It is time, I think, to face the realpolitik of health care reform. That means asking a question few reformers dare to discuss:  How will we win the Congressional votes needed to pass serious health care reform?

The American Prospect’s Ezra Klein put this question on the table at the “Take Back America” conference last week.  A pragmatic progressive (in the best sense), Klein pulled no punches:  “There are so many people in this town [D.C.] who do such smart policy thinking,” he observed. But “what we don’t give enough thought to is the politics of reform. This is a political problem. Until we have the votes in the Senate, we can’t get anything done.”

Without the votes, Klein told reformers, “you don’t have a plan; you have a position.”

Some assume that, if we elect a progressive president, he will “put the votes together” to achieve reform. But the fact is that even an optimistic, charismatic JFK wasn’t able to persuade Congress to unite behind healthcare for the elderly in the early 1960s—a time when seniors were the poorest group in America. It was only after Kennedy was assassinated that a wily LBJ (who had grown up in Congress and knew where all of the bodies were buried on the Hill) was able to leverage a martyred president’s last wishes to help pass Medicare in 1965. The fact that LBJ had won by a landslide sealed the deal.

This time around, nailing the votes that would secure something like “Medicare for Everyone Who Wants It” will be much tougher. As I noted in my first post in this series, “Obstacles to Health Care Reform,” the lobbyists representing the for-profit health care industry enjoy enormous power. The money at stake in the health care industry has grown exponentially since 1965. And thanks to generous campaign contributions, the industry’s lobbyists wield great influence, even among liberal politicians.

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Finally, the National Association of Government Employees (SEIU) has responded to the story I posted last week reporting that its affiliate, the International Association of EMTS and Paramedics (IAEP/SEIU), has been sending out letters to doctors, endorsing Pfizer’s blockbuster drug Lipitor.

Lipitor, like other statins, has been getting some bad publicity of late (see “The Cholesterol Con”) and apparently someone decided Lipitor needed a boost.

Today, I learned that someone who signed himself “anonymous” had replied to my post on Health Care Renewal, where Dr. Roy Poses, the blog’s editor, had cross-posted my SEIU piece. Here’s the response:

SEIU Does Not Endorse Lipitor or Any Other Product (Full disclosure—I work for SEIU.) If Ms. Mahar had bothered to contact us, she would have learned that as a matter of policy, SEIU does not endorse products. Official Statement from SEIU: Recently, a letter appearing to endorse a well-known pharmaceutical was circulated by the International Association of EMTS and Paramedics, an affiliate of the National Association of Government Employees (IAEP/SEIU).SEIU does not endorse products. The letter was generated by a Local Union staff member unfamiliar with SEIU’s policy against any product endorsement. Upon learning of the letter, the Local disavowed a relationship with the product in keeping with the union’s policy.

The 1.9 million member Service Employees International
Union is united by the belief in the dignity and worth of workers and
the services they provide and dedicated to improving the lives of
workers and their families and creating a more just and humane society.
SEIU members are winning better wages, health care, and more secure
jobs for our communities, while uniting their strength with their
counterparts around the world to help ensure that workers, not just
corporations and CEOs, benefit from today’s global economy.

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Reforming U.S. healthcare will be difficult,  in part because our current system is riddled with conflict of interest. Virtually any health care reformer will tell you that if we are going to have a high quality, sustainable health care system, we will need an independent health care agency that oversees quality by making sure that decision are based on the best medical science available. “Independent” means that this agency must somehow be insulated from both special interests and politics.

If this sounds Utopian, it isn’t. In my first post, I suggested that we might find a model for just such an agency in the U.K.’s National Institute for Health and Clinical Excellence (NICE). To be sure, we would not want to emulate NICE in all respects. Operating on a very tight budget, NICE puts a major emphasis on the cost-effectiveness of the treatments it approves. In the U.S., we could  vastly improve the quality of our care—and save billions—if we just looked at the “comparative-effectiveness” of services and products, without worrying about how many additional years of life $100,000 would buy.

