realize my obligation to be cautious in making judgments.
It’s probably reasonable to remain open to further data on this topic, but regardless of the exact values involved, they reinforce the need for us as a society to provide better access to healthcare for more peoople than currently have it.
Fred:
The vast majority of people who are uninsured are uninsured for short periods of time.
So when you interview them once, don’t talk to them again for 10 years, and assume that they were uninsured when they died, you are greatly overestimating the number who were actually uninsured when they died.
I just read an article in the most recent NEJM which gave “20,000” as the number of people who die annually as a result of being uninsured –not 35,000 or 45,000.
Few experts believe the PNHP number.
It’s tragic when people die because they don’t have insurance.
But it’s even more tragtic that in the U.S. such a large percentage of children live in poverty–and die 6 years earlier than people who grew up in wealthier households.
The research shows that if a child manages to get an education, earns a Ph.D., become upper-middle-class, he/she still dies earlier –and, in the case of women,is much more likely to experience complications during pregnancy.
Medical care cannot undo much of the damage done in early chldhood.
However many thousand extra deaths are attributable to lack of adequate insurance, it’s far too many.
To return to some political happenings, I enjoyed a cartoon that appeared today in the Pittsburgh Post-Gazette. It depicted an elephant dressed in a white coat, wearing a stethoscope, and holding a medical chart standing by the bedside of a patient with an i.v. drip running. The patient was labeled “Senate Healthcare Reform”.
In one panel, the elephant was telling the patient, “We’ve done everything we could”.
In the next panel, he continued, “But you’re going to live anyway.”
Oh my, what a bunch of partisan BS. Why do you have to be that way?
Maggie,
Thanks for the correction to my comment below.
In thinking about it you are correct to say that overtreatment is the more important central issue than death and dying.
And as you say, it avoids the legal, ethical and religious quagmires that the death and dying issue would precipitate.
Be Well,
Dr. Rick Lippin
Southampton,Pa
Fred & Dr. Rick
Fred– Wonderful cartoon!
Dr. Rich– Thanks- I do think we want to steer clear of the end-of-life debate.
I would love to see expanded, better-paid palliative care let patients make those decisons.
Debating it in the pulic sphere just leads to the “death panel” talk.
Though, like you, I think that our American fear of death goes a long way toward explaning overtreatment in the U.S.
Maggie wrote:
“The reason we’re not (healthier): we tolerate much higher levels of poverty.
Maybe, one day if we do manage to get everyone ‘covered’ by health insurance, we’ll finally admit that this is not the answer.”
I agree with you and Fred’s remark also.
But, one need not be in poverty or even at 200% of poverty to feel the stings of unaffordable health insurance.
We are looking at subsidizing families up to 400% of poverty.
From 2003 t0 2008, employer premiums as a percent of median household income for the under-65 population went from 15% to 17.2%.
This is the type of environment we are about to pass legislation to continue to get nearly everyone ‘covered’ before we realize what the more important fiscal problem is!
It seems to me a very heavy price to pay.
Isn’t there another way to distribute general revenues that could provide more “progress”?
Don Levit
Don–
We’re going to have to rein in the underlying cost of care before we roll out something approximating universal coverage in 2014 (or 2013).
If we don’t, the insurance will be unaffordable both for patients and for taxpayers. Premiums have gone up so much because the underlying cost of care has soared.
“But I would say the elephant in the middle of the room is not “death” but rather “over-traeatment.”
Too many people think that some huge percentage of our health care dollars are spent in the final six months of life when people are dying.
The fact is 80% of our health care dollars are spent on people with chronic diseases–diabetes, heart disease cancer, arthiritis, depression, etc.”
I think you’re both on to something, but I’d like to refine these ideas a bit (or attempt to do so).
Maggie you’re right that chronic disease care represents the lion’s share of spending. But as a clinician – and I’m admitting this may be a biased perception – so much of the overtreatment; so much of the extremely expensive care that does not seem to do any good for the patient; seems to come at the end of life. Aggressive intensive care type deaths for people with terminal disease and no prospect of meaningful recovery are just so palpably wasteful. Compared to, say, an expensive antihypertensive drug or antihyperglycemic, which surely does have a large long term cost, but holds out the possibility of improving health and quality of life for the patient.
