Today, I talked to Bob Blendon, who is a professor of health policy and political analysis at Harvard’s Kennedy School of Government, about Super Tuesday’s multi-state primary contests and what they might mean for healthcare reform.

Blendon agrees with the consensus on the Democratic race. Hillary Clinton and Barack Obama are running nose to nose, but Blendon points out, if you take a closer look at the polls, you find an unusual contradiction.  Not only are the voters split between the candidates; there are very split, within themselves.

“When you ask about the issues, Clinton wins on almost every point, including healthcare,” Blendon reports.  But when you ask about character, likability, leadership, ability to inspire—Obama is the clear favorite.

“Usually, people can’t live with that much incongruence,” Blendon adds. “Once they decide who they like, then they decide that person is the best on the issues. Normally, people don’t like incongruence within themselves.”

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In the post above I quote Harvard professor of health policy and political analysis at Harvard’s Kennedy School of Government Bob Blendon as saying that voters perceive little difference between Obama and Clinton on healthcare reform. And I think he’s right. But that’s because most voters haven’t honed in on the fine points of their plans.

Those who have scrutinized the plans, and understand the economics of healthcare reform, see important differences—differences that could be deal-breakers.

In today’s New York Times, Princeton economist Paul Krugman argues that because Obama’s plan does not require everyone to sign up for insurance, it would be more expensive—and thus less likely to pass Congress. Without a mandate, Obama’s plan “would face the problem of healthy people who decide to take their chances or don’t sign up until they develop medical problems, thereby raising premiums for everyone else,” Krugman points out. He acknowledges that “Mr. Obama, contradicting his earlier assertions that affordability is the only bar to coverage, is now talking about penalizing those who delay signing up — but it’s not clear how this would work.”

Writing on The American Prospect today, economist Dean Baker from the Center for Economic and Policy Research responds to Krugman, saying that he knows how penalties would work:

“Obama has suggested that we can have a system of default enrollment, whereby people are signed up for a plan at their workplace.

“People would then have the option to say that they do not want insurance, so they are not being forced to buy it. However, they will then face a late enrollment penalty if they try to play the ‘healthy person’ game. When they do opt to join the system, at some future point, they will have to pay 50 percent more for their insurance, or some comparable penalty for trying to game the system. “

What Baker doesn’t say is what we will do with families who cannot afford to pay such stiff penalties when they finally decide they need insurance. Would we subsidize the penalties?

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Do we know enough about measuring the quality of healthcare to pick out the best doctors?

When I asked Don Berwick that question last week, he spread his hands: “You’re looking at the cream of crap. The system is so broken,” he explained, “that even the high performers are far away from optimal performance.  Most measures of quality are simply measuring the system that the doctor is trapped in, not the doctor himself.”

Who is Don Berwick, and why is he saying such terrible things about our healthcare system?

Dr. Donald Berwick, President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI), is widely recognized as one of the world’s most respected experts on healthcare quality. In 2005, Modern Healthcare, a leading industry publication, named Berwick the third most powerful person in American medicine.  In contrast to others on Modern Healthcare’s list, Berwick “is not powerful because of the position he holds,” noted Boston surgeon and author Atul Gawande. (Former Secretary of Health and Human Services Tommy Thompson ranked no. 1 on the list while Thomas Scully, the head of Medicare and Medicaid Services, captured the second spot).  “Berwick is powerful,” Gawande explained, “because of how he thinks.”

When Berwick thinks about the U.S. healthcare system, the word he uses is “bloated.” There’s a myth that American healthcare is the best in the world,” he noted at a Families USA conference last week. “It’s not,” he said bluntly. “It’s not even close.”

“It’s thought to be the best because we have the most healthcare,” Berwick told his audience. But in fact, although we spend twice as much as the average developed country providing more care than any other nation in the world “40 percent of the care that Americans actually need is not received.” Why?

“Cost is the barrier.”

“Here is a question I often ask my students,” added Berwick, who is a Professor of Pediatrics at Harvard. “When you meet a new patient, what is the one test that you could do that would tell you how long that patient is likely to live?

Typically, students answer: “Ask them if they smoke,” or “Test their blood sugar.”

“No,” says Berwick, “Just look at the color of their skin.”

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Two seasoned political strategists, Paul Begala, and Stan Greenberg, spoke at “Health Action 2008,” a conference that Families USA sponsored in Washington last week.  There, they argued that the U.S. may be on the threshold of what Begala, a political contributor on CNN’s “The Situation Room,” called “a totally new deal.”  Greenberg, chairman and CEO of Greenberg, Quinlan Rosner, went a little further: “It is very possible that the whole conservative complex crashes.”

In an interview later that afternoon, Greenberg explained what he meant: “I think this election is going to mark an extraordinary defeat for conservatives.” Greenberg isn’t talking about the number of Congressional seats that the conservatives may lose: he is not forecasting a sweep for Democrats that equals the LBJ landslide. Instead, he’s predicting something more fundamental: that the right wing of the Republican party will be shattered. “There may be a fragmentation on the conservative side that changes what’s possible after the election.”

