Mass. Promise of "Universal" Health Care Forgotten

Reports, not research (0.00 / 0)

Uninsurance is a leading cause of death for people aged 55-64 yo in MA according to analyses by the Institute of Medicine and Families USA.

"Uninsurance" is not a cause of death.

I've been looking through some of the papers from familiesusa.org and other reports you have linked to in previous posts. I have yet to uncover a single report where insured vs. uninsured has been isolated via regression analysis. In this push to identify lack of health insurance as the culprit, the result is that a other factors -- perhaps the real reasons for outcomes -- are being overlooked.

Questions that come to mind:
What impact does distance from hospital have on outcome?
What impact does choice of hospital have on outcome?

Let's take Families USA's The  Great Divide as an example. They state:

Controlling for the severity of the condition, uninsured children were 18 percent less likely to receive laparoscopic surgery than insured children (Table 4). Uninsured children were less likely than insured children to receive laparoscopic surgery for appendicitis in 11 of the 14 states with reportable data (Table 4).

They assert that laparoscopic surgery is better because it results in less pain and shorter hospital stays, but their cited research doesn't focus on children. This report does, and it concludes there is no difference. Families USA also alleges that uninsured are denied this procedure because it costs more. Maybe the question is why hospitals choose the more expensive procedure for insured children when the procedure itself has no affect on the outcome?

I still do not think the HCFA folks have been honest enough about what the health care system will be like under their plan (wait times, rationing, ineligible procedures and medicines, etc.) or what additional costs will be required to extend AND continue the level of care currently offered in our system. The message is this won't cost anything in money or other measures, and I just don't see that happening.


Previous signature had been getting more attention than my comments. Removed out of jealousy.

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by: dweir @ Sat Apr 14, 2007 at 11:34:37 AM CDT

Research is disseminated in Reports (0.00 / 0)

dweir, we may be more in agreement than not.  The majority of the public and of voters agree we've got a major crisis of health access, cost and quality, that our healthcare system is a national and a state disgrace.

It's long past time for a fundamental overhaul of how we finance and deliver care.  We're a wealthy society and have an obligation to guarantee universal coverage to all; it's the only civilized thing to do.

A streamlined financing single-payer plan would actually cost us much less. We pay twice as much for our care per person (of all industrialized countries) and rank 37th in the world for what we get for those dollars. This can be remedied if we craft a system of social insurance where everyone pays in, including employers, and everyone is covered. Period.  Ordinary people and public budgets win.  Insurance companies lose.

And as the MA plan's details become widely known, voters will conclude that the new health reform plan does not make the needed changes for sustainable improvements in access, cost and quality of care and may likely make some of these problems worse for many in the Commonwealth.  The MA plan does not meet any of the below 5 guiding priniciples for health reform. We can do much better. In past comments I have described legislation filed to undertake these needed reforms.

Back to your concerns about research and reports; perhaps you and other readers will find this info illuminating.  I hope so.

Insuring America's Health: Principles and Recommendations 

Final Comprehensive Report issued January 14, 2004. Five related reports and fact sheets also issued. (bold and italics mine)

Lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States. Although America leads the world in spending on health care, it is the only wealthy, industrialized nation that does not ensure that all citizens have coverage. To help policy-makers, elected officials, and others judge and compare proposals to extend coverage to the nation's 43 million uninsured, the Institute of Medicine of the National Academies offers a set of guiding principles and a checklist in a new report, Insuring America's Health: Principles and Recommendations.

The report is the culmination of a series that offers the most comprehensive examination to date of the consequences of lack of health insurance on individuals, their families, communities and the whole society. The report also demonstrates how the principles can be used to assess policy options. The IOM Committee does not recommend a specific coverage strategy. Rather, it shows how various approaches could extend coverage and achieve certain of the Committee's principles.

The committee proposes a clear and compelling overall recommendation by 2010 everyone in the United States should have health insurance and urges the president and Congress to act immediately by establishing a firm and explicit plan to reach this goal. The committee envisions an approach that will promote better overall health for individuals, families, communities, and the nation by providing financial access for everyone to necessary, appropriate, and effective health services.

In Insuring America's Health: Principles and Recommendations, the committee offers a set of guiding principles, based on the evidence reviewed in the Committee's previous five reports and on new analyses of past and present federal, state, and local efforts to reduce uninsurance., for analyzing the pros and cons of different approaches to providing coverage. The principles for guiding the debate and evaluating various strategies are:

  1. Health care coverage should be universal.
  2. Health care coverage should be continuous.
  3. Health care coverage should be affordable to individuals and families.
  4. The health insurance strategy should be affordable and sustainable for society.
  5. Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.

Although all the principles are necessary, the first is the most basic and important. The principles are intentionally general, which allows them to be applied in more specific operational and political processes. A fact sheet on each of these principles and a checklist of questions based on the principles are available...

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by: AnnEM @ Sat Apr 14, 2007 at 15:00:56 PM CDT

[ Parent ]

WE ARE NOT A WEALTHY SOCIETY (0.00 / 0)

A very small segment of our society is wealthy.
We do in fact have an overindulged and entitled society.

We have a national and healthcare crisis? Compared to who? Russia, Zimbabwe, Chile, Who? Who says so---alarmists? Where are the heaps of dead that are the victims of this barbarity?

There are few healthcare providers? There will be even fewer very shortly. OB/Gyn's are leaving Massachusetts in droves because of the ambulance chasers. Who will provide this service that you speak of? Try finding a doctor on short notice imany parts of this country and/or a specialist.

You state that BCBS et al  is engaging in a conspiracy involving hush money and your organization has accpeted hush money in the past to -----what?

This demographic that you noted. What is the morbidity and mortality? Your statement is meaningless.

Our esteemed Gov Romney who went AWOL after two years and ten months on the job concocted this idiotic feel good legislation without one thought to its efficacy. The legislation is and always has been a joke.

