September 1, 2007
Single Payer Debate
Meghan McCardle, a columnist for the Atlantic Monthly wrote a piece on her blog about health care and the morality of health care finance that has attracted a bit of attention. She writes,
Moreover, as a class, the old and sick have some culpability in their ill health. They didn't eat right or excercise; they smoked; they didn't go to the doctor as often as they ought; they drank to much, or took drugs, or sped, or engaged in dangerous sports. Again, in individual cases this will not be true; but as a class, the old and sick bear some of the responsibility for their own ill health, while younger, healthier people have almost no causal role in the ill-health of others.
Perhaps they deserve it by virtue of suffering? But again, most of them are suffering because they have gotten old, often in high style. The young of today have two possible outcomes:
1) They will be old and sick too, in which case they are no less deserving of our concern than today's old and sick
2) They won't ever get to be old and sick, which is even worse than being old and sick.
As a class, the old and sick are already luckier than the young and healthy. Again, for individuals within that class--those with desperate congenital conditions, for example--this is not the case. But I'm not sure it's terribly compelling to argue that we should massively disadvantage a large group of people in order to massively advantage another, equally large group of people, all to help out the few who are needy, or deserving, or unlucky.
What lovely sentiments. . . . She writes further in her column in Atlantic.com that she was surprised by all the feedback she received. Ezra Klein has kindly decided to set her straight on why she might want to ree-think some of her positions here and here. He writes,
"I would like to hear from a large number of single-payer advocates," writes McMegan, "who will say that if the American system could be proven to provide higher quality care per dollar on average than other industrialised system, then they would be content to leave 40 million people uninsured." And I would like to hear from a large number of auto enthusiasts who will say that if the car I'm selling them can be proven to go really fast, then they won't care that it's missing two seats, a mufflers, half a door, and three cylinders.
The 45 million are not some puppies-and-rainbows issue we're talking about because they make us feel sad and draw frownie faces in the margins of our notebooks. It's not efficient to have 45 million people going without preventive care. I could name about 45 million reasons why this is so -- ranging from enhanced productivity to the cost-effectiveness of statin drugs to the young uninsured who should be in the risk pool -- but that's the fact of it. The reason policy reformers are so intent on pulling them into the system isn't because policy reformers are Really Great People, it's because their absence is mucking everything up, and causing gross inefficiencies for hospitals, clinics, Medicare, Medicaid, taxpayers, and themselves. . . .
But at least this straw reform movement which believes dogmatically in single payer for incomprehensible reasons and laughs at efficiency claims isn't around to menace us any longer. We can thank Megan for that.
August 29, 2007
Justice O'Connor and the Uninsured
Big numbers, like 45 million uninsured Americans, are hard to grasp. But that number came home to me at a recent conference. The keynote speaker was former Supreme Court justice Sandra Day O'Connor. Her topic was our healthcare system, and her message was personal and anguished.
The gist was that even she lives in constant fear of major uninsured health bills. Not her own -- those of her son. He can't afford insurance because his son -- her grandchild -- has a preexisting condition.
As I listened, a light dawned: O'Connor and the rest of us with health coverage are also uninsured. We too face terrible, albeit more remote, healthcare risks -- the risk that our employer will drop our plan, that Medicare will go bust, that our plan won't cover our needs, that premiums will eat us alive, that our doctor will stop taking our insurance, that long-term care will wipe us out, and that our uninsured friends and family members will need major financial help.
These risks are entirely avoidable. We can have an efficient, transparent system that includes everyone; treats everyone fairly; covers all the basics, including prescription drugs, home healthcare, and nursing home care; and costs little more than what we now spend. But we can't get there via the piecemeal reforms that President Bush, most of his would-be successors, and our state governors are advocating. . . . .
I don't agree with his proposed solution but it is different that what I have heard before -
My solution is called the Medical Security System. It would eliminate Medicare, Medicaid, and (by dropping the tax breaks) employer-based healthcare. The government would give everyone a voucher each year for a basic health plan. The size of the voucher would be based on one's health status. Those in worse health would get bigger vouchers, leaving insurers no incentive to cherry-pick. Furthermore, insurers would not be permitted to refuse a voucher or otherwise deny coverage.
