On HealthBeat I have talked about social solidarity as the key to meaningful healthcare reform.

Last night, President-elect Obama sounded that theme repeatedly throughout his victory speech, reminding his audience that he had been elected “by young and old, rich and poor, Democrat and Republican, black, white, Hispanic, Asian, Native American, gay, straight, disabled and not disabled—Americans who sent a message to the world that we have never been just a collection of individuals…”

In the recent past, some progressives have warned that liberals made a mistake when they reached out to minorities, new immigrants, and gays, “ignoring” the mainstream middle class.  But in fact, “mainstream” America is no longer one recognizable culture. It is fast becoming a “magnificent mosaic,” the phrase Mario Cuomo used when he ran to become mayor of New York City in 1977. 

Barack Obama won, not because he managed to win over the white middle-class, or the white working class, but because he managed to put together a coalition from so many groups—including white voters.  Many thanks to Ezra Klein for breaking down the vote: 31.82 percent of voters who chose Obama were white, just as 31.57 percent of the voters who stood for John Kerry in 2004 were white.  But Obama won. What was the difference?

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What is the biggest threat to the U.S. economy?

According to Congressional Budget Office Director Peter Orszag, it is not credit famine, the long-term price of energy, competition from China, the loss of jobs overseas, or even a surfeit of Chrysler SUVs.

It is, Orszag declared in October, “the nation’s looming fiscal gap — which is driven primarily by rising health care costs.”  Healthcare inflation cannot be ignored, Orszag added, because “If we fail to put the nation on a sounder fiscal course. . . we will ultimately reach a point where investors [will] lose confidence and no longer be as willing to purchase Treasury debt at anything but exorbitant interest rates.”

Today, investors outside the U.S. hold $2.74 trillion of Treasuries, or 52 percent of the $5.22 trillion in debt that the U.S. has issued. But now foreign buying of our Treasuries is falling. And, as Orszag has explained elsewhere, if we have to pay “exorbitant interest rates” to persuade foreign investors to  continue buying  our Treasuries, “over time, foreign investors would claim larger and larger shares of the nation’s output and fewer resources would be available for domestic consumption.”  Put simply, our standard of living would fall.

Why does Orszag single out soaring health care costs as the driving force behind our fiscal woes? Because healthcare spending accounts for over 16 percent of GDP, and it continues to grow faster than other sectors, outpacing both growth in GDP and workers’ wages. At $2.3 trillion a year and counting, our national health care bill is rising so fast that it threatens to crowd out other priorities—like spending on education, the environment, and infrastructure repair. Some in the health care industry point out that spending on medicine creates jobs, but as the cost of care levitates, we spend less in other sectors, and jobs in those areas disappear.

Moreover, unlike spending to repair bridges, strengthen schools, or protect the environment, Orszag suggests that the “excess” growth in health care spending is not adding to the wealth—or the health—of the nation. “The gains from higher spending are not clear” the Congressional Budget Office noted recently. “Substantial evidence exists that more expensive care does not always mean higher-quality care.”

Some observers took Orszag’s statement about the importance of health care spending as a signal that he was calling for universal coverage. He was not—not without simultaneously contain costs.

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Be sure to check out the most recent Health Wonk Review, highlighting the best health care

posts of the past two weeks.  David Harlow, of the Health Care Law Blog is the host, and he has done a superb job of rounding up some very interesting posts, including:

Daniel Goldberg’ piece on Medical Humanities Blog explaining the McKeown thesis.  In brief, “McKeown suggests that medicine isn’t necessarily all it’s cracked up to be — 17th-to 20th-century improvements in population health measures likely had more to do with social and economic changes (e.g., improvements in the standard of living) than with public health and medicine (e.g., drugs and shiny objects).”

Joanne Kenen’s interview with, Geisinger CEO Glenn Steele on New Health Dialogue . Geisinger has been

making the “medical home” concept work, and other hospitals and policy experts are trying to figure out how to adapt the model.

Annie, blogging at Home of the Brave, “wondering why nurses and nursing aren’t a bigger part of the discussion on health care reform, given their work in the front lines.”

Louise, of Colorado Health Insurance Insider, who agrees with HealthBeat that advanced medical technology is helping to drive healthcare costs through the roof, but takes issue with my statement that Medicare should be using its clout to negotiate for lower prices. Louise points out that Medicare “has negotiated rates that are far lower than private health insurance reimbursement amounts on many treatments—including dialysis.”  Fair enough—but I’d still like to see Medicare doing what other governments do when it comes to negotiating for discounts with drug-makers, as well as device-makers.

