I have to admit I often have found the language of healthcare “rights” off-putting.  Yet the idea of healthcare as a “right” is usually pitted against the idea of healthcare as a “privilege.” Given that choice, I’ll circle “right” every time.

Still, when people claim something as a “right,” they often sound shrill and demanding. Then someone comes along to remind us that people who have “rights” also have “responsibilities,” and the next thing you know, we’re off and running in the debate about healthcare as a “right” vs. healthcare as a matter of “individual responsibility.”      

As regular readers know, I believe that when would-be reformers emphasize “individual responsibilities,” they shift the burden to the poorest and sickest among us. The numbers are irrefutable: low-income people are far more likely than other Americans to become obese, smoke, drink to excess and abuse drugs,  in part because a healthy lifestyle is  expensive, and in part because the stress of being poor—and “having little control over your life”—leads many to self-medicate. (For evidence and the full argument, see this recent post).  This is a major reason why the poor are sicker than the rest of us, and die prematurely of treatable conditions.

Those conservatives and libertarians who put such emphasis on “individual responsibility” are saying, in effect, that low-income families should learn to take care of themselves.

At the same time I’m not entirely happy making the argument that the poor have a “right” to expect society to take care of them. It only reinforces the conservative image (so artfully drawn by President Reagan) of an aggrieved, resentful mob of freeloaders dunning the rest of us for having the simple good luck of being relatively healthy and relatively wealthy. “We didn’t make them poor,” libertarians say. “Why should they have the ‘right’ to demand so much from us?”  Put simply, the language of “rights” doesn’t seem the best way to build solidarity.  And I believe that social solidarity is key to improving public health.

Given my unease with the language of rights, I was intrigued by a recent post by Shadowfax, an Emergency Department doctor from the Pacific Northwest who writes a blog titled “Movin Meat.”  (Many thanks to Kevin M.D. for calling my attention to this post.)  Shadowfax believes in universal healthcare.  Nevertheless, he argues that healthcare is not a “right,” but rather a “moral responsibility for an industrialized country.”   

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Writing on The Health Care Blog, D.C. insider Bob Laszewski puts the chances of health care reform—at least in the form envisioned by the presidential candidates and ambitious activists—at about zero in the wake of Wall Street’s meltdown. It’s easy to see why Laszewski is so pessimistic:

“On top of the $500 billion deficit [that the government faces ]in 2009…and the cost of the Freddie and Fannie bailout . . . the Congress is now being told it must take on a total of almost $1 trillion in government long-term costs to try to turn the financial system around.”

That’s a problem. McCain claims his reform plan will cost $10 billion; Senator Obama says his will cost $65 billion. Both are no doubt low-ball estimates. Obama’s plan, for example, is more likely to cost $86 billion in 2009 and $160 billion in 2013, after it’s expanded, according to the Urban Institute. Given these numbers, Laszewski says that the candidates have to “get…real” about how they’re “really going to deal with health care reform in the face of all of these challenges.”

In an upcoming post, Maggie will dig deeper into just how health care reformers can and should ‘get real’ in post-meltdown America. But instead of talking about what reformers should do, I want to discuss another important question we have to pose in the upcoming age of austerity: will the public even care about health care reform anymore, now that the economy has gone south?

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Healthcare reformers talk of a day when every American will have a “medical home.”   But as I noted in part I of this post (“Americans Who Have Insurance—But Still No Access to Care”), it is not at all clear who will be “at home” in these homes.

While health policy wonks envision a legion of 21st century Marcus Welbys who know their patients, consult with their specialists, send out timely reminders, and keep a meticulous record of their medical histories, the truth is that we’re facing a severe shortage of primary care physicians (PCPs). A recent study of 1,200 fourth-year students published in the Journal of the American Medical Association showed that only 2 percent planned to work in primary care. In a similar study in 1990, the figure was 9 percent.
In just the last ten year years, the number of U.S. medical students choosing to enter family medicine has fallen by 50 percent according to a report released by the Texas Primary Care Coalition (see chart below).

One reason medical students shun primary care is the relatively low pay. As the chart and table below reveal, over the last decade, dermatologists, radiologists gastroenterologists and orthopedic surgeons have seen their incomes skyrocket while the incomes of family doctors and internists lag far behind.

