Monday, August 03, 2009

More Like Us

I read a quote from a TV executive that his network stays away from Health Care because it is death to ratings. Call me cynical, but I am not surprised. Remember the NPR photo, Turning The Camera Around: Health Care Stakeholders? There were ~200 "stakeholders" in the hearing room, comprised of dozens of lobbyists. But I wasn't present. In fact, I can't tell if there was anyone representing my interests there.

Our nation's health care system is a complex problem. It took a long time to get where we are today, and it won't be solved overnight. I don't mind if Health Care Reform isn't passed in the next month--as long as we spend that time productively working on a solution. But that's not what is happening. I am just waiting for Harry and Louise to come back from the grave or Florida or Hell.

Anyway, this isn't a health or disability blog. But I do happen to be diagnosed with a genetic disease, Psoriatic Arthritis, PsA. It is a progressive autoimmune condition that effects my eyes, joints, skin and nails; it also makes me chronically tired and susceptible to infections. I have been on short-term disability in the past for very bad flare ups or infections, but I am currently working 90% time (although 36 hrs/wk would make me a full-time worker in many other countries).

It's not fun, but I muddle through. And I am still alive at age 42, long past the ages when two of my aunts died. That's not really what I want to discuss. I want to offer some links that provide windows into what is wrong with health care today.

Why We Must Ration Health Care by Peter Singer. How much is too high a price to prolong life?

A nurse who works with the elderly told me about speaking to families when the end is near for mom or dad. She can't believe the number of people who want everything done, at a cost of $250,000 for a week or two of (excruciatingly painful) life for terminally ill mom or dad.

Most of those patients are on a combination of Medicare and Medi-Cal, a program for Californians who have exhausted their life savings. Each time they take extraordinary measures to prolong the life of a 80 or 90 year old, California will have to go without one or two school teachers and several teachers' aides, too.

No one can make the painful choice to pull the plug on their parents. Their choice, or failure to make a choice, means that the children of California will do without.

Who is speaking out for generational equity in the health care debate? Why are people with no access to health care forced to pay taxes to fund the health care of others? Why aren't the people who get health care coverage through work or the government taxed on those benefits? Why must the unlucky people who fell through the cracks pay for health care with after-tax dollars while the lucky ones gorge on tax-exempt health care?

Let's be truthful. Health care is already rationed right now*. Do you want a government bureaucrat doing it or a bureaucrat working for the for-profit insurance industry doing it?

What is so terrible about evidence-based comparative benefit analyses of treatment options? It was a study by the British national health system that gave me a blueprint for how I wanted to proceed with my own treatment. That study showed that Enbrel and Remicade, costing $12,000-$18,000 per year (the price varies based upon whether you have an insurance company bargaining for you; infuriatingly, uninsured people are charged the most) were no more effective than methotrexate, an older drug available in generic form for a couple of hundred dollars a year.

The more expensive drugs were touted to be safer, but that might not be true after all. People on all three drugs run an elevated risk of dying from infections. With millions of Americans suffering from autoimmune arthritis, we should do independent studies of comparative benefit--run by someone other than the drug companies who stand to benefit. Why is it controversial to say that?

That brings up David Leonhardt's In Health Reform, a Cancer Offers an Acid Test. He discussed five treatment options for prostate cancer, none better than the others, costing between $2436 and over $100,000 for treatment in the first year. Guess which options are the most popular.
“No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Dr. Michael Rawlins, the chairman of a British medical research institute, told me, “We’re not sure how good any of these treatments are.”

But if the treatments have roughly similar benefits, they have very different prices. Watchful waiting costs just a few thousand dollars, in follow-up doctor visits and tests. Surgery to remove the prostate gland costs about $23,000. A targeted form of radiation, known as I.M.R.T., runs $50,000. Proton radiation therapy often exceeds $100,000.

And in our current fee-for-service medical system — in which doctors and hospitals are paid for how much care they provide, rather than how well they care for their patients — you can probably guess which treatments are becoming more popular: the ones that cost a lot of money.

Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data.
I tried methotrexate for six months, but it made me miserable and dangerously susceptible to infections. Rather than try the more expensive drugs, which a couple of doctors told me that my insurance would likely cover, I decided to practice my own type of watchful waiting.

I slowed down my lifestyle and focus on rest, exercise, avoidance of irritating chemicals and other behavior modification. I work a little less and buy a little bit more help at home. I wear a surgical mask in crowded places or avoid them altogether. Even counting the gym membership at the fancy gym where they clean the surfaces at least twice a day, it is still thousands cheaper in the aggregate than using Enbrel or Remicade.