Roy Poses, who castigates Ascension Health for its cut and run maneuver in Detroit at Health Care Renewal, (Ascension closed an inner city hospital while building a new suburban facility).

There are just a few highlights. For the full review, see http://healthblawg.typepad.com/healthblawg/2008/10/health-wonk-review-samhain-edition.html

  Hat tip to Kevin M.D. for calling my attention to “The  Covert Rationing Blog,” where  Dr.  Rich offers a concise summary of the dilemma we   face as we move toward a consensus that healthcare is not a privilege,  but something that every human being should have. (One can call that a “right” or a “moral obligation that a  civilized   society has to provide  healthcare to everyone”).   The point Dr.  Rich is making is that once you decide everyone deserves health care, the  question is “how much care.” As he puts it:

  “Exactly how much healthcare are you entitled to  if you have a right to healthcare?  Do you have a right to certain  specified healthcare services, to a certain dollar amount of healthcare per  year or per lifetime, to  whatever healthcare it takes to achieve perfect health, or to some other limit or non-limit?

  “The question of limits (whether we should have  them or not, and what should  they be) has been a central theme of this blog and of DrRich’s book.  To reiterate the fundamental problem: 1) In  America we believe that it is wrong to limit healthcare in any way, that  everyone is entitled to the very best healthcare, that any bit of healthcare  that offers even a small potential of benefit should be provided, and that  death itself is merely a manifestation of insufficient research (or actionable incompetence,  or systematic  discrimination against the unwealthy, or corporate greed).  2) But  against that closely held belief, we must balance the unremitting law of  economics which tells us that there is simply not enough money in the known  universe to buy all the healthcare that might potentially offer some small  amount of benefit to every person.  Healthcare spending has to be limited,  or it will become a fiscal  black hole.”

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No doubt you’ve seen the ads. Barack Obama claims that John McCain plans to hollow out Medicare, arguably the most popular social program in America.

McCain says that just isn’t so.

The controversy began early this month when the Wall Street Journal reported that McCain plans major reductions in Medicare and Medicaid spending totaling $1.3 trillion over the text ten years. This will help pay for his health care plan. Douglas Holtz-Eakin, McCain’s senior policy adviser, told the Journal that “the savings would come from eliminating Medicare fraud and by reforming payment policies to lower the overall cost of care.”

Without question, there is money to be saved if Washington cracks down on Medicare and Medicaid fraud. But before reaping any savings, the government first would have to spend money to ferret out the fraudulent claims. And no one believes that Washington could recover anything close to $1.3 trillion. Meanwhile, “reforming payment policies” seems to suggest that McCain plans to pay doctors and hospitals less, at a time when many Medicare patients are having a hard time finding a primary care physicians—precisely because Medicare’s fees are already so low. This could reduce access to care.

Barack Obama quickly went on the attack with ads warning that McCain would take “Eight hundred and eighty-two billion from Medicare alone…requiring cuts in benefits, eligibility, or both.”

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At the end of last week, the Wall Street Journal published an editorial designed to terrify anyone who is afraid that a “single-payer” health care system would signal the end of democracy in America. The country is about to be taken over by the “left-wing,” the editorial warned, the same wild-eyed radicals who brought us the 1960s.  And what lies at the center of their master-plan? Medicare-for-all.

Since the piece relies so heavily on half-truths and innuendo—particularly with regard to healthcare—I feel obliged to comment.

The editorial, which is titled “A Liberal Supermajority,” begins by declaring that the election is a done deal: “if current polls hold, Barack Obama will win the White House on November 4 and Democrats will consolidate their Congressional majorities, probably with a filibuster-proof Senate or very close to it. Without the ability to filibuster, the Senate would become like the House, able to pass whatever the majority wants.”

“If current polls hold .  . .”   And, “if current polls” are accurate…

I have lived through enough presidential elections to know that the American electorate cannot be second-guessed.  Particularly in an election like this one, when highly charged issues such as loyalty to the nation, religion and race become part of the mix, one cannot assume that what a voter is willing to tell a stranger is necessarily the truth about how she will cast her ballot.

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Sometimes I agree with New York Times’ editorials. Sometimes I don’t. But I rarely learn much from them. To my mind, the problem with the form is that it encourages opining without evidence. So, I admit, I rarely turn to the editorials. .