So I do agree that “overtreatment” is potentially a helpful way to focus our thinking about cost effectiveness – let’s work to reduce treatments that do not contribute to healthy outcomes, regardless of where they fall in the life span or health-illness spectrum. But I do think we will run in to the fact that it is often at or near the end of life that treatments are very likely to provide decreasing marginal benefit.
A lot of these issues do revolve around culture. We have a culture of “more is better,” which often leads to overtreatment. We also have a death-denying culture, in which it is extremely difficult to make sound decisions about care at the end of life and to accept death peacefully. This also contributes to overtreatment.
Trying to skirt around end-of-life issues because confronting them will be culturally difficult and generate controversy will not be ultimately productive. Just as we have to confront our “more is always better” cultural bias, we will also have to confront our “prolong life as long as possible no matter what” cultural bias.
I’m with Dr Rick. I do think we need a sober serious national dialogue about these issues. It is by defintion not going to be an easy dialogue, but that is part in parcel of why it’s so important to engage these issues.
Alath–
I appreciate your thoughtful comment.
But in our very diverse culture, I don’t think we’re going to reach a national consensus on end-of-life care.
Religion plays an important role in how people view the issue. Some believe that a higher power decides when we die.
I dont’ share that belief, but I do recognize that it is deeply held by some people.
And there is no point in arguing about religion.
Most importantly, I don’t think we want religious leaders weighing in on health care reform.
The best solution, I think, is to give individual patients the opportunity to decide for themselves, in consultation with a palliative care team.
Even if this isn’t in reform legislation, Medicare can begin paying more for palliative care, and hospitals can be required to do a better job of letting very sick patients know that the team is available.
These teams are very good at laying out the options without “steering” patients.
It’s important, I think, that whenver possible, the the teams consults first with the patient, not the family. Too often, middle-aged chldren are urging doctors to do everything possible when the elderly parient is simply tired, and has suffered enough . . .
As for the expensive of end-of-life care, the problem, as palliative care pioneer Dr. Diane Meier points out, is that much of the time, we don’t know who is going to die–and who is going to make it, and who isn’t.
Many people leave an ICU, go home, and play with their grandchildren (or children). They may not be entirely well, but they can enjoy life.
As Meier puts it: “These are the sickest people in the hospital–it makes sense to be spending more on them than on anyone else.”
There are, of course, cases where it is clear that a cancer patient has only a limited amount of time left. Here, what’s most imoprtant, I think, is to level with the patient (and the family) and tell her that she has only a limited amount of time left, and lay out her options. Does she want to spend those weeks trying another round of chemo? does she want to go home and receive hospice care, etc.?
In other cases, a palliative care specialist needs to tell a patient “You may not make it. . This is why we should talk about altnerative scenarios . .”
Palliative care is so important becuase these professionals are trained to talk about death and dying. They don’t view it as a failure–they view it as a natural part of life. This helps patients come to terms with death.
We can do much better on an individual, case by case basis. But a national consensus? No.
Not in a country where religion would inevitably either begin to dominate the disucssion, or derail it entirely, turning it into a fierce argument.
(Other developed countires have done a much better job of keeping church and state separate. We haven’t.)
Insurance profit margins are not that relevant; the better stat is their medical loss rate. If they are spending less than 80% of their premiums on healthcare, while systems in other countries spend over 95% on care, that’s a problem we should be able to fix.
Why are they so inefficient? One reason is that they spend so much money paying people to deny claims and coverage. Why do they do that? Because their competitors are doing it, and if they don’t, all the sick people will come to them and put them out of business.
That’s the problem we have to fix. Other countries have fixed it already. In Japan and Germany, for example, insurance companies are not allowed to deny claims. By setting standards that all companies must meet, these countries prevent the race to the bottom that American health insurance companies are forced to engage in.
Japan spends 6% of its GDP on healthcare. Germany, around 11%. They are among the highest-rated systems in the world, using private, nonprofit insurance.
Maggie, interesting thoughts.
I agree that end of life care will always be an individual matter and heavily influenced by personal factors. I am certainly not advocating for a single, uniform approach to clinical care at the end of life.
The change I would like to see is that thoughtful consideration of options and realistic discussion of expected outcomes become the standard. Too often our status quo is to default to the most aggressive care option(s), and only consider alternatives or witholding procedures if the patient/family take this initiative. I’d like to see thoughtful, realistic, and of course individualized end of life counseling become the standard.