You can come up with any plan you like and throw hundreds of billions of dollars at it. If you have a dearth of care givers , then who will provide the care. No one ever addresses this problem, It's far more convenient and expedient to rale incessantly about the unfairness, how unkind and unfeeling they" are, whomever "they" may be.

You want to fix part of this issue. get rid of the ambulance chasers. Their killing medicine. Have any idea what healthcare practioners pay for malpractice insurance? I thought not.

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by: MCRD @ Sat Apr 14, 2007 at 16:57:56 PM CDT

[ Parent ]

You're being a bozo (0.00 / 0)

if you're mad about something else and just taking it out here you should stop.  We're trying to have a factual constructive dialogue.

We are indeed a wealthy society. Yes, the gap between the very wealthy and the middle class/the poor is widening--and that's a serious problem. But it does not mean we're not a wealthy society.  In fact I do think that we spend too much on hc already and that much of it is wasted. I disagree that "more taxes will be needed" for universal coverage.  "More stewardship" from the government re how we spend our hc dollars is what's needed!

Where are the heaps of dead that are the victims of this barbarity?...
This demographic that you noted. What is the morbidity and mortality? Your statement is meaningless.

the "heaps of dead", and heaps of the unnecessarily maimed I might add, DO EXIST. don't be so lazy that you cannot make use of links that posters make an effort to supply (ie the IOM reports, ADHC website whose "Resources" page has many useful links, and the ongoing TPMCafe discussion with experts are all very informative).

The facts about 18k unnecessary deaths and the M&M resulting from uninsurance and under-insurance speak for themselves if you would make the space in your brain and in your heart to hear them.

re malpractice costs, you should have attended the 4/12 univ. hc expert panel forum at Simmons.  see the article about it posted on the ADHC website and contact the health economist or the PNHP doc john wlash who both presented useful data on the malpractice topic.  i'm not an expert on it. malpractice costs are MUCH LESS in countries that have universal coverage and do not treat hc as a commodity, as it currently the dominant model in the U.S.

to circle back to my "you're being a bozo" comment, which part of universal coverage with single-payer financing COSTS LESS don't you understand?

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by: AnnEM @ Sat Apr 14, 2007 at 17:29:16 PM CDT

[ Parent ]

Angry----who me? (0.00 / 0)

Apparently you are not employed in medicine as I am. Try having ten pt's five with IV's running, eight on O2, three diabetic, four incontinent, three suffering dementia and lacking safety awareness, one with CHF, four COPD'ers,
and that's a typical night. Rare? Try most of the time.

Go to any medical facility and ask the pt/care giver ratio and the acuity. You have so many pt's that you can't drink because you have't time to pee, have coffee or lunch. You get to work and go. nonstop.

This is everywhere. There is no help. Forced shift extensions, forced overtime, doubles, come in on your day off.

Reimbursement is so low that MD's, PA's, RNP's are seeing people at the rate of one every ten or twelve minutes. It's a joke.

You have to have a properly trained, competent, licensed workforce in sufficient quantity to provide suitable healthcare. What you have now is a speeding train headed for an open bridge. You people don't get it. Healthcare is desperately short staffed and it's getting worse. I threw in the towel a yaer and a half ago after I was injured at work (because we were short) and I required surgery.

You folks should be first and foremost trying to recruit bright caring people to be physicians, nurses, PT/OT/radiology , lab techs etc. The most imortant criteria in patient outcome is nursing care. Nurses are leaving the profession in droves.

What you are proposing is having people standing in line at a healthcare facility with hundred dollar bills in their hands and the doors are locked and a sign on the door saying, CLOSED.

Unless you work in medicine you just don't know. Go to MGH some day. Half the pt's there aren't even Americans. They are from all over the world and their socialized medicine AKA universal healthcare sucks.

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by: MCRD @ Sat Apr 14, 2007 at 20:48:17 PM CDT

[ Parent ]

I feel your outrage and it's mine, too. (0.00 / 0)

And it's shared by thousands of other caregivers across the state. That's why the second item on the Alliance's homepage describes legislation to set minimum safe R.N.-to-Patient staffing levels.

But sling your arrows toward the necessary target, please.  Re your statement "socialized medicine AKA universal healthcare sucks." You clearly do not understand health system financing and delivery policy or you would not say that.  Please use the links at the end of this thread's original post to learn more about it and ways to help make positive change.  It's complex but it does make sense. Follow the money trail and you're more than half way there...

Getting back to the problems of unsafe staffing in many clinical settings, yes, this is a HUGE concern and that's why our group works in a statewide coalition to enact legislation that will help remedy it!
Here are the details with useful links for more info and ways to TAKE ACTION:

2. The Patient Safety Act is re-filed. Proposed legislation to establish minimum staffing ratios of registered nurses to patients passed overwhelmingly in the House last session but the Senate chose not to vote on it.  Quality care and patient safety rely on this bill becoming law.  Please learn more and get involved to support this effort. For an update on the California RN-to-Patient ratio law enacted in 2004 click here.

In some areas of the U.S. there is indeed a nursing shortage and it's gonna get worse as nurses age and especially as our entire population ages, gets sick, and needs more care. MCRD where you're wrong is this: here in Mass. we have enough nurses, it's just that they/we refuse to work in the current inhumane environments that you describe so well.  Staffing levels in many settings are dangerous to patients, to nurses, and to every other caregiver trying to give safe quality care under next to impossible situations. Set safe minimum stqaffing levels and you will see nurses flocking to return to what we love to do -- provide quality care to patients.  California is seeing just this positive phenomenon after enacting a safe staffing law a few years ago.

But just bringing new nurses into these work environments WILL NOT FIX THE PROBLEMS, plus it is unethical to recruit people into a field where most likely they will not be able to practice what they were taught--high quality patient care (and what their license requires).  I do teach nursing students but I refuse to teach or practice in many settings due to the unethical and dangerous conditions.  In a way I feel as though I am abandoning a sinking ship.