But yesterday Buckeye Surgeon pricked my curiosity by referring to a recent New York Times editorial as a “masterpiece of naiveté and contempt.”

Such strong language suggested that the editorial might be entertaining. Thus, I went back and read what turned out to be a piece congratulating Medicare for having decided it “will no longer pay hospitals for the added cost of treating patients who acquire any of 10 ‘reasonably preventable’ conditions while hospitalized. Those include incompatible blood transfusions, severe bedsores, injuries from falls, poor blood sugar control, and infections after certain surgeries.”

This is what I mean about editorials: typically they are monologues that cry out for a good copy editor who asks sensible, logical questions.  The first query that springs to mind is this:  exactly what does “preventable” mean?  How is a “fall” preventable?

If Mr. Smith decides to get out of bed, begins shuffling toward the hallway, feels woozy, loses his balance and falls, how could the fall have been avoided?  Should a member of the staff be stationed not more than six feet from each patient, ready to race in and catch him if he teeters? Or should Mr. Smith have been tied to his bed?  (Thanks to HealthBeat reader Howard B. for his comment on hospital falls about a year ago.)

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The conventional wisdom about skyrocketing healthcare costs tends to blame someone: patients who demand too much care; doctors who practice defensive medicine because they fear being sued; aging boomers, and finally, everyone’s favorite, “the insurance companies.”

In fact, none of the above is the driving force behind the nation’s spiraling health care bill, according to a brand new report from the Center for Studying Health System Change (HSC) titled “High and Rising Health Care Costs: Demystifying Health Care Spending.” (Many thanks to Robert Laszewski at Healthcare Policy and Marketplace Review for calling my attention to this report).

The culprit behind long-term health care inflation, the study reveals, is not a “who” but a what: “advancing medical technologies” combined with low productivity.  Yes, that’s right: while improved technology has boosted efficiency in other sectors of the economy, when it comes to healthcare, technological advances are associated with lower productivity.  There is no one group to be blamed for runaway healthcare inflation; the problem is systemic.

The HSC report is part of the Robert Wood Johnson Foundation’s “Synthesis Project” and it is indeed, synthetic. Paul Ginsburg, the report’s author, bases his study on an in-depth review of an “extensive literature that examines which drivers are most important in explaining increases in health spending over time.”  The conclusions “have been very consistent,” he observes. “Technological change (which in the world of medicine includes innovations in equipment, devices, drugs, tests, and surgical procedures) is the most important factor.”

But one thinks of ongoing technological advances as one of the great virtues of U.S. healthcare: how can we regret the high cost of that technology?

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At “Managed Care Matters”  (http://www.joepaduda.com/) Joe Paduda hosts a rich discussion for “Health Wonk Review,” focusing on the best of the blogosphere’s pre-election debate.

He begins with the question that I had raised on HealthBeat—and thatTom Brokaw later used to frame a health policy question during the presidential debate–Is Health Care a right or a moral obligation?”  (Do we think Brokaw readsHealthBeat?  Doubt it. Anyway, if you remember, I borrowed the idea fromShadow Fax, an emergency room doc who writes a blog titled “Movin Meat.”)

During the debate, presidential candidate McCain immediately rephrased the question from “moral responsibility” to “personal responsibility,” and then said,  “Yes, every individual is responsible for his care. This is very much in keeping with McCain’s “every man for himself” health care plan which emphasizes the individual and freedom of choice.

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Over at GoozNews, Merrill Goozner has written an excellent piece on Senator Hillary Clinton’s proposal to create a “Wellness Trust”—a fund that would consolidate the dollars that both public and private insurers now lay out for preventive health services, and then spend  that money in a way that gives us the biggest bang for our buck.

In his October 14 post, Goozner explains: “The new Wellness Trust would be run by 7-member board appointed by the president and approved by the Senate…in its first year of operation it would commission and then issue reports on the best way to supplement the existing health care workforce with certified ‘prevention health workers’; establish new reimbursement systems that would ‘align incentives’ with health promotion and disease prevention goals; and analyze current expenditures on prevention, which the bill estimates at 1 to 3 percent of health care costs or $20 billion to $60 billion.”

When Clinton talks about creating reimbursement systems that “align incentives” I believe that she, like the Medicare Payment Advisory Commission (MedPac),  is talking about the need to pay health care providers for the quality of their care—not the quantity. In other words, we want to pay for preventive care that actually leads to better health.  Some call it “paying for value,” and argue that this must be the centerpiece of health care reform.

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