Special topic: Health care reform

There has been so much drama and purposeful misinformation on the subject of health care in the US that I’d like to attempt to cut through the mess and help (along with other bloggers) initiate a national conversation on health care. This issue is so important that we must not let special interest groups or runaway ideologues of any type force their views on everyone. We must view this issue critically – as in using critical thinking skills. Perhaps we all need to read Sherry Seethaler’s Lies, Damn Lies, and Science so we can effectively compare the options to the status quo rather than making false comparisons that serve no one (yes, I really like this book, in case you were wondering).

Learning from examples

The UK, Canada, France, Australia, Italy, Iceland and Japan – just to name a few – all have some type of standardized health care. We also have a variety of systems within the US on federal, state, and local levels. Why not actually look at these systems and compare them to what we have overall in the US today? We have the opportunity to take the best of each system out there and mold something new. What type of health care system would you build?
This American’s Experience of Britain’s Healthcare System is one person’s account of the US and UK healthcare systems (h/t Tuibguy). The author opens the door to a reasoned, evidence-based discussion of what health care should be like. The post contains no yelling, no hyperbolic disaster scenarios, no conspiracy theories. Even better, there are some really really well thought out comments. This is the conversation that the entire nation should be having. Some of the excellent points made by commenters:

Corrine I wouldn’t rate the NHS as 4 stars, but I too prefer it over the capital system (and I’m Republican). We have so many services in the USA that are socially and politically run, why not have one of the most important added to the list? Schools, Fire Departments, Libraries, Hospitals. If children must be educated, fires must be put out and books made available to all why can’t we agree that health deserves the same status?”

Sarah it does come out of my taxes – but it’s only because of my healthcare that I’m actually well enough to have been able to pay taxes for the last 15 years. I’m in a good job, so adding it all together, I’m an investment. Without my thyroid medication I’d be reliant on benefits for the rest of my life, and costing a whole lot more to the state in the long term.

The power of anecdotes

Personal stories aren’t good data, but they can be compelling. The problem is that few people step forward to talk about the good things that happened to them. In some cases, the deck is stacked with people who believe one way or another, so a lot of Americans aren’t getting the entire picture. What’s your personal story, particularly if you have experience in alternative systems i.e. not commercial health insurance?
Army Medical Corps insignia.My experience with health care in the US is mixed. As a service member I received excellent medical and dental care with reasonable waits, free unlimited visits, easy access to specialists, free prescriptions, etc. I had surgery for TMD costing tens of thousands of dollars that was completely covered. My treatment at the VA for my service-connected problems has been just as good. If there was a VA hospital closer by, I’d go there for all my care, but it’s an hour away. If national health care is anything like military care, sign me up! Now, there are grumpy nurses, bad doctors, and dirty bathrooms in the military health care system – but these things happen in all systems.
Unfortunately, my experiences with health and dental insurance have been less than pleasant. The Student Health Center on campus is wonderful. All of my care is covered by my student health insurance, with no co-pay, including things like blood tests and X-rays. Anything outside the Health Center is terrifyingly expensive. I had to go to the emergency room to get 5 stitches on my thumb, and it cost $500 out of pocket. A visit to a specialist is $200. Prescriptions from anywhere besides the Health Center aren’t covered at all. My dental insurance with United Concordia was just as bad. I needed a root canal, but the closest doc on the plan was 4 hours away. I ended up paying about $500 out of pocket (luckily, I have since switched to my partner’s dental plan). As a student, this health plan is my only option. I have no choices, and can’t afford to seek health care when traveling. It’s terrible. There has to be a better way.

Listen to experts

While it is important to hear from individuals, our elected officials should pay more attention to what the experts have to say. The Mayo Clinic, one of the best health care facilities in the world, has a comprehensive list of recommendations that the House and Senate have all but ignored. These recommendations have been available since 2008. One intriguing recommendation is to pay health care facilities and workers for value rather than volume. The National Institutes of Health has a great list of resources on health policy, the economics of health care, and health care reform. If I can find these and educate myself, why can’t Senators and Representatives (or their staff members) do the same? The Obama Administration has its own collection of resources at Healthreform.gov, including The economic case for health care reform. While a health care reform skeptic might not want to take the information in these reports for granted, they are a good place to find references.