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In theory, Medicaid ensures that low-income families receive health care. But in practice, the program leaves much to be desired—and serves as a painful illustration that the existence of an insurance program isn’t enough to ensure access to necessary care.

On paper Medicaid offers pretty comprehensive coverage, seemingly even better than Medicare. For example, Medicaid covers long-term care for the elderly, nursing home care, and offers broader prescription drug benefits than Medicare.

But all the benefits don’t mean a thing if patients can’t find doctors to provide them. In a post last November, I noted that reimbursement rates for Medicaid are abysmally low across the nation as compared to both private insurance and Medicare: in New York, doctors receive $20 for an hour-long consultation with Medicaid patients, whereas a physician could earn almost $200—about 10 times as much—for such a consultation under Medicare. In 2007, the Wall Street Journal reported that Michigan’s Medicaid program pays $20 for a chest x-ray, where as Medicare pays $30 and private insurer Blue Cross, $33. For performing an appendectomy, a Michigan doctor can expect $784 from Blue Cross and just $336—about 42 percent as much—from Medicaid.

There’s nothing inherently easier about treating poor people—in fact,
Americans stuck on the lowest rungs of our socioeconomic ladder tend to
be in poorer health. Yet doctors are paid less under Medicaid and as a
result are closing their doors to low-income patients: a 2006 Center
for Studying Health Care System Change report found that the percentage
of physicians who accepted no new Medicaid patients in 2004-2005 was
“six times higher than for Medicare patients and five times higher than
for privately insured patients.” Reimbursement was a major concern
here: 84 percent of physicians who did not accept new Medicaid patients
in 2004-2005 said reimbursements were a factor; 70 percent of
physicians said billing requirements and paperwork were a factor; and
two-thirds said delayed payments were a factor. (While Medicare, a
federal program, has a reputation for paying providers in a timely
manner, Medicaid—administered by states—is a much more haphazard
affair, and can leave doctors waiting for months).

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With Medicare’s financing unraveling, Medicare reform will need to be high on the next president’s agenda. In a new report from The Century Foundation, fellow and HealthBeat Blog editor Maggie Mahar (www.healthbeatblog.org) points out that past proposals for containing Medicare’s costs, such as putting a cap on physicians’ fees or requiring beneficiaries to pay more for their care, have not worked. She calls for a fundamental set of reforms that would not only save money but also improve the quality of care that beneficiaries receive.

You will find the report at www.tcf.org later today.

Over at the Center for Media and Democracy’s PR Watch http://www.prwatch.org/node/7748  Judith Siers-Poisson writes:

“With the start of the school year, debate has heated up again about Gardasil, Merck‘s vaccine against human papillomavirus. Since writing my series of four articles on The Politics and PR of Cervical Cancer last year, I have continued to track the developments

“The push for mandatory vaccination continues, and many of its supporters have received money from Merck, including Women in Government, about whom I wrote extensively in my article, "Women in Government: Merck’s Trojan Horse." Despite a palpable turning of the tide against mandates, Women in Government still swims against the current. In a 2008 report titled "State of Cervical Cancer Prevention in America," WIG continued to push for mandates and gave higher scores to states that have introduced or passed legislation for this purpose.”

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Each presidential candidate offers a blueprint for health care reform. Neither can expect to see his plan enacted whole—legislators will leave their fingerprints all over any proposal. And, if truth be told, neither plan is perfect. Each proposal is blinkered in its own way; each ignores just how difficult true reform will be. I very much doubt that national health insurance will become a reality in the next year.

That said, I believe that we can take steps toward reform in 2009 if we begin thinking clearly—and honestly—about exactly what it is that we want and what it will cost. To that end, I believe that in-depth analysis of each candidate’s proposal can help underline the core ideological differences between conservatives, libertarians and progressives, and highlight the economic realities that any reform plan will have to face.

Recently, opponents of each plan have offered their critiques in Health Affairs (here and here) and supporters have defended their favorites  here  and here. Inevitably, many readers found the critiques too partisan. At the same time, they complained that rebuttals from the home team “read more like a stump speech with details glossed over and facts overlooked.”   

