Over at “Home of the Brave,” Annie calls attention to the following Las Vegas Sun story about a man who suffered a heart attack and went to the nearest ER for help:

“But even as Linda Scheinbaum — Morton’s wife of 24 years — was screaming [in the emergency room] for medical attention to save his life, the MountainView Hospital nurse was insisting on getting his Social Security number, emergency contact and insurance information.

“‘I’ll give you all the information later!” Linda Scheinbaum yelled at the clerk.

“It would be Scheinbaum’s tragic misfortune to [go] to the emergency room on the night of Nov. 4, 2005, when it was busy and hospital officials said there were no open rooms. The Scheinbaums were told to take a seat and wait — even though a delay of just minutes can make the difference between life and death during a heart attack…

“The precise timeline of the events of that desperate night is in dispute, but hospital records show that it was at least 41 minutes from the time Morton Scheinbaum arrived to the time he collapsed, blue in the face and foaming at the mouth. Only then was he rushed into the emergency room for treatment.

“And that’s where he died, his admission paperwork completed.”

There are many reasons to feel outraged when reading this story. But the tragedies of this tale are part of a larger—and just as depressing—picture in American emergency care. The staffing and overcrowding issues that Linda and Morton Scheinbaum faced three years ago are becoming the rule, rather than the exception, when it comes to emergency departments (EDs) in the United States.

Begin with the seeming villain of this tale, the pigheaded nurse who forced paperwork on the Scheinbaums in a time of crisis. Blogger Annie has some issues with the Sun’s less-than-probing characterization: “Is the ‘nurse’ cited an unlicensed admission clerk?” asks Annie. “A secretary?…or a licensed registered nurse who is obligated to perform triage and intervention to conform to state regulations and to the hospital’s accreditation agency standards?”

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A friend who lives in Boston complained, not long ago, about not being able to find a physician. In Boston?  “Come on,” I said. “This is like claiming you couldn’t find a liquor store.”

“They’re all oncologists and cardiologists,” he grumbled. “Last week I cut my hand badly enough that it needed stitches. I have good insurance. But I couldn’t get an appointment with my family doctor—or any of my friends’ doctors. I didn’t want to spend hours in the ER. So I wound up going to my sister’s house. She sewed it up at her kitchen table.”

His experience is not as unusual as it sounds. Some 56 million Americans do not have a regular source of care according to the National Association of Community Health Centers (NACHC) — even though many of them do have insurance. The problem is a shortage of primary care physicians (PCPs) in many parts of the country, particularly, but not exclusively, in poorer communities.

Even Docs Have to Call In Favors 

Not long ago, Bob Wachter, Professor and Associate Chairman of the Department of Medicine  at the University of California, San Francisco (UCSF) , and author of Wachter’s World warned his readers: “The Long-Awaited Crisis in Primary Care: It’s Heeere.” 

Indeed, if you try get an appointment at UCSF’s general medicine practice, you will find that it is “closed” –even if you are an UCSF physician. They just aren’t taking any new patients. “Turns out we’re not alone,” Wachter adds. “Mass General also is not accepting any new primary care patients.” 

He calls attention to “to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called ‘The Doctor Can’t See You Now,’ is the best reporting on this looming disaster I’ve heard .

Wachter summarizes highlights:  “Getting a ‘regular doctor’ (a PCP) at Mass General now takes the combination of cajoling, pleading, and knowing somebody generally referred to as ‘working the system.’ In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant.

“The report also makes clear that providing more ‘access’ through expanded insurance coverage won’t do the trick,” Wachter explains.  “Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

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Back in October, Maggie touched on America’s shortage of nurses, as well as the different factors behind the crisis—namely, hectic working conditions, insufficient academic resources for nurse training, and a hospital building boom that has outstripped the nursing workforce. Thanks to the convergence of these forces, the government predicts that the nursing shortfall will grow to more than 1 million nurses over the next 12 years.

What can be done to nip this problem in the bud? According to a new white paper, our priorities should lie with expanding the capacity of nursing schools and doing more to make sure that existing nurses work under better conditions.

First, the nursing schools: “there is widespread agreement that the primary bottleneck at this point in time is the faculty shortage,” say Jennifer Joynt and Bobbi Kimball, authors of “Blowing Open the Bottleneck,” published jointly by the AARP, the U.S. Department of Labor, and the Robert Woods Johnston Foundation. According to the authors, “a 2007 survey of baccalaureate nursing schools found that 71.4 percent of schools indicated faculty shortages as a reason for not accepting all qualified applicants.” Turning away potential nurses is a bigger problem than you might think: according to a companion write-up in JAMA, more than 42,000 qualified applicants were turned away from nursing programs in the U.S.

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My idea of a vacation is, of course, to blog.

TPM Cafe  asked TPM contributors to write

about  the convention and the  future

of the Democratic Party.

You can find the post here http://tpmcafe.talkingpointsmemo.com/2008/08/28/the_future_of_the_democratic_p_1/

Yesterday, the Census Bureau came out with a report that provides
a compelling window on poverty and health in America.

It’s somewhat modestly titled “Income, Poverty and Health
Insurance Coverage in the United States, 2007.” I would suggest it deserves a headline that
does justice to its sweep, perhaps “Connecting the Dots: Health and Poverty, America’s
Shifting Priorities, 1960-2007.

Begin with this chart:

At first glance, what is most striking is how well President
Lyndon B. Johnson’s “War on Poverty” worked in the late 1960s.  Seniors–who were then the poorest group in
the U.S– benefited most. The share of Americans over 65 scraping along
somewhere below the poverty line plummeted from roughly 30 percent in 1965 to
just over 15 percent in the early 1970s. Johnson made Medicare and Medicaid
legislation a priority, and when it passed Congress in 1965, it made an
enormous difference.