I’d also like to see more frequent involvement of professionals other than those who provide the most aggressive care options. If your only tool is a hammer, sometimes every problem looks like a nail. We need a more multi-specialty, multi-disciplinary approach.
I’m not sure if you meant to imply this or not, but I would be hesitant to frame religion as the enemy of humane and sensible end of life care. I have often found that those patients who view this life as just one stage in an eternal existence to be the most at peace with death and dying. The three most active hospice agencies I’ve worked with are explicitly religious ministries, and do a lot of the hard work in this area. Our hospital chaplains, often in cooperation with patients’ own pastors/ministers/priests, also play a major supportive role in palliative care. I know there have been some high profile cases where religious leaders (or really, politico-religious leaders) have played a less than constructive role. But in the trenches where the actual work is done, I have found the religious community to be bearing a large share of the (often unpaid) workload and an overall positive influence.
Dennis P.- and Alarth
Dennis P.–
Yes, underwriting is expensive. But advertising and marketing are even more expensive.
But in our capialist economy, we expect insurers to “compete”. I don’t think all of the advertising & marketing produces much, but that is the way we have set up the economy. If an insurer doesn’t spend money on marketing and advertising, he would begin to lose market share and go under.
Compared to many of our hospitals, our insurers are very efficient.
Many hospitals are paid 115% to 125% of what it should cost to care for patients. It costs them more becuase of teh high number of errors, complications following often unnecessary surgeries, wasteful investments in amentities rather than infection control.
You are right about Germany and Japan. But healh care is less expensive there not so much because the insurers are non-profits (though that helps) but becuase specailists in Germany earn about 1/3 of waht U.S. specailists earn (after adjusting for differences in cost of living); hospitals are far more spartan (they put the money into electronic medical records rather than private rooms, art work, etc.) and the government refuses to let drug-makers charge whatever they please.
There is far less over-treatment in Germany and Japan and prices are regulated (in various ways.)
That’s the major difference.
Alath–
I hear what you are saying. And I don’t think religion has to be the enemy of science–though, too often, it is–perhaps especially in the U.S. (We have a tradition of anti-intellectualism that seems to have infected American-style religion.)
The U.S. is supposedly the second most religious country in the world. And yet, we are so afraid of death. I have often wondered why. If so many of us are so religoius, why don’t they want to meet their maker?
I believe what you say about the hospices where you have worked
And I, too, would like to see more realistic discussions of options become the standard within our hospitals.
I’m just very wary of opening the subject up for public discusson. You are right that “political-religious leaders” would seize the microphone and I am afraid that they would begin to demand investigations of hospitals that offer palliative care.
A media that loves sensationalism would only amplify their response.
This is not a society that encourges thoughtful public discussion of hot-button issues.
As you no doubt know, some of the nation’s pioneer palliative care specailists have been singled out by “right-to-life” people and others who would impose their religion on medicine.
Unfortunately, in this country at this time, opening up difficult ethical questions to public discussions just seems to encourage legislation outlawing humane and sensible solutions.
Hello
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way to go maggie mahar.
hope you will continue to post more interesting topic like this.
Maggie, all good points, we have to attack the problem on multiple fronts. One quibble: in Japan, insurance companies are very competitive. Individuals can choose among 2000 plans (all nonprofit) and they compete vigorously.
But Japan also has the most rigorous price controls on providers. An MRI costs $100. The machine isn’t as fancy as ours but it gets the job done.
For doctors more interested in practicing medicine than running a business, these systems aren’t all bad. German doctors don’t even hire staff. Patient shows up, doc swipes his card, all the records magically appear and payment is guaranteed.
Dennis P
Yes,in most other developed countires doctors are not burdened with running a business– and they are much less likely to think of medicine as a business.
On Japan– I was curious about the competition, and looked it up. This is what I found, both on the PBS NewHour and in the NYT (2009):
“Insurers are all not-for-profit and Do Not Compete; they all cover the same services and drugs for the same price. The Japanese health ministry tightly controls these fixed prices and negotiates rates every two years with the health care industry.”
http://www.pbs.org/newshour/globalhealth/july-dec09/insurance_1006.html.
also see http://prescriptions.blogs.nytimes.com/2009/08/25/health-care-abroad-japan/.