A few weeks ago a friend who I will call Tom was scheduled for cataract surgery.   As it happens, we share the same ophthalmologist, who I will call Doctor X. (Tom recommended Doctor X to me about 8 years ago.)

Dr. X told Tom that he was developing cataracts a couple of years ago, and a few months ago, he explained that the time had come for an operation on each eye. Dr. X  planned to do  one eye at a time.

Tom was about to go on a long business trip, so he didn’t schedule the operation immediately, but when he came back, he made an appointment with Dr. X who checked his eyes again,  and showed him a video of how the surgery done.  Doctor X also sent him for a cardiogram.

A few weeks ago, it was finally time for the operation on the first eye. Then, the day before the surgery, Dr. X’s  office called three times—each time rescheduling the operation for a different time the next morning.

Exasperated, Tom  finally said: “Let’s just cancel it.”

Since we had been talking about the operation and about Dr. X,  he called me.  “I feel like an idiot, canceling at the last minute,” he said. “I’m not afraid of the operation—these days it’s pretty simple, but there’s something about Doctor X . . .”

I couldn’t help but agree. Over the years, I have found Dr. X annoying. His waiting room always  is crowded;  it is not  unusual to wait  1 ½ to 2 hours to see him.  It struck me that he was trying to see too many patients, but when I mentioned the long waits  he blamed “my genius office staff" for over-scheduling him. 

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This post was written by Maggie Mahar and Niko Karvounis

Life expectancy is a pretty simple concept: it’s an estimation of how long the average person lives. Anyone can understand that. So how is this for a compelling data point: if you look at life expectancy in nations around the globe, you’ll find that over the past 20 years, the U.S. has sunk from ranking  No. 11 to  ranking No. 42. In other words, a baby born in 2004 in any one of 41 other countries can expect to live longer than his or her American counterpart.

This may come as a surprise. Sure, we all know the health care system in the U.S. is broken, but life expectancy isn’t just tied to medicine—it’s also related to quality of life in a larger sense. (I can live in a nation with the best health care system in the world, but if it’s in the throes of civil war, my life expectancy will be short). As we all know, the American standard of living is the envy of the world.  After all, we’re the richest country on the globe. So what gives?

While some of us are rich, the average American is not.  And while the rich are living longer, the poor are living shorter.  Factor in the profit motive that drives U.S. healthcare, and you will begin to understand why American medicine has done little to heal the gap between rich and poor.  Over the past twenty-five years, we have poured money into healthcare, but have paid relatively little attention to public health.

This may seem a bold claim, but last month the Congressional Budget Office (CBO) issued a report that provides the numbers:  “In 1980,” the CBO found that “life expectancy at birth was 2.8 years more for the highest socioeconomic group than for the lowest. By 2000, that gap had risen to 4.5 years.”

The report notes that “the 1.7-year increase in the gap” between socioeconomic groups “amounts to more than half of the increase in overall average life expectancy at birth between 1980 and 2000.” In other words, even though the average life expectancy has increased in the U.S., it has grown more slowly because of widening socioeconomic disparities.

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If healthcare reformers hope to capture the Congressional votes they will need to make universal coverage a reality, they must unite. Only then can they hope to form a wedge strong enough and sharp enough to divide the opposition. With that in mind, last week I wrote about the debate in The American Prospect‘s May 2008 Special Report, The Path to Universal Health Care, underlining areas where reformers agree, as well as issues that still divide us.

By clarifying our differences, and offering each other arguments and evidence for our positions, I am hoping that reformers can move closer together. In this second post, I consider the cost of universal coverage, the argument that talking about cost-control only hands ammunition to those who oppose reform, and, finally, whether American Prospect co-founder Robert Kuttner is right when he says that “there are not the votes in Congress to enact a true universal health-insurance system. Any progress toward universal coverage will necessarily be incremental.”

Last week, in part 1 of this post, I explained why many reformers who might  prefer to see a single-payer plan replace employer-based, private insurance have nonetheless rallied around Yale political scientist Jacob Hacker’s alternative—a proposal that gives Americans a choice between private insurance and a public-sector plan modeled on Medicare.

