Saturday, June 13, 2009
Ezra Klein on socialized medicine
The words "socialized medicine" and"single-payer health care" get thrown around with such gleeful abandon that they've both become a bit unmoored from their actual meanings. In the American health-care debate, they tend to refer to "whatever the Democrats are proposing." But that's not what they mean.
Socialized medicine is a system in which the government owns the means of providing medicine. Britain is an example of socialized system, as, in America, is the Veterans Health Administration. In a socialized system, the government employs the doctors and nurses, builds and owns the hospitals, and bargains for and purchases the technology. I have literally never heard a proposal for converting America to a socialized system of medicine. And I know a lot of liberals.
Single-payer health care is not socialized medicine. It's a system in which one institution purchases all, or in reality, most, of the care. But the payer does not own the doctors or the hospitals or the nurses or the MRI scanners. Medicare is an example of a mostly single-payer system, as is France. Both of these systems have private insurers to choose from, but the government is the dominant purchaser. (As an aside here, unlike in socialized medicine, "single-payer health care" has nothing in particular to do with the government. The state might be the single payer. But if Aetna managed to wrest 100 percent of the health insurance market, then it would be the single payer. The term refers to market share, not federal control.)
Socialized medicine is far outside any discussion we're having. Single-payer medicine has a genuine constituency but is also a vanishingly unlikely outcome. But the promiscuous use of the terms has created a rather confused population. "Socialized medicine" is the thing we don't have. In some case, it's the thing we don't like. The graph atop this post comes from a poll conducted by the Harvard School of Public Health. They found that Americans actually preferred socialized medicine to our system. Or take this question, about our current system:
You're reading that right. About 30 percent of Americans think HMOs are socialized medicine. Which implies a couple things. First, the term "socialized medicine" has been diluted beyond all meaning. Second, it's no longer considered a terrifying outcome. And third, nothing that's this amorphous -- and actually preferred by a plurality of the population -- is likely to prove a terribly effective attack against health reform. Socialized medicine has become such a stand-in for "not this system of medicine" that it's begun to look good in comparison.
Meanwhile, what we're actually going to get is not socialized medicine or single-payer health care. It's a hybrid system. Private insurers, hopefully competing with a public option. Private doctors and private hospitals. Government regulation and subsidies. It's going to be complicated and messy and inefficient and hopeful and the product of a strange mix of corporate preferences and public compassion and latent populism. It will, in other words, be a uniquely American system, and hard to describe with a single epithet.
Friday, June 12, 2009
The New York Times reports on new ways that doctors and patients interact. Dr. Pauline Chen writes,
A survey released today by the Pew Internet and American Life Project reports that 61 percent of Americans go online for health information, and the majority of them have turned to user-generated health information. But a quick scan through peer-reviewed journals reveals only a handful of articles, and no evidence-based guidelines, to guide doctors on the use of social media. It is unclear whether such engagement adds to or detracts from a therapeutic patient-doctor relationship, and clinicians are unsure about what constitutes good standards of care and professional responsibility on these platforms. For example, should doctors give out diagnoses or prescribe treatment on Facebook or a blog? If doctors and patients communicate on Twitter, is a doctor liable if she or he misses a patient’s tweets about the acute onset of shortness of breath?
Dr. Sean Khozin, who blogs and can be found on Twitter @SeanKhozin, is an internist and founding member of Hello Health, a paperless “concierge” practice based in Brooklyn that utilizes e-mail, instant messaging and video chat for coordinating care. “There are so many layers of bureaucracy between health care providers and patients,” Dr. Khozin said. “We can use social media to coordinate care with patients and with different specialists, all using the same platform. I can monitor my patients, and they can also use these tools to become empowered through a better understanding of their own disease state and active engagement.”
In Dr. Khozin’s practice, that engagement occurs on a secure site, as patient privacy remains a major concern with all forms of social media. But on platforms such as Twitter and Facebook, where privacy is more difficult to insure, those concerns also extend to physicians.“ ....
Taking on the responsibilities of yet another form of communication can also be onerous for physicians, many of whom already feel overburdened by multiple demands on their time. “Physicians are really busy,” Dr. Sands said. “In our current health care environment, the only commodity they have is time. Doctors don’t want to introduce new technologies of unknown value, which is why many were hesitant about e-mail. Something like Twitter is going to take longer to accept because the value proposition is even hazier.”
Still, there continues to be anecdotal evidence regarding social media’s potential to strengthen the patient-doctor bond. “One way I see that power is through education,” said Dr. Christian Sinclair, a physician for Kansas City Hospice who has created a palliative care network through his blog and Twitter (@ctsinclair). “I can help to inform the public, I can put the knowledge I have out there. And if there are patients or families who need this knowledge, I can help them because of this network.” Dr. Sinclair has, for example, helped individuals he has met through Twitter connect with local hospices, a process he believes was expedited by Twitter’s particular platform.
And social media can also help patients and physicians widen illness support networks, which in turn can augment the patient-doctor relationship. Health care providers have long known that patients with chronic or life-threatening diseases benefit from support groups made up of people who can sympathize and empathize with them. But such support is difficult for physicians or hospitals and clinics to cobble together when patients and families are physically isolated or homebound, or when they have an orphan disease like Eddie’s....