These are but a few of the reasons why growing numbers of caregivers and the general public are passionate about reform and starting to get a bit less polite about demanding fundamental healthcare system improvements.

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by: AnnEM @ Sat Apr 14, 2007 at 21:57:26 PM CDT

[ Parent ]

Well Ann (0.00 / 0)

All I can respond is that you and I diverge on the solution. You want to emancipate hundreds of thousands of people into a health care system that cannot sustain the present patient load. You wish to send hundreds of thousand or so of more malingerers and whiners into the system because they no longer have to pay for their Munchausens because the state will. Unfortunatley the folks that need to be legitimately seen will be forced to the wayside. If you work in medicine (in the trenches) you know how many people are seen for essentially psychiatric/emotional issues as opposed to legitimate phsyiologic problems. I see your solution as catastrophe.

My solution will take ten years. Start a nationwide recruitment of caregivers and provide stipends for medical education. As more people become licensed and trained then begin to set pt/caregiver ratios. Initiate a new standard of care that is practical and based on acuity. Initiate new triage systems. Folks with nickel dime ailments should be seeing PA's and RNP's. You have to build a foundation prior to erecting the building.

The entire medical delivery system must be changed prior to initiating universal healthcare (so called) otherwise our present system will collapse and the only people getting decent healthcare will be in black market private hospitals.

As it is medicaid and medicare are about to collapse very shortly, AND you are dead wrong. There is an acute shortage of RN's in Massachusetts. Granted there are thousands of nurses who still hold licenses, but you you couldn't get them back to work at gunpoint and it's not just because of Pt load.

I suggest you contact the DPH and inquire re EDS's, MRC, and MSAR. DPH is walking around on cracked eggs because in the event of pandemic flu (H5N1)there won't be enough people to bury the dead let alone take care of the sick.

Some folks seem to think that you fix problems by legislating them, away----like crime. We'll pass a law outlawing XYZ and it will stop. Like domestic battery, 209's certainly fixed that problem. Tougher sentencing laws----that certainly fixed illicit drugs and murder.
Solutions begin by little people doing little things in great numbers. Americans have never quite figured that out. Asians have. The huge crater formed by one large bomb on the Ho Chi Minh trail was filled in by three thousand N Vietnamese with very small wicker baskets, working at a frantic pace, with little food and water in intense heat, and smothering swarms of mosquitos. Think that could happen in this country. No one wants to get their hands dirty, no one will work without being compensated beyond what is reasonable, and everyone wants someone else to pay for it.

I'm not so sure most Americans are worth saving. How many people go into the service? How many in the Peace Corps? How many do volunteer work in their communities, paint and clean their schools. Rake the leaves at town hall and pick up litter on the public ways? No, Americans want someone to do it for them, they want something for nothing.
No one gets a free ride. No one.

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by: MCRD @ Sun Apr 15, 2007 at 12:40:21 PM CDT

[ Parent ]

Health Insurance vs. Health Care (0.00 / 0)

I only skimmed, but that report seems no more rigorous than the others.

Germany offers insurance for legal costs. In the US, for the most part, people do not need insurance in order to cover legal defense costs. The government will provide a public defender. No one is suggesting that we mandate legal insurance.

Maybe we should be focusing on health CARE not health INSURANCE. Insurance is but one means of paying for care and delivering profits to insurance companies.  :-)

Here is what I'm thinking:

We've been told lack of preventative care is a problem. Let's have a system of public health clinics. Salaries would be below market, but benefits would be great (typical public sector incentive). Require all new med school grads would be required to serve 3 years in these clinics. Anyone could go to a public clinic, but for the uninsured, the amount you pay (or not) would be based on your income.

Supplemental revenue for the public clinics could be from a  tax on insurance companies, thereby creating an incentive for them to make their products more affordable. Hospitals would then have a place to refer patients who show up in emergency rooms for non-emergencies. Uncollected costs would continue to be spread through the system as they currently are.

Bottom line is that I don't see the connection between health insurance and costs. Health care is expensive. As it is today, everyone has access to catastrophic care, although there is room for improvement in primary care. This is not entirely due to the lack of insurance, but can also be blamed on the lack of access to facilities throughout many parts of the country.

Previous signature had been getting more attention than my comments. Removed out of jealousy.

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by: dweir @ Sun Apr 15, 2007 at 10:16:13 AM CDT

[ Parent ]

Thank you for using quotation marks around "Universal" (5.00 / 1)

Because only in your mind (as well as in the minds of other progressives) was our health care "reform" meant to be a government-run, single-payer program.

If you want a government-run, single-payer program, say so and push for that legislation and all the increased taxes and bureaucracy that will be required.  My guess is that you'd be unable to move that proposal forward.

So instead, you sneak around trying to pass a constitutional amendment making health care a right with the intent of pursuing a judicial mandate forcing the Commonwealth to provide Health Care For All.  I'm happy it didn't work.  (Btw, if health care is a right, why not housing?  Why not employment?)

And your organization, Alliance to Defend Health Care never mentions your advocacy of a single-payer system, only that no one should ever make a profit from providing health care.

If that's not socialized medicine, I don't know what is.  It's certainly not what anyone counted on when we supported "reform," however that plays out.

As ADHC's executive director, you tirelessly advocate transition to a single payer system.  You belittle and criticize and blame the healthcare industry for opposing your silly and utopian ideas, ideas which you are afraid to make public as official policy of your anti-competitive organization, ideas the body politic in past proposals has rejected.

Can't you give it a rest for a couple of calendar quarters, see what happens with the reform that was passed, instead of always trying to use that reform as the starting point for socialized health care in MA?

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by: bostonshepherd @ Sat Apr 14, 2007 at 15:16:12 PM CDT

bostonshepard, you're way off the mark on a number of items (0.00 / 0)

Way too many to go thru them one by one, but I will address the biggies:

1. re your statement: "Thank you for using quotation marks around "Universal"" - that's from the title of the Taxpayer & Consumer Rights organization's news release, not my doing.  I agree with you that the quotation marks are appropriate.

