Map of life expectancy at birth from Global Education Project.

Tuesday, May 12, 2009

Oh yeah, that again

Now that the Obama administration has worked down the laundry list and arrived at health care reform, I suppose I need to start writing about it obsessively again. Sort of a civic duty. I really don't know what more I can say about it, but I suppose not every post here has to be completely innovative and new.

As I noted yesterday, the key battles now seem not to be over whether something will happen, but whether that something will include:

  1. A public insurance option open to all;

  2. Some variation on a National Institute for Clinical Excellence that promulgates guidelines for effective and cost effective clinical practice. As of now, opponents have drawn their line in the sand well in front of the real target, by opposing even trying to learn what treatments work best. Contrary to the imperishable values of Faber College, Republicans once again proclaim that "Knowledge is Bad.";

  3. Top-down reallocation of resources away from specialty care and heroic interventions to primary care and preventive services.

What all of these elements have in common is that they are about stopping somebody's gravy train. The medical-industrial complex is more than willing to go along with covering everybody, if that just means 45 million more "covered lives," as they say in the insurance biz, from which to render more gravy. But what we have to understand is that covering everybody is insupportable and unsustainable if we don't put the fat cats on a low-cal diet. (Sorry about that -- you try being clever every morning at 9:30.)

I am truly afraid that we will squander this historic opportunity by settling for a Massachusetts-style reform -- which is already failing in Massachusetts -- that just puts more money into the system; forces people who happen to have just the wrong combination of age and income to buy crappy insurance that just vacuums money out of their pockets and then doesn't pay for their health care; continues squandering a quarter of the whole pile on insurance company profits and boondoggles and half of the rest on ineffective, overpriced, and or futile services; and fails to keep people healthy, is not equitable or consistently humane, and is not affordable. The bastards are just going to rip us off once again, with a good segment of the left cheering them on in the name of compromise and bipartisanship.

I will address each of these elements in turn in coming days, I'm not sure yet in what order. Meanwhile I still have the backlog of Housing First, dog bites, and the length of primary care visits to deal with. Should be busy.


robin andrea said...

If we don't get it done the right way now I fear we we will never get it. What's it going to take? I think we need a million person march for health. Nothing talks like boots on the ground. It may be the only thing that speaks louder than money.

Bill Flowers said...

Many discussions about the "solutions" to our health care crisis seems to be about how to allocate funds, how to collect merely pushing the money around perhaps more efficiently. All those ideas are relevant and can lead to some savings, but we'll never get far unless we scrub out the inefficient, wasteful parts. For example, we have to get a grip on why about 75% of our health care dollars are spent on the life-end procedures. Shannon Brownlee's book about unnecessary treatment touches on many of the issues, and, by the way, she supports the finding that we spend about $800 billion (with a "b") of our 2.3 trillion (with a "t")of health care dollars on unnecessary treatments. Worse, she shows how some of those treatments worsen the health of patients.

Money driven medicine? Yes, a resounding yes. Good ol' captitalism at work, but in health care for everyone, it doesn't do the job.

Cervantes said...

Well Bill, it's true, but it's also a little tougher than it seems. While a lot of money is spent on futile end of life care, that's often clear only in retrospect. Futility is not always apparent in prospect. So the real number that could be saved there in practice is probably smaller than $800b. But it is still substantial and we do need to have a serious, open, public conversation about this.

And RA, I don't know if a big march on Washington is the best way but yes, some form of popular uprising is necessary.