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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Health Beat Blog is getting a new look. Some of you have asked for larger type, so we’ve re-designed the blog to make it more readable, while including a few extra features– including a link to our “Most Read Posts.”

We’re rolling out the new design on Monday, February 4. If something isn’t displaying property, please be sure to refresh your browser. In Internet Explorer, this is the button with green arrows to the right of the address bar (F5) and in Firefox, this is the blue arrow button to the left of the address bar (Ctrl+R).

Earlier this month, I wrote briefly on how the relationship between high cholesterol and heart disease is growing murkier than has been traditionally assumed. Today, by way of Gary Schwitzer’s Health News Blog, I came across a recent BusinessWeek article by John Carey that cracks this story wide open—in part by addressing an incredibly important, but often misunderstood and misused—statistic: the “number needed to treat.”

The succinctly titled piece, “Do Cholesterol Drugs Do Any Good?,” notes that “Americans are bombarded with the message from doctors, companies, and the media that high levels of bad cholesterol are the ticket to an early grave and must be brought down. According to these ubiquitous messages, statins [cholesterol-lowering drugs like Lipitor] “are the most potent weapons in that struggle.” Carey notes that Lipitor advertisements claim that the drug “reduces the risk of heart attack by 36 percent…in patients with multiple risk factors for heart disease.” Sounds pretty effective, right?

Hold the phone—there’s more to that number than meets the eye. Carey notes that the 36 percent is accompanied by an asterisk stating that “in a large clinical study, 3 percent [or three out of every hundred] of patients taking a sugar pill or placebo had a heart attack compared to 2 percent [or two out of every hundred] of patients taking Lipitor.”

Now, Pfizer’s number isn’t an outright lie. Pfizer, Lipitor’s manufacturer, says its potion reduces risk by  36 percent because the difference between two patients getting a heart attack on Lipitor and three patients getting a heart attack on placebos is one patient—or about a third the number of heart attacks that would have happened without Lipitor.

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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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Today, as the first in an ongoing series of updates on what’s new in international health care, I want to take a look at recent reforms in Germany. As a whole, we Americans pay precious little attention to what’s going on in other countries unless the news involves war or David Beckham. I’m hoping to buck this trend a little.

The big story in German health care is Chancellor Angela Merkel’s late 2006 reform that resulted in series of changes that, for the most part, were implemented in April of last year. Below, a look at these reforms; but first a little political background: Merkel heads up a "grand coalition" government, i.e. one where the largest political parties govern in collaboration due to inconclusive election results (a relatively common occurrence in parliamentary systems). In other words, social democrats and conservatives are in a constant tug-of-war. The new plan reflects this fact, juggling solidarity and competition in equal parts. And while this might sound like a good balance, virtually no one is satisfied with the compromise.

On to the big changes:

Mandatory Health Insurance: Many folks think that European health care means, by definition, universal public coverage. Not so. Germany has a public/private system, and before the April 2007 reform, public coverage was only compulsory for those within a certain income range (roughly speaking, working and middle class citizens). Higher-income and self-employed Germans, along with public servants, could opt-out of SHI by purchasing private insurance. They could also forgo insurance all together.

Due to this set-up, until recently some 200,000 Germans were uninsured—about 0.2 percent of the population. As of April ’07, all Germans must purchase health insurance. In the past, private insurers (who traditionally offer plans with many bells and whistles) had the right to refuse coverage for high-risk individuals. Now, they must take all comers. In this way, the new German plan is like Hillary Clinton’s proposal for health care reform: insurers can no longer shun the sick but everyone must sign up—citizens cannot wait  until they are sick to enroll.

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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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A few days ago, Merrill Goozner at Gooznews posted a great commentary on a recent New York Times article that reveled in the so-called “revolution in medical prognostication.”

This time, the amazing innovation is a DNA test that helps to predict mens’ risk of getting prostate cancer at the low, low price of $300. But as the article points out, this test “cannot predict which men will get aggressive cancers” and thus “could lead to more screening and unnecessary surgery and complications.” In other words, it gauges the risk—not the inevitability, and not the severity—of prostate cancer. Defenders of the test say that if all goes according to plan, men “may want to get the new genetic test when they are young” so that they can get a jump on prostate cancer treatment.

But here’s the problem: prostate cancer treatment is, more often than not, less useful than you might think. Merrill points out that it’s “already overdiagnosed and overtreated with horrendous side effects for thousands of late middle-aged men.” Here at Health Beat, Maggie has also noted that while the risk of prostate cancer is often hyped, almost every authoritative medical body on the matter agrees that the benefits of screening and treatment of early-stage prostate cancer are highly uncertain. There is no evidence that early treatment prolongs life by a single day.  We excel at finding out if there might be the need to do something, but we know very little about the impact of what it is we actually do.

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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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Yesterday I was watching television and was bombarded with the following infomercial for a dietary supplement called Lipozene:

No doubt your bull-you-know-what detectors are going haywire already, as well they should. But before you write off Lipozene as a joke, consider this: there’s nothing that the manufacturer of Lipozene—the Obesity Research Institute (ORI)—does that prescription drug companies don’t do every day. In fact, by analyzing Lipozene’s marketing, we can get a clear picture of the fundamental building blocks of Big Pharma’s business practices.

The active ingredient in Lipozene is glucomannan, a complex carbohydrate found in the konjac plant. Since glucomannan is an insoluble fiber, it absorbs water to form a thick gel that coats the stomach, making you feel full—thus reducing your eating.

For all that ORI’s advertisement irritates, it does contain a kernel of truth: the appetite-suppressing effects of glucomannan have been shown to help weight loss. A 1984 study showed that 1 gram of glucomannan before meals helped obese people lose an average of 5.5 lbs over eight weeks. Of course, this specific number is never cited in the Lipozene materials, with advertisements instead touting the fact that 78 percent of every pound loss was pure body fat and that “people were not asked to change their daily lives.”

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