The HCFA/ACT group's reform plan as well as BCBS/Partners' plan and Romney's plan were never intended to achieve universal coverage nor were they trying to change the status quo of our terribly expensive wasteful and dysfunctional hc financing and delivery system.

2. I and the ADHC are committed to reforms that will bring responsible stewardship of our health care resources, financial and otherwise.  Single-payer reform is the ideal approach in terms of reducing bureacracy and freeing up dollars for care, but other approaches will be thoughtfully considered as well.  That's why the ADHC is not a "one approach only organizationn" but is an active member of the Mass-Care (Single-payer group) statewide coalition that HCFA is a member of too, BTW.  That's why the ADHC highlight's MassCare's resources in the top right corner of our website.

3. No one "snuck around" (that's absurd) with the HC Amendment campaign.  The goal of establishing a permanent and binding legal right for all residents to have "comprehensive affordable equitably financed health insurance...and prescription drugs" is exactly what our group is all about. 

We believe that corporate profit making is incongruous with a person-centered, clinically focused and cost effective helahtcare system.

4. Socialized healthcare is what England has-both the financing and the delivery are run by the government--and it is not what "single-payer" (a confusing phrase that I don't particulary like) reform must look like. Single-payer refers only to the financing mechanism but NOT the delivery system.  Canada's Medicare for All model uses single-payer financing and a private delivery system.  That is what I as a person and the ADHC as a member of the MassCare coalition are advocating for. Socialized financing, yes. Socialized delivery system, no.  I hope that's useful; it can be confusing to understand since the language is less than ideal.

5. The "body politic" supports single payer financing for universal coverage. Every time a single-payer reform ballot question has appeared (many non-binding ones have been undertaken over the years) it has won, not been rejected.  Please get your facts straight. This is a life or death issue for many people and affects the economic solvency of many more.

6. No, I will not "give it a rest". I cannot. I am a nurse and a caring citizen.  I've worked in healthcare for 30 years and increasingly feel the burden of our harmful wasteful system on both my prefoessional duties as a clinician and a teacher of nursing students, as well as a burden on my personal duties as an ethical person.  I'm not the type to shirk my duties.

Another way of putting it: "If you're not part of the solution, then you're part of the problem".

"Take a rest"? Not possible. 

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by: AnnEM @ Sat Apr 14, 2007 at 16:03:10 PM CDT

[ Parent ]

ANNEM (0.00 / 1)

I have no idea who you are or what your organization is, but I am convinced that you are not a licensed medical provider/practioner in this state or in any other state, at least not in this country.

My suggestion is that you go back to school and then get a job in a teaching hospital, then work pediatrics, then do geriatrics, then long term care then work in the warehouses that store the organisms that look like people, but the brain is nonfunctional. Machines maintain life. Then please come back and tell us about changing healthcare delivery and cost.

There are people out there that are delusional. We are where we are at because of the unremitting lawsuits. Every healthcare practioner has the threat of lawsuit running around in their mind. By necessity you don't do what's medically prudent, you do EVERYTHING that will keep you from being sued. Even then you are going to have someone sue you. Then you have legislators that listen to crying mothers about whatever issue  and then they promulgate feel good legislation that does nothing than waste money.

You go to foreign countries and the reason that they are not drowning in red ink is because they let people die.
You have renal failure, you smoke, sorry, no dialysis for you. You have colo-rectal cancer, history of alcohol abuse, sorry, go to the end of the line.

Americans are so indulged medically it is mind boggling. I suggest that you travel to some of the countries and do some research morbidities/ co-morbidities and what they will and won't do. You will likely be very disappointed.

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by: MCRD @ Sat Apr 14, 2007 at 17:17:32 PM CDT

[ Parent ]

MCRD (0.00 / 0)

I have no idea who you are or what your organization is, but I am convinced that you are not a licensed medical provider/practioner in this state or in any other state, at least not in this country.

the Board of Registration in Nursing is a state government website. Visit it and you can find my licensure if you're that interested to do so. Then actually read thru the Alliance to Defend Health Care's website to learn what we're about.

In fact, I HAVE worked as a nurse in academic hospitals (MGH and the BIDMC) and in geriatrics with the Boston Visting Nurses, and I have 2 young children who both have had health probelms (severe broken leg and allergies)--well treated and well controlled, thank heavens. Where I do agree with you is that our culture and our hc system is failing miserably in how we care for the dying. We fail by not having an honest nation-wide discussion (where's the leadership on this?) and in not setting compassionate policies to ration care based on clinical needs, cost/benefit, and quality of life issues.

Instead we often ration based on wallet biopsy, or allow misguided policies that threaten to break the public budget.

MCRD, you need to get away from the nursing home or whatever setting you work in.  It sounds like you are way over the edge with burnout and you seem to pose a toxic danger to the health profession--both to patients, families and professional colleagues.  I'm concerned about you and those around you.  Get help.

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by: AnnEM @ Sat Apr 14, 2007 at 17:47:41 PM CDT

[ Parent ]

That rates a zero ... (6.00 / 1)

because it's all predicated on a personal attack and a credentials attack. I think it's pretty easy to find out if Ann Eldridge-Malone is a licensed medical professional.

On the other hand, "MCRD", who the hell are you?

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Blue Mass. Group
So what politics do you deserve?

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by: Charley on the MTA @ Sat Apr 14, 2007 at 20:03:00 PM CDT

[ Parent ]

thanks charley (0.00 / 0)

i was going to add to this post, but i became such a nasty exchange that i said to heck with it.