Lock out lobbyists

Unfortunately, at least some elected officials choose to gather information from sources that are less than credible, such as the Facebook notes of people who have no training in health care policy or economics. One such official is Senator Grassley of Iowa. Interestingly, this vocal opponent of health care reform is one of the biggest recipients of funding from lobbyists. In 2008, he has received $334,237 from the health sector and $72,000 from the insurance sector. Over his career, Senator Grassley has received $1,876,479 from the health industry and $858,224 from the insurance industry, according to the Sunlight Foundation. Unfortunately, Senator Grassley is not alone – both Democrats and Republicans have received exorbitant amounts of money. How much of their public policy is a result of quid pro quo? Health care is the single biggest argument for campaign finance reform. It’s unrealistic to think that Senators Grassley and the rest will be able to make decisions on health care that don’t include some thought of who’s financing their next campaign.
Even worse, there is evidence that corporate fertilizer feeds the astroturf presence in the health care debate. Instead of discussion between elected officials and their constituents, the health care industry is paying PR firms to stir up opposition to health care reform. This includes the spread of blatant falsehoods, use of inflammatory language, inappropriate comparisons, and fear tactics. One example is the infamous “Health Care Bureaucracy Maze”, which can be found on the Republican funded Obama Experiment website. The chart implies that the new plan will create the maze, when in fact, most of the agencies already exist, and are arguably quite important, such as the VA. It also implies that there is not currently a bureaucracy between patients and doctors, which is obviously false (insurance companies are quite good at creating bureaucracies). The New Republic magazine asked The Kaiser Family Foundation to help put together a chart of Your Health Care System for comparison.
I’m not satisfied with a system that places politics and corporate interests above the recommendations of experts. This isn’t democracy, it’s disgusting.

End of life counseling

The biggest example of misinformation is end of life counseling. I am stunned by the intentional twisting of this incredibly important provision in the House bill. This issue is very important and sensitive to me because my grandmother recently passed away after a long and painful illness, during which she was often unable to tell us what she wanted. She had the foresight to have an end of life counseling with her doctor and my aunt (her primary care taker) before she fell ill. In this counseling, she decided that she wanted to be in hospice care, rather than in the hospital, and that she did not want heroic measures taken when the time came. Because she had decided for herself, my family was not left with the painful decisions of whether or not to employ a feeding tube, etc.
Let’s see what HR 3200 America’s Affordable Health Choices Act of 2009 Section 1233 Advance Care Planning Consultation actually says (parsed for clarity):

• Nurse counseling patient from Spartanburg Regional Hospice.Each individual may receive an optional ‘advance care planning consultation’ (ACPC) by a physician, nurse practitioner, or physician’s assistant who has the authority under State law to sign orders for life sustaining treatments.
• An ACPC may take place every 5 years, or more frequently if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility, or a hospice program. Initial preventive physical examination, including any related discussion during such examination, does not count towards the 5-year limitation. [Note, an individual may have as many ACPCs as desired, but only ones every 5 years or sooner with life-threatening illness will be paid for under Medicare and any other government health programs.]
• An ACPC shall include the following:
  • An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to.
  • An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.
  • An explanation by the practitioner of the role and responsibilities of a health care proxy.
  • The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965).
  • An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports.
  • An explanation of orders regarding life sustaining treatment or similar orders, which shall include
    • the reasons why the development of such an order is beneficial to the individual and the individual’s family and the reasons why such an order should be updated periodically as the health of the individual changes
    • the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order
    • the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decision maker (also known as a health care proxy).
• An ACPC may include the formulation of an order regarding life sustaining treatment that
  • is signed and dated by an appropriate health care provider and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care
  • effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual
  • is uniquely identifiable and standardized within a given locality, region, or State
  • may incorporate any advance directive.
• The level of treatment indicated in an advance directive may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include
  • the intensity of medical intervention if the patient is pulse less, apneic (unable to breathe), or has serious cardiac or pulmonary problems
  • the individual’s desire regarding transfer to a hospital or remaining at the current care setting
  • the use of antibiotics
  • the use of artificially administered nutrition and hydration.
• This information will be added to the Medicare & You Handbook not later than 1 year after the date of the enactment of this Act:
  • An explanation of advance care planning and advance directives, including living wills; durable power of attorney; orders of life-sustaining treatment; and health care proxies.
  • A description of Federal and State resources available to assist individuals and their families with advance care planning and advance directives including
    • available State legal service organizations to assist individuals with advance care planning, including those organizations that receive funding pursuant to the Older Americans Act of 1965
    • website links or addresses for State-specific advance directive forms
    • any additional information, as determined by the Secretary.