The truth is that the majority of Americans who have employer-based insurance want to keep it. As I’ve discussed on Health Beat, poll after poll makes it clear that they will not accept a government edict telling them that they have give up what they know for an unknown—a single-payer plan designed by Washington.  Most people are afraid of change, and the last eight years have not boosted their faith in programs run by the federal government. Congressmen know that this is how their constituents feel.  And this is why they will not vote for single-payer.

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I’m  always looking for new (or unnoticed) healthcare blogs that might interest  HealthBeat readers. Recently, I discovered “What If” (American Had a HealthCare  System That Worked).

The  blog is run by Georgia Berner, (founder and Director) and Emily Cleanth  (content manager/ researcher). Berner, who  owns a small to medium size company in Western  PA where she pays the entire health insurance costs for her 60 employees, has  become familiar with the inequities in our system both as an employer, and by  talking to voters while running for U.S. Congress in 2006.  Cleanth has a Master’s in Public  Policy and Management from Carnegie Mellon.

Not long ago, “What If” took a look at healthcare  for Veterans. I have reprinted the post below.

I  would add only that, since 2000, funding for the VA system has fallen far  behind the needs of returning troops and veterans. In the 1990s, the VA was  overhauled and became a very good health care system. I’ve written about it  here (The VA should not be confused with Walter Reed  hospital, which is run by the army. The Veteran’s Administration oversees the  VA.) But over the past eight years, funding has not kept up with the needs of badly  wounded vets returning from Iraq. Meanwhile, Vietnam vets are aging. This has led to impossibly long lines  and, in some cases, has meant that the VA has not been able to hire and retain  the medical staff that they need.

“What If “points out that conservatives have  protested increased funding for the VA, pointing to and explosion in  “entitlement programs.” Like Berner and Cleanth, I believe that veterans are  fully “entitled” to timely, high quality care.

I also agree that the cost of healthcare for  wounded troops should be included in the cost of the war. Why doesn’t it show  up as part of the total cost now? “Because,” they point out, “it essentially  doubles the cost of the war in Iraq.”

Shellshocked:  Veterans Health Care

Originally posted on “Whatif” . . . (American Had a HealthCare System That  Worked)  

According to polling in the past few months, the biggest issues troubling  Americans are health care and the war in Iraq.  What gets talked about less often is the point where these two issues  intersect. . .

Around 12% of the 47 million uninsured people  in the United    States are  veterans and their families: this adds up to 1.8 million  uninsured veterans. These 1 in 8 veterans are typically  45-year-old men who worked in the past year and are earning from $30,000 to  $40,000. Almost two-thirds of uninsured veterans were employed, and nearly 9  out of 10 had worked within the past year.

Why are they  uninsured?

  Defense Department data released in late 2007  show that thousands of National Guard and  Reserve members who had to give up civilian jobs when they were  deployed overseas have now permanently lost these jobs and with them their  health insurance, pensions, and other benefits. (Federal laws are supposed to  protect them from being penalized for leaving civilian employment for wartime  service.)

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Can we reach a consensus on what we need to do to achieve meaningful health care reform in the U.S.?

This week, I have been mulling over The American Prospect’s May 2008 Special Report: The Path to Universal Health Care At first glance, it might seem that the eight articles in the report take eight different roads to reform. But I’m glad to see agreement on many pivotal points.

Yet there are still major issues that could divide reformers:  Should we acknowledge that we won’t be able to cover everyone unless we learn to “control costs”? Should we move directly to a single-payer system?  And finally, should we try to move quickly, to cover everyone, or should we aim for incremental progress while sticking, stubbornly, to first principles? 

In the months ahead, I think it is crucial that would-be reformers try to hash out their differences on these issues and unite under a single banner. Only then, can we divide opponents who have billions invested in preserving the status quo.

With that in mind, I decided to weave together some of the strongest insights in the Report—focusing on recurring themes—while also addressing the areas where reformers remain divided.