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by: fairdeal @ Sat Apr 14, 2007 at 20:29:22 PM CDT

[ Parent ]

make that . . . "it", not "i" (0.00 / 0)

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by: fairdeal @ Sat Apr 14, 2007 at 20:31:34 PM CDT

[ Parent ]

hey, this topic brings out the passion in people (0.00 / 0)

and it seems like maybe we're (shep, mcrd, and me) not as far apart as it first appeared.  so fairdeal, say something--please! :)

MCRD seems to have been walking through the hellfires of our current greed and ivory-tower driven policies (and laws) that increasingly treat healthcare as a commodity rather than as a social good and human service.  Chilling. Dangerous. Deadly.

And way too expensive for how crappy the care often is. Oh don't get me started--the IOM report "To Err is Human" detailed that as a direct result of uneven quality care in the U.S. hc system, there are at least 98,000 preventable deaths EACH YEAR (and poor staffing levels have A LOT to do with that).  This situation is so over the top and beyond the tipping point; we don't need more studies, we need bold action that will put people before profits.

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by: AnnEM @ Sat Apr 14, 2007 at 22:09:06 PM CDT

[ Parent ]

Who's Ann Eldridge-Malone? (0.00 / 0)

Am I now clairvoyant?

I was insuating from my post that I do not know who the poster is, nor do I possess any knowledge of that persons bona fide. From my perspective the poster was someone who wants to make changes based on anecdotal evidence. And like any organization you have folks that have the license and that's about it. Acamedicians are famous for passing out advise, but have never spent a day in the trenches, Looks good on paper, try and make it work.I'm also suspicious of people who spend a few years in the field and then go else where to pursue other meaningful rewards.

No personal attack at all. I was asking the questions. No one asked me anything.

Apparently AnnEM knows me well, due to her observations that I am toxic and dangerous. I could be a policeman.  Who's attacking whom?

You are absolutely correct. You have no idea who I am. I ask a question, you make assumptions.

The point I'm trying to make is that the entire system is broken. We don't need to fix the wing, we need to build an entirely new plane. You start monkeying with this plane in flight and you may cause it to come down and kill everyone in the plane and on the ground.

Our medical schools and nursing schools need to start graduating far more competent doctors and nurses. OR techs, X-ray techs, lab techs, PT, OT, respiratory, physiology all just as important.

We need a larger, stronger, bedical fondation prior to making any other changes.

Answer me this. Will the availability of more medical practioners be met by greater pt loads, puting us back at square one. Will "free" care result in a ten fold increase of visits to the doctor . What will the result be? Will we be subject to the law of unintended consquence?

One payer---who? The government. The government has never touched anything that it didn't screw up. It will result in a gigantic bureaucratic boondoggle where 60% of healthcare dollars go to the bureaucracy and 40% to the care givers.

Well this toxic and dangerous person gas gotta go.

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by: MCRD @ Sun Apr 15, 2007 at 14:14:55 PM CDT

[ Parent ]

Most of this discussion is around the rather irrelevant "around the edges" standpoint. (0.00 / 0)

Interesting, but picking at nits

A few points.

One, the sad fact is that nobody in the US particularly cares about the number of "excess deaths".  Just look at the reaction to the (highly regarded) Johns Hopkins study of excess deaths in Iraq from last fall.  The statistical methods were excellent, and the study, after it was published was--not torn to shreds (it couldn't have been*)--it was just ignored.

*The study couldn't have been torn to shreds, because the sampling methodology was the same methodology that had been approved by the US government in Rwanda and the Congo.

I have touted the German health insurance system, and the German health insurance is succinctly described at http://www.howtogerm...  It is Gesetzlich, but not single payer.  That means that it is organized by the state, but it is not paid by the state (in some cases it is) and it allows for a rather flourishing private insurance industry.

Two, one of the things that you apparently don't recognize is that the inefficiencies in the American health care delivery system, and the American health care insurance system (I've noted both here in recent days) employ people.  People whose employment is largely unnecessary.  But it gives them jobs.  Claims handlers, the three-to-one (x-ray/radiologist/physician or ultrasound/technicial/physicial) examples I mentioned here earlier.  Those are just a few of the sources of the inefficencies of the USofA's medical care delivery system.  The inefficiencies that make the US health care system about 50% more expensive than the Europeans.

Three, just to let you know, I understand the problem of the US reigning in the cost of its health care system.  I really do.  And it isn't corporate greed.  The thing that you have to understand, and what many "progressives" don't, is that, for every whack that might be made at a corporate position, a corporate employee will lose his or her job.  And that last is the problem that you have.  It isn't the CEOs who will get whacked, it's the minions.  The minions know that, and they will resist it. 

And that, quite frankly, is why you are screwed.  There are too many minions who want to keep their jobs, and health care costs in the USofA will never be seriously reduced.  It really is as simple as that.

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by: raj @ Sun Apr 15, 2007 at 05:39:23 AM CDT

Economy (0.00 / 0)

The inefficiencies that make the US health care system about 50% more expensive than the Europeans.

Now it's 50% more expensive? I haven't heard that data point before. More commonly, I've heard the percentage of GDP figure, where the US comes in almost double that of the UK, but only about 30% more than Germany.

I do wonder about the use of GDP, too. What is counted as health care spending? Does it include investment in biomedical research and technology? I also wonder how much of a factor wages play in our higher costs.

I took another look at Germany's system. Interesting points:

- A select few can opt out of the public plans -- higher income earners (have a choice of public v. private), the self-employed (no choice, must be private), and public employees (no choice, must be private but will receive some reimbursement). The rest of the population must get public insurance. Is the private insurance so much better that they must ration it out to the wealthy and public employees? Why are so many denied the ability to choose how much insurance to purchase?

- Public health insurance costs 14% of your income. As employers pick up half of that cost, it would be interesting to see what affect that has had on wages. Is there an incentive for business to push salaries above the minimum threshold necessary to qualify for private care? Perhaps, there is an incentive to depress wages so that the employer doesn't need to pay more in health tax. In 2003, he government froze health care workers salaries to control costs, so this isn't out of the realm of possibility.