Insurance pays for medical care, but not reducing the need for medical care.

I pay for that myself.

Lastly, I hope you will read Malawi halts nursing brain drain by Christine Gorman. It encapsulates so much of what is wrong with the world. Medical care is mostly performed by nurses. Nursing is difficult and dangerous work, and, in general, not highly paid. There is a shortage of people worldwide willing and able to perform nursing work. Rich nations suck up caregivers (nurses, nannies) from poorer countries.

The health care debate over compensation is all about whether some doctors will earn $500,000 or $250,000 per year. Is anyone talking about nurses torn away by global economic forces from their country (and their children) to care for strangers halfway around the world?

Countries don't come much poorer than Malawi, but its health care system worked well back in the 1970s and early 1980s.

When the former British colony gained independence in 1964, president Hastings Banda, himself a physician, maintained a high level of training for nurses that included teaching all classes in English.

By the late 1990s, however, Malawi was reeling from the AIDS epidemic. As if that weren't bad enough, the government also had to cut spending on health care and education as a condition for getting help from the U.S. and other countries to liberalize its trade and economy.

The publicly funded health system, on which more than 95 percent of Malawians still depend for treatment, quickly started to fall apart.

Registered nurses began leaving in droves.

In the interest of fiscal responsibility, we (rich nations) demanded that a poor country, that was able to provide health care for all, dismantle their health care system. Why? So that they can become more like us.

Yeah, right. I wonder how much health care the money we spent on TARP could have bought in Malawi. Actually, Cash for Clunkers would probably fund health care for all of Malawi. We could have used the TARP funds to cover low-income Americans.

* I've seen it happen to other patients who were denied services that my own more generous plan paid for. One of my doctors dropped all HMO plans after the insurance company refused to pay for an operating room to remove a peach-sized goiter from another patient's neck. The insurance company employee told the doctor that goiters can be removed in the office, saving the expense of hospital operating room. The doctor asked the bureaucrat where he went to medical school. ;-)


  1. Thanks for the link to the CNN piece. I think your analysis shows plenty of hard-won wisdom.

  2. I really enjoy reading these posts, they bring insight to this complex issue that I I haven't seen elsewhere.

    I also wanted to share that I also work 36 hrs/wk due to a medical condition (fibromyalgia). And I also find it ironic that this would be considered full time or more in many other countries :)

  3. Christine, I should thank you for covering such an important issue. It can't possibly pay as well as covering celebrity baby bumps.

  4. As always an interesting analysis and group of articles.

    I currently pay considerably more for my health insurance than it cost when I was employed, and it is a less generous plan than I had before. In my area, although we have guaranteed coverage without underwriting, it is almost impossible to get a non-hmo based plan as a private payer, and even that is prohibitively expensive.

    My health insurance is our second largest expense, topped only by income tax. And yet I cannot move out of a small 5 state region because I would be uninsurable in most other locations, and although I am generally healthy, when I have needed medical care it has tended to be expensive.

  5. Good post.

    Interestingly, I've also got a health care post stewing in my brain. Whenever I hear someone worry that we'll "lose what we have" in health care, I want to scream. Our current system is broken, even for the lucky people who have insurance. I am so angry at people who are using scare tactics to confuse the public (like the rumor that a government employee is going to visit everyone on medicare and ask them how they want to die... the truth is that one cost-saving reform being discussed is a provision to allow medicare to pay for the doctor's visit if a person WANTS to talk to their doctor about their end of life choices. I can't even begin to fathom why that would be bad- surely no one wants to put their children through these gut-wrenching decisions?)

    But the thing that's really setting me off right now is management of labor and delivery. I'll save my rant on that for my own post.

  6. I'm highly skeptical of government run health care because I have my own scar to prove how inefficient it can be. Norway has only 4 million people and is one of the world's richest nations. If they can't get it right, who can?
    No matter the outcome, our health is a HUGE personal responsibility. Thinking that doctors, pharmaceutical companies, lawyers, insurance, and government will look after us can only be described as wishful thinking. Darwinism is alive and well. Thankfully, today we have the internet, which is an invaluable tool for researching ANYTHING. I will never again allow a doctor to do any procedure without first doing my homework. Same goes for medication. Those idiotic phara ads should be the first thing to go, they're simply absurd.

  7. I am a normal Canadian in that I am used to and depend on the government health care system.
    I have zero complaints about paying taxes for others' healthcare treatments now, as who knows what I may need later? I also don't want my friends and colleagues to go bankrupt taking care of their parents or having a baby.
    Yes I agree with your commenter from Norway that patients do have to do their own research, but that would apply to any medical system.
    Very complex issues indeed!


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