First, as I wrote two weeks ago on TPM Café the high and rising cost of health care may be the greatest obstacle to health care reform.  In the American Prospect report, Ezra Klein captures the problem with brilliant simplicity at the very beginning of his piece: “If health insurance were cheap, we could all buy it. If universal health care could get 60 votes in the Senate, we’d all have it. But these two imperative—tthe need to control costs and the need to attract the 60 Senate votes required to overcome a filibuster—point in opposite directions. This is the central paradox of health reform.”

Congressmen are loath to vote for a plan that would rein in spending for two reasons. First, they fear that if they call for “cost-control,” voters will hear “rationing.”  Secondly, they know how lobbyists will react to any attempt to cut the waste in our bloated healthcare system. One man’s hazardous waste is another man’s income stream.

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Last week, the Economic Policy Institute released a disturbing report revealing just how many white-collar workers have lost their employer-based health insurance in recent years—even though they didn’t change jobs.

Many workers believe that if they hold onto their job, their insurance is safe. Professionals with jobs near the top of the occupational ladder are especially likely to assume that their employer is not going to cut their coverage. That may well have been true in the 1990s, when the job market was tight—but not today.

The EPI report shows that in just the first six years of this century, the share of U.S. workers with employer-provided health insurance (EPHI) fell from 51.1 percent to 48.8 percent.  Moreover, workers in white-collar occupations—including executives, managers, and workers in professional specialties—were just as likely as blue-collar workers to lose their safety net.

Perhaps this shouldn’t come as a surprise, since employers typically pay a much larger share of premiums for higher-income employees, as I discussed on HealthBeat last month.  So as insurance premiums soar (up 78 percent since 2001), employers are beginning to chafe under the very costly burden of providing first-class benefits to white-collar employees. (Insurance premiums rose “only” 6.1 percent in 2007, but going forward, experts expect sharper increases because the cost of medical technology continues to skyrocket).

Most employers will just shift more costs to employees in the form of higher co-pays and deductibles. But some will decide that they cannot continue to offer insurance.

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In a society hooked on growth, “enough” just isn’t part of our vocabulary. Thus, the latest issue of The New England Journal of Medicine reports: “Despite the fact that there are now more physicians per capita in the United States than there have been for at least 50 years, the Council on Graduate Medical Education (COGME) recently predicted a 10% shortfall of physicians by 2020…The Association of American Medical Colleges has responded with calls for a 30% expansion of U.S. medical schools and a lifting of the current cap on Medicare funding for graduate medical education so that federal dollars can support the expansion of the workforce.”

Do we really need more doctors?  The boomers are aging and we’ve been told that this will lead to a huge spike in the need for health care. But as I explained just last month, the boomers will age, just as they were born, gradually, over decades.

And while the boomers are, indeed, a demanding group, the fact is that many boomers have taken quite good care of themselves. It all began twenty-five or thirty years ago when they quite smoking and switched from red meat to fish; from scotch to white wine, from tanning to jogging. In the next decade or two, they just won’t need as much healthcare as their parents did at the same age.

Moreover, as the article’s authors, Dr David C. Goodman and Dr. Elliott S. Fisher, point out: “Physician supply varies dramatically by region of the country. COGME is concerned about a 10% shortfall at a time when the regional supply of physicians varies by more than 50%.” In other words, while more doctors may be needed in some states, in other places we have more than enough, thank you.

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This week, Health Beat is hosting “Health Wonk Review,” a biweekly round-up of the best of health policy blogs. Below, snapshots of posts that we found particularly interesting.

–Maggie Mahar and Niko Karvounis

News about Docs

In the past, Roy Poses has posted on Health Care Renewal (here and here) about the little-known fact that medical schools often fail to pay or otherwise reward faculty to actually teach.

Poses, who has a sharp nose for the ironies of our healthcare system, asks a fair question: “Why are medical school faculty expected to teach in their spare time, and spend their working hours …bringing in large amounts of what is euphemistically called ‘external support’” (a.k.a. $$$$) — while faculty in other schools are actually paid for teaching and other academic activities?

