Map of life expectancy at birth from Global Education Project.

Wednesday, May 06, 2009

JAMA says wonk you out

Unfortunately, they have yet to succumb to the ordinarily awesome influence of Stayin' Alive and make the articles available to you, the wretched refuse, but the editors of JAMA have given us three commentaries on health care reform prospects, and four if you count the one about China, which is not entirely irrelevant. You can't read the articles because you are worthless trash, but you can access the first 100 words of each of them here, along with full citations.

It would be feckless for me to try to adequately summarize these discussions here -- I may write a long-form article on the subject and try to get it posted somewhere -- but I'll make a few observations. These writers all pretty much give up on doing what's right before they even get started. We face two categories of obstacles they all consider more or less insuperable -- the political culture, in which tropes such as "individual responsibility" and "private enterprise" suffice to abort all rational discussion; and the power of vested interests, notably insurance companies, pharmaceutical manufacturers, and highly paid medical specialists. So we're looking for workarounds that can get us at least two steps ahead and only one step back.

Samuel Sessions and Allan Detsky discuss the obvious downside of cost containment -- it means people lose jobs and/or income. So-called health care (a misnomer in my view but I've just about given up fighting it) now consumes 16% of the economy. If we don't get costs under control, Medicare and Medicaid spending alone will consume 8.4% of GDP by 2030, which will be 40% of the projected federal deficit. (Forget about Social Security, there's no crisis there.) Ten percent of the workforce is in "health care," of which more than 1/4 of the jobs are clerical. Most of these people, of course, aren't helping to provide "health care," they're busy doing things like denying it, figuring out how to game the billing, marketing, etc. But anyway, if we wring waste out of the system, those people will be out of work, and they don't tend to have skills which are much good elsewhere. (You can get an Associates Degree in medical billing, believe it or not, but it's not much good in rapidly growing industries like guns and ammunition, or debt collection.) As a component of any successful reform, we'll have to reduce the incomes and probably the numbers of many highly paid medical specialists, and pay more money to more primary care physicians. But the cardiac surgeons aren't going to like that.

So, in other words, we need a plan, and we probably will have to settle for a gradual transition. Which is where Troyen Brennan and Michelle Mello come in. They want to expand Medicare to cover people under 65, to provide competition for private insurance, while expanding regulation of private insurance to limit medical underwriting, while implementing an individual mandate with subsidies for the near poor. That's more or less what Massachusetts has done except for the expanded Medicare, which is necessary to soak up the much larger numbers of uninsured working poor outside of the People's Republic of Massachusetts. Our reform, as such, wouldn't work in Texas. (Actually, it won't work here either, but I won't go into that.) This is more or less Obama's proposal, but unfortunately, they have touched the third rail here, because it is precisely that public option that the Republicans have vowed to filibuster into oblivion. And whatever Arlen Specter wants to call himself, he won't vote for cloture, it won't happen. That's why Obama wants to use the budget reconciliation process to avoid the filibuster, but "Democrat" Specter says he opposes that as well.

Finally David Orentlicher, in an essay entitled "Health Care Reform: Beyond Ideology," undertakes a rational, pragmatic analysis which is intended to dodge the rhetorical brickbats from all sides and take us to the reasonable, pragmatic, common ground truth. Which turns out to be universal, comprehensive, single payer national health care. Except that he can't call it that. Oh well.

Kathy the cat fancier turns us on to this interview with the Prez by David Leonhardt, in which he addresses health care near the end. It's very strange to have a president who produces syntactically well-formed utterances arranged in logical, well-informed discourse. But there you have it. He dodges and weaves a bit, but do check out his ruminations on end of life care. He doesn't have the answers, but he says we need to have a discussion. Yes we do. But we'll have to cross that kettle of fish when we come to it, after we've got a payment system in place that can deal with it.


kathy a. said...

i don't have much idea from these JAMA blips what is discussed in most articles -- but providing aftercare and housing and services for chronically ill homeless adults brings costs down. that sounds hopeful.

there is going to be a lot of moaning about reforming the health/insurance industry. part of that is the loss of unfettered profits to investors. part may be lost jobs, one assumes mostly at lower levels -- and isn't a lot of that stuff being shipped overseas, anyway? like medical transcription and maybe billing?

we're making the US auto industry get its stuff straight. huge numbers of jobs there have been lost over decades. people would buy american if the choices were better -- in 30 years, we have bought only foreign cars, mostly used, because they met our needs.

we've seen the dot-com boom and fail, but technology did not die in the process.

i think the transformation is do-able, over time.

kathy a. said...

oh, i meant to say also -- cracking down on tax loopholes for jobs shipped overseas is a very sensible measure. i hope the end result is that there will be a shift toward employing people here who want to work.

kathy a. said...

OK, i'll shut up after this. but helen thomas, the journalist who has long covered the white house, has just spoken out in favor of single-payer health insurance for all:

Michael said...

it always makes me laugh when you mention JAMA and their policy re the many-headed multitude. I live in Japan, where 'jama' means "get in the way" or "be a nuisance"

that's all i have to say, nothing constructive to add.