- There's a second mandatory health insurance tax for long range nursing care. Perhaps this is to offset the fact that everyone after the age of 65 no longer needs to pay the regular health insurance tax. If so, what are the implications of a decling population, where more people draw from than pay into the system?


Previous signature had been getting more attention than my comments. Removed out of jealousy.

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by: dweir @ Sun Apr 15, 2007 at 09:54:31 AM CDT

[ Parent ]

Depending on the country... (0.00 / 0)

Now it's 50% more expensive?

...it's anywhere from 30% to 50% more expensive, both on a per capita basis and per GDP.  When I was in the US a few months ago, I did a little research over the Internet, and was amazed by what I found.  I don't have URLs to the relevant web pages here in Germany, but it was quite interesting.  Yes, the health care expenditure in the US is 30-50% more expensive than other major industrial nations (Canada and western Europe).  The different countries have different expenditures, hence the difference in the percentages

Regarding your three points

(i) A select few can opt out of the public plans -- higher income earners (have a choice of public v. private), the self-employed (no choice, must be private), and public employees (no choice, must be private but will receive some reimbursement). The rest of the population must get public insurance.

Which means that everyone who is employed pays something into the health care financing system, and those who have a legal right to be in Germany (Aufenthaltsgenehmigung) and who have a claim on the health care system have paid into it--for at least a while.

Let's understand something.  No health care financing system will be perfect.  But, as far as I can tell, the US has so bastardized its health care financing system--some fedgov (medicare), some joint fed/stategov (medicaid), some private (employer and/or private pay), and some none (charity) that it is virtually impossible to figure out what the health care financing is.  As far as I can tell, the private pay get screwed, because medicare, medicaid and employer-based plans negotiate their prices down, and the private pay can't.

Regarding a few nits in the quoted text.  I doubt very seriously that government employees must be private.  And, for "self-employed," presumably they could incorporate their business, become employees and become part of the public system if they wished.  Whether or not that's correct, I really don't know.

(ii) Public health insurance costs 14% of your income.

As I understand it, public health insurance is part of Germany's social security system, which includes old-age pension and other matters (Pflegeversicherung, downstream).  And it is maxed out at a certain income level--much like the US FICA system.  And, yes, half is a tax on the companies. 

But, it ensures that everyone who is employed and who is covered pays something.  That isn't the case in the US.

(iii) There's a second mandatory health insurance tax for long range nursing care. Perhaps this is to offset the fact that everyone after the age of 65 no longer needs to pay the regular health insurance tax.

I believe you are incorrect.  Everyone has to carry (this from above) Pflegeversicherung.  What that covers is home nursing care, and so forth (help in cleaning, a little meal service, etc) that means that people can stay in their homes when they are infirm, and not have to rely on Altenheimen (old folks homes) for care, which is much more expensive.  My mother-in-law made use of this service (she was private-pay, by the way) after she had a rather severe accident in which her upper leg was broken.  It kept her in her house and out of the Altenheim.

(iv) Consolidated

I do wonder about the use of GDP, too. (a) What is counted as health care spending? Does it include investment in biomedical research and technology? (b) I also wonder how much of a factor wages play in our higher costs. (indices added)

Regarding the bolded part of (a), I don't know.  But, I will let you know that there is more than a bit of health care research paid for by European companies.  You might be surprised at the number of Big Pharma companies, even who have subsidiaries in the US, are actually European companies.

Regarding (b), on the assumption that you are referring to wages paid to health care providers, it is almost assuredly the case that incomes of health care providers are lower than in the US.  But, on the other hand, given the subvention by the government of universities in Germany, the fact is that health care providers don't graduate with the huge debts that similar personnel have in the US.  And, I've described the efficiencies in the US system (Lahey) elsewhere, which only serves to drive up the cost of health care in the US.

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by: raj @ Sun Apr 15, 2007 at 23:51:14 PM CDT

[ Parent ]

YES AND NO (0.00 / 0)

Small changes over an extended period of time will work. One payer will not.

America's largest problem is that the elderly vote and children cannot. Our priorities are reversed. We spend little or nothing on prenatal care, neonates and infants/small children and we spend hundreds of billions on folks who are in the twilight of thier lives ie  (ME).

Why should my life be prolonged a month longer if it will result in the expenditure of hundreds of thousands or millions and a child goes without. A child will be around for another sixty years and I may be around ten (maybe). This is insane.

Well you can argue that I paid for it, and I sacrificed, or I deserve it. Perhaps I deserve nothing and I should be happy with the life I've had so far and let nature take it's course.

What is a human life worth? Who do we save? Who is more deserving? Hospital ethics committees and physicians make these decisions all the time. How about us as a society? These are all legitimate questions. They demand answers. Are we to save everyone and eventually save no one? Is this a slippery slope that everyone finds abhorrent? We have X amount of healthcare dollars. Who's going to get them? Everyone can't---should they? Who gets the short end of the stick? Kids? Because they have no voice?

I honestly don't have the answers. I know that giving away the store to people who contribute nothing is a recipe for disaster. Giving anything to anyone over an extended period goes from a kindness to a disservice. Most of us knows the result of what happens when you give a kid whatever they want whenever they want. There is but a few degrees of seperation from a child and an adult.

I must go out and do something toxic and dangerous now.
Right Ann?

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by: MCRD @ Sun Apr 15, 2007 at 14:50:42 PM CDT

[ Parent ]

I wish that you go out in peace, MCRD (0.00 / 0)

truly, I do. I also wanted to say that I appeciated your conclusion that seemed to say we were close to agreeing to disgree, as stated in an above comment partially excerpted here:

Well Ann
All I can respond is that you and I diverge on the solution. You want to emancipate hundreds of thousands of people into a health care system that cannot sustain the present patient load...

regarding the "clarivoyant" item, if anyone who wants to they can easily click on my BMG poster name. This shows a brief bio that states I'm the director of ADHC (a volunteer position for many months now) and on the ADHC site you can find my full name etc. quite easily along with those of all our caregiver board members.