Social media platforms can turn 10- or 20-minute doctor’s visits into an ongoing dialogue, where sources of information and, potentially, support are continually available to the patient and the doctor. “Platforms like Twitter can be powerful if doctors are a lot more active in disseminating their expertise,” Dr. Khozin said. “Patients are being bombarded with information online, but I don’t think all that information necessarily empowers them. You also need expertise.”....
Thanks to Jen Dowing for the link.
Yesterday, the World Health Organization declared a swine flu pandemic. The New York Times reports,
The disease has reached 74 countries, and probably met the technical definition of a pandemic — or global spread — weeks ago. Nearly 30,000 cases have been reported, but disease experts think hundreds of thousands or millions of people have actually been infected. So the agency made official what had become obvious: that the H1N1 virus is spreading quickly in different parts of the world, and its chief, Dr. Margaret Chan, said, “Further spread is considered inevitable.”
The announcement does not mean that the illness, which has been mild in most people, has become any worse. The term pandemic reflects only the geographic spread of a new disease, not its severity. Pandemics typically infect about a third of the world in a year or two, and sometimes strike in successive waves.
“Globally, we have good reason to believe that this pandemic, at least in its early days, will be of moderate severity,” said Dr. Chan, director general of the health agency. So far, 144 people have died from H1N1.
Thursday, June 11, 2009
The Wall Street Journal on-line reports that the Senate passed the tobacco regulation legislation and states,
Companies are weighing the impact of the bill, which they say also puts severe, perhaps unconstitutional, restrictions on advertising and packaging. Those limits, they worry, could undo business plans based on smokeless tobacco products, which they have been developing in anticipation of this day.
Former FDA Commissioner David Kessler, who spearheaded the original effort to treat the nicotine in tobacco as a drug, hailed the Senate vote of 79-17. "It's as strong a bill as we could have ever imagined," he said.
He said the industry fees mandated by the bill to pay for FDA regulation will enable the regulator to strictly enforce new rules, such as a ban on candy- and fruit-flavored cigarettes. "With $600 [million] to $700 million from industry to support it, I think the administration can set it up."
Critics said the bill will establish a new federal bureaucracy and unfairly benefit Philip Morris USA, a unit of Altria Group Inc., which dominates U.S. cigarette sales. Sen. Richard Burr (R., N.C.) said restrictions in the bill will hinder smaller companies from introducing new products.
In a statement, Altria praised the legislation overall, saying it will require all tobacco makers to operate "at the same high standards." The company said, however, that it has First Amendment concerns about some advertising curbs. Industry officials said lawsuits could tie the legislation down. . . .
The New York Times reported today that the AMA does not support a public health care option. Robert Pear writes,
The opposition, which comes as Mr. Obama prepares to address the powerful doctors’ group on Monday in Chicago, could be a major hurdle for advocates of a public insurance plan. The A.M.A., with about 250,000 members, is America’s largest physician organization.
While committed to the goal of affordable health insurance for all, the association had said in a general statement of principles that health services should be “provided through private markets, as they are currently.” It is now reacting, for the first time, to specific legislative proposals being drafted by Congress. . . .But in comments submitted to the Senate Finance Committee, the American Medical Association said: “The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans.”If private insurers are pushed out of the market, the group said, “the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers.” . . .
Later in the day, ThinkProgress reports on the AMA release in response to the New York Times story which somewhat softens its stance:
Today’s New York Times story creates a false impression about the AMA’s position on a public plan option in health care reform legislation. The AMA opposes any public plan that forces physicians to participate, expands the fiscally-challenged Medicare program or pays Medicare rates, but the AMA is willing to consider other variations of the public plan that are currently under discussion in Congress. This includes a federally chartered co-op health plan or a level playing field option for all plans. The AMA is working to achieve meaningful health reform this year and is ready to stand behind legislation that includes coverage options that work for patients and physicians.(emphasis from ThinkProgress site).
Wednesday, June 10, 2009
10:00 Regulating Tobacco
Congress seems poised to give the F-D-A authority to regulate how cigarettes are labeled and marketed. We'll discuss possible implications of federal control over tobacco products.
Gardiner Harris, science reporter for "The New York Times"
Dr. Michael Siegel, physician and professor of Social and Behavioral Sciences at the Boston University School of Public Health. He also writes a blog at tobaccoanalysis.blogspot.com
Matthew Myers, President of the Campaign for Tobacco-Free Kids
Steven Weiss, senior director, Communications & Media Advocacy, American Cancer Society Cancer Action Network
DailyKos' Sarge in Seattle writes about the annual health insurance renewal process for his small business and states,
Jennifer Xxxxx, RHU, and Rebecca Xxxxxx, SPHR opened the discussion, as always, with "good news and bad news".
The bad news being, as always, a huge increase in cost of our existing health plan for my small business comprised of 11 employees. This year that increase is 19%. It would have been a mere 4.5%, I was told, if not for the unlucky circumstance of my staff getting a year older. As it were, some of our employees have unfortunately slipped into the next age bracket. Having neglected to fire, as any shrewd and frugal entrepreneur would, some of my long time employees in favor of younger ones, I am presented with an $8,350 annual increase in health insurance premiums.