The War on Poverty also helped kids: the share of the
nation’s children trapped in poor households fell from roughly 23 percent in
1965 to 15 percent during the Carter years.

By contrast, look at what has happened during the latest
economic cycle.  As the Economic Policy
Institute’s Jared Bernstein points out,  “Despite
strong overall economic growth, the
cycle that began in 2000 and ended late last year has turned out to be “one of
the weakest on record for working families.”

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The Massachusetts experiment in health care reform is all about expanding access.  But it doesn’t try to control costs.  This, in a nutshell, is why it’s running into trouble.

The plan didn’t reform health care delivery, just coverage. Granted, in terms of bringing more people in under the tent, it’s been a success: Since the plan went into effect in 2006, 439,000 people have signed up for insurance—a number that represents more than two-thirds of the estimated 600,000 people uninsured in the state two years ago. This surge in coverage has reduced use of emergency rooms for routine care by 37 percent, which has saved the state about $68 million. (Going to the ER for routine care drives up health care costs by creating longer wait times and tying up resources that can be used to help patients who are critically ill).

But even with these savings, Massachusetts is having trouble funding its plan. Earlier this month the Boston Globe reported that the governor’s office is planning to shift more responsibility for funding to employers. Currently, the Mass. Health care law requires most employers with more than 10 full-time employees to offer health coverage or to pay an annual ‘fair share’ penalty of $295 per worker:  this is called ‘pay or play’, an employer either provides coverage or pays a fee toward the system for not doing so).

To “play” rather than “pay,” employers must show either that they are paying at least 33 percent of their full-time workers’ premiums within the first 90 days of employment, Or that they are making sure that at least 25 percent of their full-time workers are covered on the company’s plan. (In other words, they must be paying a large enough share of the premiums so that 25 percent of their employees can afford the plan they offer.)   

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Recently BuckEye Surgeon offered a compelling window on what it is like to be a surgeon (or, for that matter, any type of physician), and realize that patients think that you are practicing pure science.

First, he admitted that he had been reading Cicero, (yes, that Cicero—the late, great Roman orator and statesman), and had come across a quotation that “grabbed him”:

"For the better he is at his job, the more frightened he feels about the difficulty… about its uncertain fate… about what the audience expects of him."

“Cicero was talking about the stresses that afflict a great orator; the pressure to reproduce the excellence of past speeches,” Buckeye explains. “The audience has come to listen and expectations are high and even one minor insignificant error can ruin the overall impression of an otherwise articulate, inspiring speech.

“In many ways, this is what we’ve come to in medicine. The expectations are almost insurmountable. Infallibility is the performance standard. The delivery of healthcare has been relegated to the category of ‘commodity, like automobiles and hair care products and soybeans. Where’s my warranty, my guarantee? Why did I get an infection? Why didn’t you realize I had breast cancer when it was 0.5mm instead of 2mm? Did you wash your hands well enough before you came into my room?

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I first wrote about Gardasil on The American Prospect online in the summer of 2006, just weeks before the Merck vaccine designed to protect against cervical cancer went to market.

There, I noted that “the hullabaloo began in June when the FDA approved Gardasil, a vaccine widely described as ‘100 percent effective’ in preventing cervical cancer, a disease that kills some 233,000 women worldwide each year. The drumbeat grew louder last month when a federal panel recommended that all American girls and women ages 11 to 26 should be inoculated. And now there is talk that states may mandate the vaccine for all school-age children.

“But before prescribing for the entire population,” I suggested, “it’s worth asking a few questions: Why does the vaccine cost $360 for a three-shot regimen? How much do we know about the new product? And is this a cost-effective use of health-care dollars?”

I reported what we knew at the time:  Although Gardasil was commonly described as “100 percent effective” if you scrolled down far enough in most news stories, you would find that the vaccine is “100 percent effective” against  “only two strains of HPV (human papillomavirus) that causes cervical cancer. And those two account for just 70 percent of all cases. The vaccine has no effect on the viral strains which account for the other 30 percent.”

Read a little further and you would discover that because the vaccine protects against less than three-quarters of all cases, inoculated patients still will need regular Pap smear tests to check for signs of the disease.

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What this country needs is more lobbyists, representing more interests groups.  This is what Nicholas Lemann, Dean of the Columbia School of Journalism, all but declares in a contrarian piece published in a recent New Yorker. Basing his argument on The Process of Government: A Study of Social Pressure, a classic written by Arthur Fisher Bentley in 1908, Lemann declares that in the end, politics is all “about interest groups struggling against other groups and finally making deals, through politicians and agencies and courts.”  And this, he implies, is the way it should be.

Under Bentley’s rules there is no such thing as “the public,” Lemann explains. “There are only groups.” And “the public interest” is a “useless concept,” because there is “nothing which is best literally for the whole people.”  Bentley dismisses any idea of what I might call “the public good.”  We live in a society divided against itself, in groups with very discreet, often warring interests.  So much for making common cause for the common good.

As I read Lemann’s piece, I could not help but wonder:  what does this mean for national healthcare reform?  And I realized that there are some reformers who endorse something uncomfortably close to the process that Lemann describes.

Like Lemann, they believe that reform can be accomplished only by letting the interest groups duke it out. Big Pharma, the device-makers, hospitals and insurers all should take their rightful places at the negotiating table (after all, they paid our legislators for those seats), alongside primary care docs and RNs, surgeons and radiologists, hospital workers and  hospital administrators,  each group defending its  turf. Then there’s the AARP, the AMA and the AHA, the libertarians who oppose mandates, the progressives who want mandates…But wait, didn’t I leave someone out?

Oh, right, the patients.  When elephants fight, says a Swahili proverb, the grass suffers.

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