The government would set the total voucher budget as a fixed share of gross domestic product and determine what a basic plan must cover. We would choose our own health plans. If we cost the insurer more than the voucher, he would lose money. If we cost him less, he would make money. Insurers would compete for our business and could tailor provisions, like co-pays and incentives to stop smoking, to limit excessive use of the healthcare system and encourage healthy behavior.
Nothing would be nationalized. Virtually all of the cost would be covered by redirecting existing government healthcare expenditures as well as tax breaks. Doctors, hospitals, and insurers would continue to market their services on a competitive basis.
This is not a French, British, or Canadian solution. It's an American, market-based solution that Republicans should love. It's also a progressive solution that Democrats should love. (Democratic presidential candidate Mike Gravel has endorsed it.) The poor, who are, on average, in worse health, will receive, on average, larger vouchers. The rich will lose their tax breaks.
Why can't a country as rich as ours come up with a system that works? This, in essence, was Justice O'Connor's parting question.
But, in fact, we can. Now if we can just get the big cheeses in the Oval Office or on their way there to start thinking big . . .
Mahablog has further commentary on the need for reform.
August 28, 2007
World Health Organization and Spread of Infectious Disease
The New York Times writes about on the WHO's report concerning the spread of infectious diseases in our increasingly mobile world. The report informs us that more communication and sharing of data is essential:
New infectious diseases are emerging at an “unprecedented rate,” and far greater human mobility — by planes, trains and ships — means that diseases have the potential to spread rapidly across the globe, a World Health Organization report warned this week.
Because of this risk, greater international cooperation among governments and scientists is essential, said Dr. Margaret F. C. Chan, director general of the health organization. “Given today’s universal vulnerability to these threats, better security calls for global solidarity,” Dr. Chan said in a statement that accompanied the World Health Report 2007, issued in Geneva, where the organization is based. “The new watchwords are diplomacy, cooperation, transparency and preparedness.”
Much of the report focuses on how health officials should respond to a more globalized world. In 2003 the outbreak of SARS, or severe acute respiratory syndrome, was spread from mainland China to Hong Kong and then on to Singapore and Canada via airline passengers. Another factor is that many migrants now travel around the world for work. A polio epidemic that started in Nigeria most likely moved to countries including Yemen on ships carrying migrant workers, organization officials say.
Dr. Chan, who was Hong Kong’s top health official during the SARS outbreak there, has been in her new office less than a year, and the health organization’s experiences during her tenure have underlined the need for improved international cooperation and communication.
I didn't realize that profit was concern in these situations --
For much of the year, the World Health Organization was haggling with China and Indonesia over their unwillingness to share samples of the avian influenza, or bird flu, virus. Both countries have serious problems with the disease, and such samples help international scientists at the health organization track the spread and evolution of the virus, to better predict the likelihood of a global pandemic. But the samples can also be used for vaccine development, and some countries express fears that the profits and credit for a vaccine would be lost if samples were sent to Geneva. . . . .
August 27, 2007
Breast Cancer Rates and Hormone Therapy
Reuters reports on recent data published in the 5th Journal of the National Cancer Institute showing a decline in breast cancer rates which appears related to a decline in the use of hormone replacement therapy.
"It's encouraging that breast cancer rates decreased with decreases in use of hormone therapy," Dr. Karla Kerlikowske told Reuters. This implies that women who stopped using hormone therapy in a relatively short period of time have a risk of breast cancer similar to women who have never used hormone therapy."
Kerlikowske from San Francisco Veterans Affairs Medical Center and the University of California, San Francisco, and colleagues examined whether parallel declines in postmenopausal HRT use and rates of breast cancer are present among women undergoing routine screening mammography.
They point out that the breast cancer detection rate is higher in women undergoing mammography, so "the proportion of women in the population undergoing routine screening mammography will influence population-based estimates of breast cancer incidence."
The prevalence of postmenopausal HRT use started to decline about the same time that observational studies in early 2000 linked use of estrogen and progestin combinations to greater breast cancer risk than use of estrogen alone. An even greater decline followed the release of the Women's Health Initiative study in 2002.
The current study involved over 600,000 screening mammograms on women 50-69 years of age, of whom 3238 had breast cancer. The rate of estrogen receptor-positive invasive cancer was stable until 2001, but declined 13 percent per year from 2001 to 2003, the report indicates. Rates of estrogen receptor-negative invasive cancer did not change during this interval. . . . .