In his most recent post on the topic, Poses points to a story from the (Tucson) Arizona Daily Star reporting that University of Arizona Medical College Faculty are “On the Verge of Desperation.”

“Maybe it has something to do with having to do 10 hours a day of clinical work to bring in ‘external funds,’ and then being expected to teach,” Poses speculates. It turns out that U. of Arizona medical faculty are actually supposed to do three things:  provide high-quality teaching, care for a full load of patients (thereby bringing in the money),  and build a competitive research program—all at the same time.

“This looks like another case of mission-hostile management at a well-known medical school,” Poses observes, “albeit one that is probably representative of problems around the US.” 

Offering us a glimpse of how medical students see the world Scott Shreeve of Crossover Health grapples with the crisis in primary care. Speaking first-hand from his experience as a medical student at the University of Utah, Shreeve notes that there were efforts to convince students that primary care was the way to go, but that “both the message and the messengers were unconvincing.”

Why? Because, as many of us tend to forget, doctors are what economists call “rational actors” just like the rest of us. (Other social scientists have some doubts on this matter, but that’s another post).

According to Shreeve, decisions about specializing “came down to what specialty can provide the best outcome in terms of attaining the quality of life, financial security, and career stability students desire  at a price they are willing to pay in terms of years of training, lifestyle, and financial considerations.

“In the end,” says Shreeve, “the current financial system we have in place creates overwhelming incentives to go into a specialty.”

What Shreeve says about weighing lifestyle issues against costs makes sense. But is anyone else distressed that having an intellectual interest in a certain part of the body (the brain, for example), a particular disease (cancer, perhaps) or being drawn to a particular type of patients (children, for instance, or the elderly) never seems to come up as a factor in the decision-making process? 

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No doubt some of you saw Monday’s story in the New York Times reporting that health insurance companies have begun forcing very sick patients to pay as much as 20 percent to 33 percent of the cost of some of priciest drugs on the market. As a result “patients may have to spend more for a drug than they pay for their mortgages, more in some cases, than their monthly income.”

But this isn’t just a tale about insurers letting patients down. As with so many health care stories, there is more than one villain in this piece, and plenty of blame to spread around.

First, let me re-cap the background to the Times’ report.  Normally, insured patients are not required to shell out a percentage of what a drug costs. Instead, they just chip in a flat co-pay of $10, $20, or $30, depending on whether the insurer lists the drug on tier 1, tier 2 or tier 3. But now insurers have invented a new category—tier 4—for hundreds of super-expensive drugs used to treat diseases like multiple sclerosis, hepatitis C and some cancers. Since some of these drugs can cost $100,000 or more a year, a 33 percent co-pay can add up to $33,300.

Insurers began this practice with the infamous Medicare Advantage plans that we wrote about on HealthBeat the other day. Eight-six percent of Medicare Advantage (MA) plans now require whopping co-pays for tier 4 drugs, so read the fine print before signing up for an MA policy. And now, tier 4 is showing up in insurance policies that people under 65 buy on their own, or through their employers. This is the fastest growing segment in private insurance, Dan Mendelson of Avalere Health, a research organization in Washington, told the Times.

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The first controlled medical trial in world history was staged in 1601 by a British ship captain named James Lancaster, reported Professor Ajit Lalvani, head of the Infectious Disease department at the Imperial College Healthcare in London, at the World Health Care conference last month.

Four ships were traveling from England to India around the Cape of Africa, Lalvani explained, when Lancaster decided to give the sailors on his ship three teaspoons of lemon juice every morning. No doubt Lancaster was acting on reports that had come from Sir Richard Hawkins during a voyage to the South Pacific, eight year earlier, when Hawkins had observed that the most effective protection against scurvy appeared to be “sour oranges and lemons.”

As the chart below shows, the hypothesis proved correct: by the end of the voyage, 40 percent of the sailors on the three ships where no one received their Vitamin C had come down with scurvy and perished. On Lancaster’s ship, no one died of the disease.

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