For many who came of age in the 1980s and the 1990s, this must seem unimaginable. For the past 28 years, the U.S. government has been held captive by the conservatives. Ronald Reagan sowed the seeds and George W. Bush harvested the fruit of a political movement bent on deregulation and smaller government while consolidating and preserving the wealth of the country’s richest citizens.

At the beginning of Bill Clinton’s first term, it seemed that the nation might be ready for deep changes, in large part because we had entered a recession that was threatening not just blue collar but white collar workers.  Middle-class and upper-middle class employees were afraid that they were going to lose not only their jobs, but their health insurance.  But as that recession eased, Bill Clinton’s first major initiative went down in flames.  A health care reform plan that would have signaled the beginning of progressive economic reform failed, in  part because Americans were no longer as anxious as they had been when Clinton captured the White House.  (Ezra Klein recently did a superb job of putting the death of the Clinton healthcare plan in context, explaining how a combination of “bad timing, political misjudgment and human error” conspired to kill what had been a “courageous effort” to pass health reform.)

But now, Begala and Greenberg say, the time is ripe for radical reform. They make their argument based both on the fact that the conservatives are in disarray and on what Americans now say when they talk to pollsters about healthcare reform.  In September, 62 percent of those polled said that “rising health care costs are a very serious problem in the economy”—up from 50 percent a year earlier. And, as the recession deepens, that number is likely to climb.

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Tomorrow (Tuesday) night, at 8:30, HBO will air a documentary titled “Baghdad Hospital: Inside the Red Zone.” The film offers an inside look at Al-Yarmouk hospital in Baghdad, as seen through the eyes of a doctor. Once an ordinary hospital, Al-Yarmouk has been transformed by insurgency and sectarian strife into a “field hospital in a civil war.” It is the epicenter of hope and despair for thousands of wounded Baghdad civilians and their families. 

Filming inside Al-Yarmouk’s emergency room was too dangerous for an American crew to attempt.  Only an Iraqi ER doctor could do the job.  This is his story.

With the film’s debut on HBO, Dr. Omer Salih Mahdi reveals his identity to the world for the first time. Until now, he has remained anonymous to protect himself and his family. Dr. Mahdi’s face is not revealed in the film and an actor has recorded his words.

Given permission by hospital authorities to use a hand-held camera inside the emergency room, Dr. Mahdi reveals some of the horrific injuries sustained by Iraqi men, women and children, and exposes the substandard conditions, low morale and danger that its doctors and nurses endure on a daily basis.

Like the American GIs in HBO’s acclaimed 2006 documentary "Baghdad ER," many of the people hospitalized in this film are victims of gunfire or improvised explosive devices (IEDs). Here, however, the victims are Iraqi civilians caught in the crossfire of the ongoing sectarian violence between Iraqi Shiites and Sunni insurgents.

Life inside the hospital is dangerous: Gunshots frequently ring out inside the ER, and insurgent militia fighters often storm its doors. Doctors are targets, partly because, as one puts it, "We’ll treat anyone: Shiite, Sunni, whoever." But it’s much more treacherous for those working outside. Ambulances are sometimes shot at and ambulance workers have been killed, either mistakenly by Americans or deliberately by extremists.

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Today I’m in Washington, attending Health Action 2008. Families USA organized the event and invited me to come down and blog about it. Yesterday morning we heard Congresswoman Nancy Pelosi lay out her views on the health care issues facing Congress and I was both surprised and impressed by the strength of her speech.

Pelosi stressed equality: “We must fund bio-medical research,” she declared, “and the benefits must belong to every single American.”  She went on to point out that “in order to have this research available to all, we have to have a common electronic record—bringing everyone into the loop.” In other words, a single electronic medical record could provide the database everyone needs to see what works and doesn’t.

To be truly valuable, that database must be as broad as it is deep. As Pelosi put it, “the healthcare of the most privileged person in American benefits if everyone has health care, and if we have a common electronic record.”  (Pelosi also emphasized that this record must respect the privacy of everyone involved, keeping medical information about individuals confidential.)

She went on to say that while “bringing everyone into the loop, we must eliminate the disparities [in the quality of care that different groups in this country receive], not just from a sense of fairness—which would be justification enough alone—but in terms of insuring better health for the nation.”

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As part of a continuing series on health care spending, last week I looked at what share of our health care dollars goes to pay for physician’s fees and clinical services. As the pie chart below shows, 22 percent of the $2.1 trillion that we spent  on  health care last year went directly to doctors. That’s up from 19.4 percent in 1960.

Most of the jump came in the 1960s and 1970s—though physician incomes continued to grow in the 1980s, rising 30 percent from 1984 to 1989, or about twice as fast as the average increase for other full-time workers.

I promised that this week I would publish a Part II to last week’s post and look at how much doctors are paid in other countries, how hard they work compared to doctors in the U.S., and how patients are faring as physicians’ incomes continue to outstrip both inflation and wages nationwide.  Finally, I said I would discuss whether we are spending too much on physicians services—and how we might change the way we pay them.