Readers are still looking for an unbiased, in-depth report on the two plans that clarifies the details and the differences. Earlier this week, the Urban Institute, a nonpartisan economic and social policy research organization, published an assessment of the two proposals that sets out to do just that. Overall, the Institute’s report seemed to me remarkably fair—and certainly worth discussion. 

The Strengths of the Obama Plan 

First, the Institute notes, rightly, that Obama’s plan would “substantially increase access to affordable and adequate coverage for those with the highest health care needs, including those with chronic illnesses” by:

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I’ve said it before, and I’ll say it again: the doctor-patient relationship is just that—a relationship, a mutual connectedness between two human beings, each with their own values, dispositions, and priorities. Like all relationships, this one is complex, but there is a single concept that manages to capture a lot of what doctors are expected to bring to their partnership with patients: empathy.

Empathy is key to what we’ve traditionally called “bedside manner,” or the ability of doctors to identify with the concerns and emotions of their patients in order to reassure them and more generally ensure effective communication. Every one of us probably has an intuitive understanding of why empathy is a valued trait in doctors, but it’s worth exploring the issue further—especially since it seems to be in short supply amongst today’s doctors, in part thanks to the rigors of medical school.

We’re not talking about warm and fuzzy nonsense here. Empathy is “more than a nice idea,” say Donald Scott and William R. Harper, two professors at the University of Chicago, “it’s a pragmatic skill that stands at the center of the patient-doctor connection, on which so much else depends.” That skill isn’t just about feeling for patients, but also about expressing those feelings, through words, body language, and tone. In 2006, Harper gave the University of Chicago Magazine an example of empathy’s importance: “If the connection is strong, the patient is more likely to follow a doctor’s recommendations. You can order the fanciest test in the world but if the patient does not buy into it, it doesn’t matter.”

The best way for patients to ‘buy into’ treatments is to feel that their doctors understand and appreciate their situation.  “Irrespective of the disease, when you find someone who will feel for you, you feel better,” U of C neuroscientist Jean Decety told the university magazine. Indeed, studies show that a stronger doctor-patient relationship contributes to improved health outcomes by ensuring that health situations are clearly understood and patient priorities are met. Empathy also reduces the burden on the friends and family who care for terminally ill patients.

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Yesterday, the John D. and Catherine T. MacArthur Foundation named 25 new MacArthur Fellows for 2008. The recipients will each receive $500,000 in "no strings attached" support over the next five years. The new Fellows work across a broad spectrum of endeavors and include a neurobiologist, a saxophonist, a critical care physician, an urban farmer, an optical physicist, a sculptor, a geriatrician, a historian of medicine, and an inventor of musical instruments. All were selected for their creativity, originality, and potential to make important contributions in the future.

HeathBeat has written about both Meier (the geriatrician) and Pronovost (the critical care physician). To read their stories, click here and here. Meier also is a member of the working group on Medicare Reform that I have put together here at the Century Foundation.

Please feel free to share your thoughts/comments about these pioneers and their work here on HealthBeat.

Today, The Guardian UK published a story that should be shocking–but isn’t: "More than Half of U.S. Drug Studies Never See the Light of Day." This serves as further proof–if we needed it– that pharmaceutical companies should not be allowed to control what doctors and patients know, and don’t know, about new drugs.

The story follows below.

More than half of US drug safety studies never see the light of day
Only 43% of the evidence of safety and efficacy that the US Food and Drug Administration uses to approve drugs is published in scientific journals. The authors of the survey say this amounts to "scientific misconduct."

James Randerson, guardian.co.uk,Tuesday September 23 2008 10:46 BST

The results of more than half of all clinical trials that demonstrate the safety and effectiveness of new drugs
are not published within five years of the drug going on the market,
according to an analysis of 90 drugs approved by US regulators between
1998 and 2000.

The researchers, who traced the publication or otherwise of 909 separate clinical trials
in the scientific literature, wrote that the failure of drug companies
to publish the evidence relating to new medicines amounted to
"scientific misconduct". They said it "harms the public good" by
preventing informed decisions by doctors and patients about new
medicines and by hampering future scientific work.

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