What is remarkable about NICE is its independence. And this is what we should take as a pattern for what is possible.  Founded in 1999, the institute operates with almost no interference from either private sector lobbyists or government.

Sitting at the very center of the U.K.’s health care system, NICE is charged with watching over the quality of care in the U.K. by drawing up “best practice guidelines” for physicians, while also reviewing new and existing medicines, technologies and treatments. The National Health Service of England is legally obliged to provide funding for drugs and procedures recommended by NICE’s independent technology appraisal board. So implicitly, NICE also is deciding what the national health system will cover.

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Today, AlterNet published a provocative story by Mark Weisbrot , co-director and co-founder of the Center for Economic and Policy Research, about the emerging battle between Big Pharma and the developing world.

Some large pharmaceutical companies are “up in arms,” Weisbrot notes, because “developing countries are importing less expensive generic versions of drugs for which these companies hold a patent monopoly.”

But “the procedure is perfectly legal, even under the World Trade Organization’s pro-pharmaceutical-monopoly rules. The only question is whether these huge corporations –who used their political muscle in Washington to prevent our government from lowering the price of Medicare prescription drugs—will intimidate governments that are trying to provide essential medicines to their citizens.”

Weisbrot points to Thailand as “the latest target of this bullying last winter when it issued ‘compulsory licenses’ for three drugs. Two were anti-AIDS drugs (efavirenz and lopinavir/ritonavir) and the third is used to treat patients with cardio-vascular disease (clopidogrel). A compulsory license allows for the production or import of a generic version of a patented drug, without the permission of the patent holder. It is completely legal, and in fact the United States has used compulsory licenses many times.

“But the U.S. government has sided with the big pharmaceutical companies and put Thailand on a special ‘Priority Watch List,’ which could potentially lead to trade sanctions against Thailand. Actual sanctions are unlikely, but Washington and its pharmaceutical allies have made a serious threat. Now that pressure is reportedly being used to block similar licenses for three cancer drugs”

Below, I’ve reprinted the rest of Weisbrot’s story. He makes a powerful argument that countries like Thailand are trying to do what is right for their citizens.

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Imagine a society that lets its automakers oversee crash tests on new models, allowing the industry to report results, as it sees fit, to government and consumers. Sometimes, an automaker might not reveal the outcome of a test that turned out badly, deciding that the dummies in the vehicle had been too short—no wonder their chests were crushed!

In other cases, a company might postpone reporting on crash test results for a year or two, hoping that later trials would turn out better. In these cases dozens of trials might be required in order to achieve the desired outcome. The car maker would, of course, pass the additional costs along, in the form of higher sticker prices.

In this society, crash tests are not run and paid for by an independent entity like our National Highway Traffic Safety Administration (funded by taxpayers) or the Insurance Institute for Highway Safety (funded by insurers). Instead, the auto industry itself finances and controls the trials. Automakers also provide most of the funding for the government agency that rules on car safety. Finally, under this system, head-to-head comparisons of cars in a similar weight class are frowned upon. Such trials would create winners and losers—and who wants to be a loser? Instead, each company tests its own cars, and when outcomes finally are published, they tend to be excellent.

Probably you already have guessed where I’m heading.  The system I’ve sketched comes pretty close to describing how we try to assure the safety of the prescription drugs and medical devices sold in the U.S. We may be the only country in the developed world that allows the companies that manufacture and peddle medical drugs and devices to control what we know about them.  The industry also provides much of the funding for the Food & Drug Administration, the agency responsible for weighing the risks and benefits of these products. No wonder the FDA doesn’t require manufacturers to test their products against similar, less expensive products already on the market. Instead, the FDA asks only that the sponsor to test its new entry against a placebo—demonstrating that it is “better than nothing.”

In the U.S., medical research is rife with conflicts of interest. As Merrill Goozner recently testified before the Institute of Medicine (IOM) panel on “Conflict of Interest in Medical Research, Education, and Practice,” the  share of our clinical research funded by industry has doubled over the past 30 years, and now accounts for well over 60 percent of all clinical trials. As a result, Goozner testified, the medical literature is riddled with:

• reports of negative research results being suppressed
• delays in publication 
• failure to report serious adverse events in clinical trials
• the slanting of systematic reviews of medical evidence
• and a systematic bias in research results that favors the outcomes desired by study sponsors.