But first, let me very quickly re-cap the background to this story. In recent years, doctors’ fees have come under pressure. In the 1990s, managed care companies set out to pare costs by questioning virtually every bill that doctors sent them and in recent years Medicare has been trying to keep a lid on spending by refusing to raise most doctors’ fees.  Many private insurers have been following Medicare’s lead. Meanwhile, the cost of running a practice has been climbing, making it hard for some doctors (particularly primary care physicians) to stay afloat financially.

Nevertheless, by increasing the number of patients they see and the number of procedures they perform, many doctors have been able to boost their incomes.  More entrepreneurial doctors also have been making investments in surgical centers—creating a second income stream.  Thus, the overall amount that we spend on physicians’ services continues to rise: up 6.2 percent in 2000, up 8.3 percent in 2003, up 7.3 percent in 2004, up 7.4 percent in 2005, and gaining another 5.9 percent in 2006.

But not all physicians are prospering. The charts I ran last week show pediatricians, family doctors and others who practice what some call “cognitive medicine” (talking to and listening to the patient ) making as little as $115,000 a year while specialists who perform the most aggressive procedures haul home $800,000.

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As a nation, we are spending well over two trillion a year on health care. What exactly are we paying for? In a December 6 post, I asked how much of that $2 trillion goes to private insurers in order to cover “administration”– which includes advertising, marketing, underwriting, lobbying, multi-million dollar executive salaries, and profits for  shareholders.

As the pie chart below shows, it turns out that in 2006, after taking in premiums and  paying out reimbursements,  private insurers  kept  close to $95 billion—or about 4.5 percent of the $2.1 trillion we spent on care—to fund everything from advertising to CEO bonuses.  Meanwhile, private insurers paid roughly one-third of the nation’s health care bills.  (By contrast, the government picked up nearly half of  the $2.1 trillion tab through programs like Medicare, Medicaid, SCHIP while spending only $525 billion —or about 2.5 percent of the $2.1 trillion—on administration.)

Ninety five billion dollars represents the difference between what private insurers received in premiums and what they paid out in reimbursements, and it’s a big number. But as I commented in my December post, even if we eliminated the private insurance industry’s role in our health care system, the $95 billion saved would be wiped out by just one year of health care inflation.

Inflation: that is the elephant in the middle of the room. In 2006, total spending on health care climbed by 6.7 percent, or $132 billion, to $2.1 trillion. In 2007, economists expect an even bigger jump.The pie just keeps on growing, year after year, far faster than the average workers’ wages: up 8.6 percent in 2003, up 6.9 percent in 2004, up 6.5 percent in 2005, up 6.7 percent in 2006…And there’s no end in sight.

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At Wachter’s World, Bob Wachter, Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco explains more about how the government’s attempt to stop the use of checklists in ICUs could undercut efforts to improve quality in hospitals nationwide.  He also gives you a chance to write to your Senator or Congressman. Go take a look.

Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, published an op-ed in the Wall Street Journal last week that returned to the much-exploited story of Nataline Sarkisyan, the 17-year-old Californian who died before receiving a liver transplant. Gottlieb used the story to make the argument that “the U.S. has the best health care in the world.”

Gottlieb is squaring off against John Edwards, who has been suggesting that if Nataline had lived in a European country she might have lived.  Edwards blames CIGNA, her for-profit insurer, for refusing to cover the procedure. Dr.  Gottlieb, who is a former FDA official, responds with a double-barreled argument: “Americans are more likely than Europeans to get an organ transplant, and more likely to survive it too.”  He sounds confident, and at first glance, his argument seems persuasive.

But a closer look reveals that Gottlieb makes his case by carefully culling the numbers that fit his argument, while omitting those that don’t. Unfortunately, too many people involved in the healthcare debate play fast and loose with the facts. Everyone interested in reform should be on the look-out for those who don’t cite solid evidence for their assertions. If they don’t give you their source, it may be because they don’t want you to look it up—and because they realize that they are cherry-picking the numbers.

Before engaging Gottlieb’s argument, I should acknowledge that, as I have said in an earlier post, I think Edwards has picked a bad case to make his argument for healthcare reform. I am not at all certain that the transplant would have helped this particular patient.  And while Edwards puts all of the blame on CIGNA, Nataline’s insurer, I am bothered by the fact that the hospital asked for a $75,000 down payment on the surgery and then refused to go forward without it. As one physician/blogger from the very same hospital where Nataline was treated asked: “Why didn’t the hospital simply perform the surgery and defer payment from the family or CIGNA [Nataline’s insurer] until later? If it was such a great idea, why didn’t they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA’s assessment?” 

That said, I agree with Edwards and other proponents of health care reform that, in other countries, decisions about whether or not to pay for expensive procedures like transplants are not based on whether the patient has the money or the insurance to pay for the operation. Instead, in other developed countries, such decisions turn on whether the benefits of the treatment outweigh the risks—and whether the procedure is cost-effective.

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