Perhaps it comes down to you and I holding divergent sets of basic values about our fellow human beings, modern society, and the shared obligations we have to each other, both as individuals and collectively as members of a civilized society.  We likely could be in the exact same crowded E.R., look around, and have very divergent thoughts about the life experiences, needs, and worth of the people around us who are seeking healthcare.

I do not want to "throw more money" at our hc crisis. I believe we are spending too much already and that much of it is poorly spent.  Yes, there are people who get too much care yet there are many many others who are denied the most basic timely healthcare. This latter group dies younger after living sicker lives because they lack quality insurance.

I agree with you that it's a big problem that such an excessive amount of hc resources are spent on end-of-life care, much of it care that the dying individual didn't even want!! (living will instructions are reoutinely not respected, has to do with our cultures fear of death, guilt of family members, and "death as failure" culture of U.S. western medicine).  My MSN is in oncology/HIV nursing so I've thought, studied, and cared for this population intensely.

I do feel VERY strongly, and carry quite a lot of anger over it, that at all levels of state and national government in the U.S. we have an galling lack of stewardship around how hc dollars are collected and allocated. Public budgets pay the highest hc bills of all; there is more public spending on hc than private spending in the U.S..  In fact, our current public spending alone is at the level of the industrialized countries that have UNIVERSAL coverage!!. We're already paying for universal coverage but not getting it.  It's both infuriating and it's shameful, actually.

The lack of regional healthcare planning has led to all kinds of problems, some of which MCRD describes including our pathetic lack of preparedness for any large-scale public health emergency (avian flue, bio terror attack etc).

MCRD, you said "no one asked you any questions" but actually I asked you where you worked in healthcare on a previous thread; you never answered.

And to raj and dweir- unsafe staffing levels is not nit picking around the edges.  It can and does cause preventable deaths (google Linda Aiken,RN,PhD at U Penn and the HSPH study on nurse staffing and quality of care) and it is in no small way destroying the nursing profession.  Serious stuff.

re: the displacement of paper pushing workers when we succeed in truly reforming our hc system to benefit people not corporations, here are a few thoughts:

With a transition to universal coverage using SP financing many if not most of the displaced workers can be taken care of by being offered positions -- and new training as needed -- to have gainful employment within the new healthcare system. And they'll actually get to do jobs that help people!!

We need folks who can organize health promotion sessions (especially with kids), do community outreach, safe medication management teaching, teach and support non-drug management of common heath problems, triage calls coming in to healthcare facilities (when's the last time you called a doctor's office or clinic and actually had a caring human being directly answer the phone?!). All kinds of new jobs will be needed for the new focus on HEALTH rather than the current focus on treatment of disease.

Of course it will not be an easy task, but none of this easy. But it will be the right thing to do.

Finally, MCRD, BTW I pick up trash all the time and like you I'm really irritated that it's there -- ask my 6 yo about what I do while we wait for the school bus in Boston and during our 1/2 mile walk to and from the bus stop each day.

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by: AnnEM @ Sun Apr 15, 2007 at 20:07:03 PM CDT

[ Parent ]

Um, (0.00 / 0)

AnnEM @ Sun Apr 15, 2007 at 21:07:03 PM EDT

And to raj and dweir- unsafe staffing levels is not nit picking around the edges.

Where did you get anything like that from any of my comments?  Please.

If you actually read what I wrote, you would see that I was contrasting efficiencies between the doctor doing an x-ray and ultrasound himself interpreting the result and making a diagnosis thereupon here in Germany, with the inefficiencies at Lahey.

I will tell you something AnnEM.  If they had to run through the same procedures here in Germany, with the resultant delays, that they did with me at Lahey, my spouse might have died from his thrombosis.  The fact is, that he isn't dead.  The doctor here in Germany himself conducted the untrasound that showed the thrombosis, sent him off to the local hospital (which admitted him immediately) and gave him very good care.  It didn't take three people to do the ultrasound, the doctor did it himself.  And that was my point, whether or not you wish to understand it.  BTW, I have the color picture on the doctor's letter that shows his thrombosis.  The doctor conducted it himself.

Unsafe staffing levels in the US?  It strikes me that sometimes the "unsafe" part is from having too many people who are unnecessary intermediaries.

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by: raj @ Sun Apr 15, 2007 at 23:48:27 PM CDT

[ Parent ]

raj, thanks for explaining; I think our points are not mutually exclusive (0.00 / 0)

we were more just talking over each other, or whatever that phrase is :). I agree with your points that there are too many personnel in some settings within the system, but that is largely not the case at the bedside at inpatient settings. I am so glad your partner rcv'd timely needed care in Germany and know that the U.S. scenarios you describe do contribute to bloated, expensive and poor quality care here.

when I use the short-hand term "unsafe staffing" it refers to inpatient settings and nurse staffing levels. My use of the term comes from being a nurse and experiencing various inpatient clinical settings settings where the nurse-to-patient ratios are so low it causes unsafe and poor quality care, hence "unsafe staffing". (unclear jargon, to a degree, and i'm sorry for that).

All hospitals except for the very wealthy ones perpetuate this problem and event the wealthy ones with big budgets have uneven staffing levels. In part this is because there is no required minimum staffing level as a safety measure for pts.

As an example this minimum provider-to-recipient of care ratio does exist in daycare settings, as it should. These are settings where the children cannot care for themselves and where financial pressures might lead to having not enough skilled teachers try to take care of too many kids, resulting in unsafe conditions. (and acutely ill hospitalized patients are not similarly vulnerable...?)

In longterm care settings such as nursing homes this is an extremely serious problem. More than in hospitals it involves inadequate numbers of nursing assistants as well as inadequate numbers of nurses -- the former group, the CNA's, does the lion's share of direct patient care and they are incredibley overworked and underpaid for what they do caring for our loved ones who are so needy, frail, and vulnerable.