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Be sure to take a look at the latest edition of Health Wonk Review (HWR) on Joe Paduda’s excellent blog, “Managed Care Matters” (http://www.joepaduda.com/archives/001157.html)

HWR offers a round-up of some of the most insightful health blogs posts of the past two weeks including a post explaining the source of the opposition to universal coverage in San Francisco by Anthony Wright, and a Health Affairs analysis of the  crash and burn of the health reform initiative in California, and Tom Lynch’s four-part post on why the U.S. health care system is nowhere near the best in the world.

Joe himself offers a provocative “modest solution to the ever-growing problem of ever-increasing pharma costs by establishing a cap on national drug costs, allowing the market to figure out the best way to meet that cap, and if the market fails, requiring the Feds negotiate for price and allowing any and all payers access to that negotiated pricing.”

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A couple of weeks ago Dr.  Alicia Fernandez, an associate professor of clinical medicine at UC San Francisco, received a very unusual letter from The International Association of EMTS and Paramedics, an affiliate of The National Association of Government Employees (IAEP/SEIU).

The letter began by noting that Fernandez is part of the union’s approved physician network, and then launched into what can only be described as a shameless sales pitch for Lipitor, Pfizer’s blockbuster cholesterol-lowering drug.

First, the alarming statistics presented in the letter:

• 1 in 3 adults has some form of CVD (cardio-vascular disease)
• About every 26 seconds, an American will suffer a coronary event
• Stroke is a leading cause of serious, long-term disability in the United States
• Every 45 seconds, someone will suffer a stroke. 

Then, the endorsement: “Lipitor is available to our members through their prescription plan. IAEP leadership stands behind LIPITOR as the lipid-lowering agent of choice when it is prescribed by a physician. [my emphasis]  This confidence in LIPITOR is based on its proven efficacy and is supported by its vast clinical experience of more than 15 years…"

The letter went on, at length, to praise Lipitor’s benefits and to downplay the drug’s risks. In clinical trials, the letter states, “the most common adverse events were constipation, flatulence, dyspepsia and abdominal pain.” But while other risks may not be as “common” they are certainly worth mentioning. They include memory loss which can look like Alzheimer’s and severe muscle pain.

A few days ago, Fernandez received a second, identical letter.  Never before in her professional experience had she received a drug ad from a union.

“I’ve never seen anything like this. I’ve never seen Labor endorse a
drug product,” she told me. “This is incredible.” Unfortunately,
Fernandez adds, this is not the
first time that she has seen a drug company use a progressive
organization to promote its product.

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Berlin, March 13, 2008 —  By bringing 600 government and industry leaders together from more than 50 countries, the “World Health Care Congress Europe” (WHCCE),  which began Monday, offered  a splendid  window on  the wide variety of  solutions that countries  around the world are using as they struggle  toward health care reform. One constant theme of the conference: “No One Thing Works.”

When the three-day conference ended yesterday, it also was apparent that developed countries share many of the same problems.  One that stands out is the fact that our populations are aging. Each country faces the same question: how will a shrinking workforce possibly pay for the medicine their nations’ retirees will need?

This brings me to Princeton economist Uwe Reinhardt’s speech on the very first day of the conference. The only American to speak at WHCCE, Reinhardt focused on what he called “the folklore that people bring to the health care policy table.” By nature an iconoclast, Reinhardt spent the next 20 minutes shattering some of the myths that have become part of the received wisdom among policy-makers.

Begin with the notion that an aging population is a major factor driving health care inflation.  In the U.S. this is accepted as a justification for why the nation’s health care bill now equals more than $2 trillion dollars—and why we must expect it to climb ever higher.

