Map of life expectancy at birth from Global Education Project.

Wednesday, February 25, 2009

Talk is cheap

Here is the section on health care from the president's speech last night, and my profound comments.

For that same reason, we must also address the crushing cost of health care. This is a cost that now causes a bankruptcy in America every thirty seconds. By the end of the year, it could cause 1.5 million Americans to lose their homes. In the last eight years, premiums have grown four times faster than wages. And in each of these years, one million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas. And it's one of the largest and fastest-growing parts of our budget. Given these facts, we can no longer afford to put health care reform on hold.

Mad props to the prez for emphasizing cost as the key to the problem. It's not the whole problem, of course -- but we can't achieve universal coverage, high quality, and the best health outcomes if we don't wrestle the cost monster to the ground. Furthermore, this seems to be good politics -- people are worried first and foremost about the economic catastrophe and lost jobs, and by putting health care into that context he gives us the best chance to get something major done.

Already, we have done more to advance the cause of health care reform in the last thirty days than we have in the last decade. When it was days old, this Congress passed a law to provide and protect health insurance for eleven million American children whose parents work full-time.

Certainly, I was in favor of expanding S-CHIP. But, that really doesn't get us anywhere. When you get into the weeds of eligibility, coverage limits, sliding scales and what not with S-CHIP as with the rest of the patchwork of federal, state and private plans, the mind boggles and the tongue ties trying to sort out the perverse incentives. Expanding our current dysfunctional disease care system adds a small modicum of justice, but no common sense.

Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.

Hoo boy is this ever a can of worms. Electronic medical records systems have a lot to be said for them, but ensuring privacy is not on that list. They create huge privacy problems. Those may be solvable but at considerable cost. EMRs can indeed reduce errors but the biggest payoff comes from a universal system in which an individual's record attaches to the individual, not a provider institution, and is accessible from everywhere, by all providers. Whether we will see anything like that in my lifetime is questionable, and it poses the greatest challenge for privacy. We may get a patchwork in which more and more physician practices and institutions, not just academic medical centers, use their own proprietary systems, but getting these to talk to each other is a nightmare. For small practices, EMRs are just not cost effective, because of the initial capital costs and learning curve, so they'll need substantial subsidies. Fully integrating behavioral health, nursing homes, specialists -- oy. Electronic order entry systems -- a subset of the whole EMR concept -- can reduce prescribing errors, but beyond that, using EMRs to reduce medical errors will require a huge investment in decision tools and has considerable potential to backfire, if we end up substituting one-size-fits all rules for sound physician judgment. Can we really save money this way? I don't think so.

It will launch a new effort to conquer a disease that has touched the life of nearly every American by seeking a cure for cancer in our time.

We now know that there is no such thing as "cancer," that is a term for innumerable different diseases characterized by abnormalities in cellular gene expression that cause abnormal tissue growth. There will never be "a" cure for cancer, though we are slowly, sloggingly making progress against various specific manifestations. Unfortunately, as we grow older, genetic abnormalities accumulate in our tissues, so even if we do manage to cure one cancer, the longer we go on living, the more likely we are to get another one. So cancer is never going to go away, and even worse, the more treatments we develop for more and more different kinds of cancer, the more money we are going to spend using them. Expanding cancer research might be something people want to do, but it sure as hell isn't going to save money.

And it makes the largest investment ever in preventive care, because that is one of the best ways to keep our people healthy and our costs under control.

Yes to proposition A -- some preventive measures are helpful in keeping people healthy -- but no to proposition B -- preventive medicine does not save money. I wrote about this recently, and there are two recent articles -- one in JAMA by SH Wolfe (Feb. 4), the other by Louise B. Rusell in Health Affairs -- but unfortunately they are both subscription only (booo!) so I can't let you read them. I mention this only so you don't have to take my word for it. Basically, with few exceptions, you have to spend money, even if it's a small amount of money, on a whole lot of people in order to prevent disease, and it usually ends up costing more than it saves. That doesn't mean it isn't worth doing -- it's often cost effective, but that doesn't mean it's cost saving, it just means we don't mind spending a few bucks to prevent disease.

Cost saving measures are available, but for the most part they aren't preventive care -- i.e., they don't happen in the doctor's office. They are public health measures, like tobacco control and promoting better diets and physical activity. But the president didn't mention the words "public health." Maybe next time.

This budget builds on these reforms. It includes an historic commitment to comprehensive health care reform - a down-payment on the principle that we must have quality, affordable health care for every American. It's a commitment that's paid for in part by efficiencies in our system that are long overdue. And it's a step we must take if we hope to bring down our deficit in the years to come. Now, there will be many different opinions and ideas about how to achieve reform, and that is why I'm bringing together businesses and workers, doctors and health care providers, Democrats and Republicans to begin work on this issue next week.

Okay, so we're going to do something, it's just that so far, we don't have even a hint of what it's going to be. I know we aren't going to get what we really need right away, so I am going to judge the proposal which emerges on one criterion and one criterion only: does it create a path toward universal, comprehensive, single payer national health care? If it makes that even harder to attain, I'm agin it. If it's neutral on that objective, it isn't worth doing. If it takes us a step closer, I'll take to the streets to support it.

I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough. So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.

Definitely: if we're going to do something good, let's do it right now, before the wingnuts have a chance to get up off the rug. For the next few months, nobody will care how loud they scream about socialism and big government. Now's the time.

Meanwhile, here's David Leonhardt, explaining why conservatives are completely, utterly, abysmally wrong. Not that this will get through to anybody.


robin andrea said...

I'm pleased that he's going to try to tackle the problem, perceiving right off the bat that there is a problem to begin with! What I want and what we're likely to get will probably be worlds apart, but if there's access to reasonably priced insurance, it'll be an acceptable beginning. Taking the profit out of insurance would be a good start.

Cervantes said...

Taking the profit out of insurance would be more than an acceptable start! It's the nut of the whole problem -- it's precisely because the insurance industry is such a powerful vested interest that we can't get real reform. If we can eliminate their profits, we're already past the barrier and we can do whatever we want, as I see it.

Alas, that's the hard part. That's why Medicare Part D ended up being so screwed up - because they only way they could get a prescription drug benefit was to put the insurance companies in the middle scooping up profits.

kathy a. said...

i was just going to comment along robin's lines.

what exactly are the benefits of insurance via for-profits? i mean for consumers, who care about access to medical care with low additional costs -- obviously, the shareholders of the for-profits like skimming the profits.

there are administrative structures, but these are not in sync nor do they necessarily work to the advantage of patients -- nearly everyone has denial of coverage nightmare stories when something expensive comes up.

i guess one of the arguing points is that single-payer might reduce choices. there is a lot of that going around anyway -- hmo's, for example, have a great deal of control over who gets what and who you get to see. the low payments for medicare patients [or patients needing poorly covered specialties, like psychiatry] have made it very difficult for patients to find doctors, and driven a lot of doctors out of practice or away from taking insurance at all.

and those are just problems faced by insured people; uninsured people have few or no good choices. the fact so many end up in ER's after their health has gone into crisis is not only bad for them, but a pretty damned expensive way of providing care -- not just in dollars, either.

Cervantes said...

Insurance industry profits do no good for anybody except shareholders and executives. But, they are a powerful vested interest that has the political clout to block reform that gets rid of them.

Single payer doesn't have to mean less choice for consumers at all - it means socialized insurance, not health care. In fact it gives you more choice, because you can take it to any doctor or hospital, you don't have to worry about who's in the network.