There is nothing to be afraid of in Section 1233. On the contrary, not having a living will is frightening! Have we so quickly forgotten the terrible saga of Terri Schaivo?
Instead of emphasizing the benefits of end of life consultations for individuals and families, the benefits are often described in terms of health care savings. This may lead to people thinking that the government would encourage people to choose cheaper procedures. However, the bill doesn’t put any bureaucrats between you and your doctor – it simply funds an optional visit with your health care provider in which you can discuss end of life issues. The article End-of-Life Provision Loses Favor in the Wall Street Journal explains that the bill makes available a service that is currently not available – a service that would help people and save money:

The Urban Institute, a nonpartisan research center, found that the government could save $90.8 billion over 10 years by better managing end-of-life care. The savings would result from training aimed at discouraging doctors from providing care simply because they would get paid for it, and from having teams at hospitals help terminally ill patients manage their pain once they chose to stop treatment, among other things.
The institute’s report, issued last month, concluded that much end-of-life spending isn’t sought by patients and goes against their families’ expressed preferences.

I’ve read/scanned the whole bill and haven’t found anything scary, but then again I support a public option along the lines of the UK and Canada. What parts of the bill do you like or dislike? A commentable and easily searchable copy is available at Open Congress (I don’t know how frequently this gets updated, though).

The bottom line

There is no question that something needs to change. Right now, rising health costs are causing real problems for real people, whether they have insurance or not. I’m not an economist, but I wonder how many of the problems in our financial system are due to those costs. The National Coalition for Health Care put together a fact sheet with some very interesting (and sad) facts, with proper references to back them up. Just a taste:

• A recent study by Harvard University researchers found that the average out-of-pocket medical debt for those who filed for bankruptcy was $12,000. The study noted that 68 percent of those who filed for bankruptcy had health insurance. In addition, the study found that 50 percent of all bankruptcy filings were partly the result of medical expenses. Every 30 seconds in the United States someone files for bankruptcy in the aftermath of a serious health problem.
• About 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs.
• A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses.
• According to a recent report, the United States has $480 billion in excess spending each year in comparison to Western European nations that have universal health insurance coverage. The costs are mainly associated with excess administrative costs and poorer quality of care.
• The United States spends six times more per capita on the administration of the health care system than its peer Western European nations.

Why do we let health care cost so much money? There are some people going into bankruptcy because of bad decisions, and I don’t have a lot of sympathy for them – but what does it say about America and Americans that we force people to choose between financial health and bodily health health? What does it say that we force people to choose between food and health care, shelter and health care?
Even if we look at the situation completely without compassion, health care is an investment that leads to tax revenues. By extension, health care is also an investment that will stimulate the economy. People struggling with health care bills, putting off care and getting sicker and sicker do not stimulate the economy. Small businesses struggling through the complex and expensive process of finding and providing health coverage for their employees do not stimulate the economy as much as they could be, as in the CNN article Health care costs choking small businesses (h/t Hawg Frog).

Moving forward

Deciding what reform measures to consider and eventually enact is complex. It should be done slowly and carefully – but the longer it takes, the more time opponents will have to spread misinformation to the public. It also gives opponents of reform time to remove important provisions from the bill, such end of life counseling, which originally was supported by members of both parties, as described in GOP backs away from end-of-life counseling. It also gives President Obama time to back away from serious reform, as seems to be happening in White House ready to accept health co-ops?. I can only hope that all of our legislators remember who they are representing and decide to start focusing more on facts than fiction. I also hope that constituents choose to let reality rather than fearmongering dictate what they say at town hall meetings.