Bad news is often more gripping  than good news, and  “if you want to be a popular speaker you need to feed the paranoia of your audience,” Reinhardt  observed, pointing to the first slide of his Power Point presentation—a  chart illustrating just how quickly we can expect a horde of wrinkly boomers to take over the nation. Some stooped and shriveled, others proudly bloated, these former members of the Pepsi generation will be far more demanding, we’re told, than the World War II veterans who preceded them.

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“The rich geographical diversity of the United States is part of its appeal. The diverse performance of the health care system across the U.S., however, is not,” notes The Commonwealth Fund in “Aiming Higher: Results from a State Scorecard on Health System Performance.”

This comparative state-by-state study of care in the U.S. pops off the page as part of a report released this month, “Health Policy Reform: Beyond the 2008 Elections,” and explodes some myths about where the best care can be found.

Find your state on the map below. You may be surprised to discover that when it comes to overall performance, health care systems in states such as New York, California and Texas—places known for being home to some world-class academic medical centers—don’t turn up in the top quartile. (States that do rank in the top 25 percent appear in white).

Reputation is one thing; medical evidence about quality of care, access to care, unnecessary treatments, excessive costs and bad outcomes is another. U.S. News & World Report is good at many things; ranking hospitals is not one of them.

How did the researchers who drew this map rank states? They used the 32 indicators listed on the table below (click to open a larger version in a new window) which measure:

• “Access” (based on how many of the state’s adults and children have no insurance, and how many went without needed care)
• “Quality” (measured by yardsticks such as the percent of adults and children who receive recommended preventive care; the share of hospitalized patients who received recommended care for acute myocardial infarction, congestive heart failure, and pneumonia; the percent of surgical patients who received antibiotics at the right time to prevent infections; the share of Medicare patients who gave the treatment they received high marks and said their provider listened to them, explained, and showed respect; the percent of nursing home patients suffering from bed sores resulting from not having been turned often enough; and the share of nursing home patients who were strapped to their beds)
• “Potentially Avoidable Use of Hospitals and Cost of Care” (measuring how many patients were hospitalized who might not have needed hospitalization if they had received proper care in the first place– and the cost of those unnecessary hospitalizations)
• “Healthy Lives” (indicating the chance of living a long and healthy life in a given state based on the percent of deaths that might have been prevented if the patient had received good care, the percent of breast cancer deaths, colorectal cancer deaths, infant mortalities, and the share of seniors whose activities are limited due to physical, emotional or mental health problems)

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Julia Hallisy recently sent me her book, The Empowered Patient (PatientsafetyCA.org, 2008).  It is at once one of the most pragmatic and one of the most moving healthcare  books that I have ever read.

Hallisy’s daughter, Kate, was diagnosed with an aggressive eye cancer when she was five months old. Over the next decade, she went through radiation, chemo, reconstructive surgery, an operation to remove her right eye, a hospital-acquired infection that led to toxic-shock syndrome and an above-the-knee amputation. Kate died in 2000. She was eleven years old.

Remarkably, The Empowered Patient is not an angry book. It is not maudlin. To her great credit, Hallisy manages to keep her tone matter-of-fact as she tells her reader what every patient and every patient’s advocate needs to know about how to stay safe in a hospital.

First she reminds us of the mind-boggling number of errors that occur in our hospitals every year. “As many as 95,000 people die annually” as a result of adverse events ranging from infections to fatal drug reactions.  It’s hard to grasp just how many people are dying until Hallisy gives us what she calls “a tragic reference point.” The number of lives lost to medical error is roughly equivalent to a World Trade Center attack occurring every two weeks during the year.    

Hallisy’s 300-page book is eminently readable, and filled with enormously useful detail. As she points out “the media and the government do try to warn us against the dangers we are up against with admonitions such as, ‘Make sure all your healthcare providers wash their hands before touching you,’ or  ‘Don’t sign blanket consent forms,’ or ‘Check your medication . . .’ 

“Good advice,” writes Hallisy, “but what exactly are you supposed to do to ensure that these things actually happen? Many of you reading this right now don’t know that you have a right to customize your consent form.”

I certainly didn’t.

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