(I don't recall the excuse for the 22% proposed increase by Premera last year, all I remember is we dumped them for the more "reasonable" Regence plan which, nevertheless, at the time represented both an increase in cost and decrease in benefits.)
The good news, as always, was "we have options", a euphemism for passing more of the cost of health care onto our employees, who are already burdened with a $1080 aggregated annual payroll deduct (25% of the premium), 100% of premiums for additional family members, a fee so outrageous, no employee other than me opts for (more on that later), plus a $500 plan deductible, co-pays for office visits, tests, procedures, drugs, etc., and Lord knows what exclusions.
Jennifer works for Xxxxx Benefit Services, Inc. as a Health Insurance "consultant", meaning the various insurance
deniers providers – Premera, Regence, Aetna, etc., pay her company a commission to enroll groups into their plans.
Rebecca works for the employee benefits/payroll company to whom we outsource virtually all of our human resource management functions: Payroll and related taxes, 401K, Cafeteria 125, health insurance administration, vacation accruals, employee orientation and handbooks, and so forth. . . .
As wonderful as my employee benefits company is (and their fees are reasonable), the health care expense for my family is nonetheless extraordinary, and illustrative of the inviability of continuing a market based health care system that relies on for-profit insurance providers.
Get this, Congress: Factoring in the 19% increase for my Regence health plan, which costs us plenty for deductibles and co-pays, and adding the separate VSP vision plan (which is pretty good relative to the small premium, actually) and pathetic Met Life dental insurance, the total cost for health "insurance", not health care, mind you, but health care "coverage", is, as proposed by two accredited benefits professionals, for my family of four, on an annual basis, $18,070!
Yeah, we have the greatest health care in the world. Lucky us! . . . .
Tuesday, June 9, 2009
The Washington Post, already doing a wonderful job on the health care debate with Ezra Klein, has a new blog - the Health Care Rx - that provides a great overview of what certain players within the health care industry are thinking about health care reform and what provisions they hope to see in the final legislation.
Thanks to DemFromCT for the link.
In the lower chamber, the Ways and Means Committee has released an outline of their coming health reform bill. And the Senate Finance Committee, of course, is looking to unveil its bill next week.
It's worth taking a step back for a second to consider the weight of the moment. It's been 15 years since Congress last tried, and failed, to reform the American health care system. Fifteen years in which everything has gotten worse. In which health care costs have risen and insurance coverage has contracted. In which individuals have lost their protection and businesses have lost their competitiveness. . . .
Monday, June 8, 2009
Ezra Klein provides an excellent overview of a public health plan. He writes,
The private insurance market is a mess. It's supposed to cover the sick and instead competes to insure the well. It employs platoons of adjusters whose sole job is to get out of paying for needed health care services that members thought were covered.
Moreover, public insurance is simply more efficient. Medicare holds costs down better than private health insurance. The substantially public systems employed by every other industrialized nation cost less and cover more than the American model. So the question became how to marry the policy need for public insurance with the political need to preserve the status quo.
Enter the public insurance option. It doesn't replace the insurance individuals already rely on. But it provides an alternative. It lets them make the decision. It's the health care equivalent of being pro-choice. And it thus serves two purposes. The first is to act as a public insurer. To use market share to bargain down the prices of services, much as Medicare does. To lower administrative costs. To operate outside the need for profit, and quarterly results. . . .
But that's not the most likely outcome. Rather, the theory here is simple: If you can't replace them, convert them. If the public plan works, then private insurance will work better as well. In this telling, the simple existence of the public plan forces a more honest insurance market: Private insurers need to offer premiums closer to their marginal cost, and they have to cut administrative costs, and they have to work on their reputation for cruelty and capriciousness. The existence of another option changes the market. Individuals will have access to private insurers, but they'll no longer be stuck with them. . . .
ThinkProgress provides information on the draft health reform bill put forward by the Health, Education, Labor and Pensions Committee in the Senate. The legislation is entitled the "American Health Choices Act" and contains provisions concerning universal coverage and a public health care option. Thinkprogres provides,
As previously reported, the new public plan would reimburse providers Medicare rates plus 10 percent. Under this arrangement, the new public option would not have to negotiate its own rates, but could piggy back off of Medicare’s considerable reach. Using Medicare plus 10 rates, rather than the prevailing market rates, would lower costs and allow the plan to charge lower premium rates.
Moreover, the bill aims to improve access to coverage by regulating insurers, expanding Medicaid and SCHIP, and building state-sponsored insurance gateways (or exchanges) to help Americans find affordable coverage. Individuals and employers would be required to purchase insurance, but families earning up to 500 percent of of federal poverty line (FPL) ($110,000 for a family of four) could “buy insurance on a sliding scale with government subsidies” and anyone earning up to 150 percent of the FPL ($33,000 for a family of four) would also be eligible for Medicaid; the bill also expands SCHIP to cover people up to age 26, from age 18. Currently, an adult with no dependent children could be penniless but still ineligible for Medicaid coverage in 43 states. . . .