Many Americans assume that all European health care systems are essentially the same: single-payer, government run systems that were created, from scratch, by wise and benevolent reformers.

Nothing could be further from the truth, as Harvard surgeon and author Dr. Atul Gawande reveals in the most recent issue of The New Yorker. 

In virtually every country, accidents of history have provided the foundation for reforms that are unique to each country.  “Reform” did not mean sweeping change. Instead, each country used the hand that history dealt it, and built upon the system it already had. Gawande suggests that the U.S. should do the same.

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Health Wonk Review, a round-up of some of the best of the last two weeks of healthcare bloggery is up on Jaan Sidorov’s Disease Management Care Blog. Sidorov has set his piece to music; to see what I mean click here.

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As you no doubt have heard, the healthcare blogosphere has been seriously divided on President Obama's nomination of CNN chief medical correspondent Dr. Sanja Gupta as our next surgeon general.

Over at The American Prospect, Ezra Klein liked the pick. Klein sees the surgeon general as "the country's leading medical and lifestyle educator," and it's that role " Klein wrote, that  "Gupta  is uniquely positioned to fill. There's not a doctor in this country with half his media training and experience, nor one with a rolodex of editors and reporters a tenth as large." Klein  also expects that Gupta will be an effective  advocate for the President' s health care plan."Sanjay Gupta, arguably the nation's most trusted health care authority, will be back on TV screens arguing for Obama's universal health care plan, lending it his credibility as a doctor, a trusted media presence, and the nation's surgeon general."

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       When President Obama said “The time has come to put away childish things,” I couldn’t help but recall healthcare reformer Don Berwick, sounding discouraged last winter, as he said “Maybe this country just isn’t mature enough for health care reform.”

         Berwick, who is the president of the Institute for Healthcare Improvement, was referring to the fact that at times, it seems that everyone wants healthcare for all—but no one wants to pay for it. And few want to hear about the trade-offs: that the young, healthy and wealthy will have to help pay for the poor, the old and the sick; that we will have to give up our unreasonable demand  for every test, treatment or drug that we think we want—or have heard of — even if there is no medical evidence that it works.  Most of all, we have to give up the unreasonable expectation that somehow, we can beat death—that if someone does die it’s because she ate too much, or the doctor made a mistake, or the HMO refused to give her that last miracle treatment.  We have come to think of death as an error.

        Turning to the economy, Obama suggested that most of us don’t yet realize what lies ahead: “we are in the midst of a crisis that is not well understood.”  He hints at the need for sacrifice: “it is ultimately the faith and determination of the American people upon which this nation relies. It is the kindness to take in a stranger when the levees break, the selflessness of workers who would rather cut their hours than see a friend lose their job which sees us through our darkest hours.”

        He also reminded us that the economy was weakened, not only by the greed of a few men, but by a “collective failure to make hard choices.”

       In his words, I heard an echo of JFK’s “And so, my fellow Americans: ask not what your country can do for you—ask what you can do for your country.”

       JFK’s speech was more original, and had a stronger cadence:

       “So let us begin anew—remembering on both sides that civility is not a sign of weakness, and sincerity is always subject to proof . . . .

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            \When Tom Daschle testified on the Hill earlier this month he reassured many by saying that as Health and Human Services Secretary, he would be working for healthcare reform “guided by evidence and effectiveness, not by ideology.”  Daschle, like Laszlewski, was suggesting that reform could and should be bi-partisan.  But as I suggested in part 1 of this post,  Daschle is only half-right. Medical evidence should guide our decisions about what to cover; but when it comes to questions of whom to cover—and how much coverage they should receive– we are going to have to wrestle with “ideology."

     For many, the word “ideology” carries negative connotations. This is in large part because,  during the Cold War, we used the word to refer to Communism.   Capitalism, we argued, was not an “ideology”—it was true.  But if you open the American Heritage Dictionary, you’ll find that the word itself is neutral: it simply means: “A set of doctrines or beliefs that form the basis of a political, economic, or other system.”   Those beliefs can be true or untrue.  “It is one of the minor ironies of modern intellectual history that the term "ideology" has itself become thoroughly ideologized,” observes the anthropologist Clifford Geertz in Ideology as a Cultural System. http://www.gongfa.com/geertz1.htm

        Granted, “a set of doctrines” sounds potentially rigid or “doctrinaire.” But there is nothing wrongheaded about having a “set of beliefs” about how a society or an economy should operate. Most of us do have convictions about what constitutes a just or an unjust society. And health care reform is about both those beliefs and science. We can try to sweep that under the rug, but I doubt we will get very far. In the debate over health care reform, differences in the ideas that conservatives and progressives hold dear will continue to crop up.

      Conservatives believe that “the market” can solve our healthcare problems. Progressives believe that you cannot count on “the market” to decide in favor of the public good.  I would add that “the market” is not moral or immoral; it is “amoral.” If we want a fair health care system, government is going to have to weigh in with laws and regulations that steer the system toward “the common good.”

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Over at Healthcare Policy and Marketplace Reform, Bob Laszewski reports that “the extension and expansion of the State Children's Health Insurance Program (SCHIP) has now passed the full House and the Senate Finance Committee and is on its way to the full Senate where it will undoubtedly also pass and then be reconciled with the similar House bill.

“However,” he warns, “the way it is being done does not give me a good feeling.

“In the Senate Finance Committee the Democrats were only able to get the support of one Republican–Maine's Olympia Snowe–on the way to a 12-7 approval.

“They did not have the support of the ranking Republican, Chuck Grassley of Iowa.”

Laszewski is worried: “Senate Finance Democrats lost the support of the Republicans when they insisted on departing from last year's bipartisan agreement to leave existing policy on covering the children of legal immigrants as is. As it now stands, a legal immigrant agrees not to apply for Medicaid and SCHIP benefits for the first five years they are in the country. Under the new rules states would have the option of covering legal immigrants. The new bill also left out provisions from the earlier bipartisan comprise to limit benefits for higher income families.

“Without judging on the merits whether these two new provisions should have been in the bill, what the Democrats have done is moved away from earlier bipartisan agreements,” he points out, “ and in doing so lost moderate Republicans like Grassley who showed good faith in reaching an earlier bipartisan compromise.”

He concludes: “As I have repeatedly said on this blog, major health care reform is not possible unless it is bipartisan.”

Here I have to disagree with Laszewski.  Inevitably, healthcare reform will be partisan because it is all about social values—and our beliefs about what is fair.  Progressives tend to emphasize a collective vision of the common good. Conservatives are more likely to stress the rights of the individual.

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Today, the Kaiser Network reported that on Friday, the Medicare Payment Advisory Commission (MedPac) approved a set of recommendations that would revise the current Medicare payment system, which was implemented in 1983, for hospice care providers serving terminally ill patients.  CQ HealthBeat reports that these recommendations will be included in a report to be issued in March to Congress and to take effect in 2013. (Thanks to Brad F. for calling my attention to this piece of news.)

Apparently, MedPAC has been concerned that for-profit businesses have been driving growth in Medicare spending by targeting hospice patients who need relatively long periods of care. The new payment system intends to remove incentives for long hospice stays.

So MedPac is recommending that Medicare change its payment system to include relatively higher payments per day at the beginning of the episode, and relatively lower payments per day as the length of the episode increases. 

Call me cynical, but do you suppose that would give for-profit hospices and incentive to toss patients out and send them home if they linger on too long? Alternatively, the hospice might encourage them to “let go”…

The whole idea of “for-profit hospices” strikes me as a truly terrible idea—right up there with “for-profit prisons” (which have not worked out well). 

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According to the American Bar Association’s Commission on Legal Problems of the Elderly, the notion that everyone should have a living will is a “myth.”  

In theory, a living will gives healthcare providers a window on the patient’s wishes regarding end-of-life care, telling caregivers whether he wishes to be resuscitated, intubated, or artificially hydrated.

In practice, doctors who deal with the dying say that such wills rarely capture the complex realities of being critically ill. An article published today in American Medical News quotes Angela Fagerlin, an associate professor of internal medicine at the University of Michigan Medical School and co-author of a study of living wills published in the Archives of Internal Medicine: “There are so many contingencies in medical scenarios that you can’t put them all down in a living will. You’re putting a lot of undue pressure on surrogates to correctly interpret advance directives.”

Even the patient who makes out a will may not know what he wants. After illness and hospitalization, three in 10 patients adjust their views, desiring more or less aggressive care than they previously thought they wanted.  “If patients’ own preferences are so unstable, then how reliable are their advance directives as a guide to what they would have wanted?” AMNews asks.

“People have a hard time anticipating the care settings in which they’ll face decisions in the future,” says G. Caleb Alexander, assistant professor of medicine at the University of Chicago Pritzker School of Medicine. “You can quote Yogi Berra: ‘It’s tough to make predictions, especially about the future'.”

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