Large numbers nursing colleagues have either left bedside nursing or cut way back on their hours becuase of these working conditions. In many places poor staffing levels are more the norm than the exception.  What MCRD describes is very illustrative:

Try having ten pt's [on your shift assignment] five with IV's running, eight on O2, three diabetic, four incontinent, three suffering dementia and lacking safety awareness, one with CHF, four COPD'ers, and that's a typical night. Rare? Try most of the time.

Go to any medical facility and ask the pt/care giver ratio and the acuity. You have so many pt's that you can't drink because you have't time to pee, have coffee or lunch. You get to work and go. nonstop.

This is everywhere. There is no help. Forced shift extensions, forced overtime, doubles, come in on your day off.

This is an all too common reality and it is why the Mass. Nurses Association, back in 1996, launched a statewide "Safe Care Campaign" and has been re-filing legislation to set safer minimum staffing levels for inpatient settings. There are many other components to the safe care campaign, single payer universal healht reform is one of them.  But I'll stick with staffing issues here.

The "Patient Safety Act" is proposed legislation to establish minimum staffing ratios of registered nurses to patients. It passed overwhelmingly (80% in favor) in the House last session but the Senate President (good ol' boy Trav) blocked a vote on it. Quality care and patient safety rely on this bill becoming law and there is a strong stateside Coalition for Patient Safety working for its passage this session.

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by: AnnEM @ Mon Apr 16, 2007 at 00:42:38 AM CDT

[ Parent ]

AnnEM, we largely do not disagree... (0.00 / 0)

...my (same-sex male) spouse was involved in medical records in the US and over the decades that he was in state service he told me what the RN profession devolved into.  It's a shame.  RNs wanted to go into RN service to provide patient care.  But, according to him (and I have no reason to doubt him) they basically became paper-work-filler-outers.  The people who were primarily providing the care were LPNs (Licensed Practical Nurses) and "candy stripers" (no denigration intended--is there another term?).  Not RNs.

And many RNs were frustrated, because they really did want to provide patient care, not fill out forms.

I do believe that I have left you with the miss-impression that, by my comparison Germany-Lahey, I intend to denigrate other medical service personnel in the US.  That is not my intention.  I am well aware of the fact that trained personnel--particularly RNs, and also LPNs--are quite capable of conducting examinations, interpreting them and probably diagnosing their interpretations.  (But, they are not permitted to.)  My intention was not to denigrate any of them.  My intention was merely to illustrate inefficiences in the American health care system.

If my spouse's ultrasound had been conducted by one of the practice's several nurses, and she had diagnosed his thrombosis, he would have been treated in the same way.

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by: raj @ Mon Apr 16, 2007 at 01:10:57 AM CDT

[ Parent ]

Expand it a bit... (0.00 / 0)

...what you are asking is, what is the social contract?  And what should it be?  That really is the issue, isn't it?  The inter-generational social contract.

People in their prime earning years pay to raise and educate children (whether or not the children are their own--we have no children, but we pay to educate, etc., children of other people), partially in anticipation that those children will, when they (the children) get into their prime earning years will support the elderly who--paid for their rearing and education. 

But the undetermined part is as follows.  Just what is the extent, in money, etc., of the social contract?  Just how much are those in their prime earning years supposed to pay so that the elderly can live a couple of weeks longer, or so that the young, who might not turn out to be productive, be supported, so that those who might be productive will be? 

That really is the question isn't it?  In wartime, they use the term triage to determine who should be cared for and who can't be because of limited resources.  Should elderly, who the medical community determines aren't going to recover to be allowed to die in peace?  Or are they, like Terry Schiavo, to have the machinery of their bodies be kept artificially alive, at whatever cost to the community?  Just how much of the limited resources is the US government and other health care financing operations going to devote to this?  The sad fact is that the US government could, if it wanted to, bankrupt itself through an unlimited financing operation.  Is that what Enkel (grandchild) of Oma (grandmother) in Nebraska really wants?  If so, let him say so.

What to do here and now?  At either end of the scale?  I sincerely don't know.  Some people believe that human bodies should live forever, whatever the price assessed to the community who is paying the price, but, that doesn't quite work.  Resources are not unlimited, and people don't live forever.

I honestly don't have the answers.

I honestly don't have the answers, either.  But, I have to tell you, that people who tear at the heartstrings, such as AnnMN, aren't providing any answers, or even any suggestions at answers.

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by: raj @ Mon Apr 16, 2007 at 00:43:47 AM CDT

[ Parent ]

the end of this otherwise informative and constructive comment ends on a note that's inaccurate and unfair. Why? I'd like us to aim for working together, not tearing each other down. (0.00 / 0)

But, I have to tell you, that people who tear at the heartstrings, such as AnnMN, aren't providing any answers, or even any suggestions at answers.

raj, Can it truly be that you haven't seen any of my repeated specific suggestions here on BMG about healthcare system reforms to address our current problems? ie see blockquote below. Sure, you mighta' missed more than a few of my BMG posts and comments, but I do try real hard to combine speaking from the head and the heart about the problems (and it's a low blow to demean that with your "tear at the heartstings" comment, IMHO) with detailed recommendations for the answers.

Below please find multiple specific suggestions.  Specific feedback welcome and valued--Thanks.

So true, but hardly anyone is willing to speak the truth!!!

One reason this law is so fatally flawed is that it contains practically NO MEANINGFUL cost control measures or reforms of our wasteful hc financing and delivery mechanisms (that raj touches on quite well). What follows is a beginning list of a few of the major cost control reforms that must be taken ASAP if we are to maintain the newly expanded coverage for the poor and keep the entire hc system from bankrupting more families, and from bankrupting the state!!! (remember that pesky budget deficit of >$1Bil?)

HC Affordability requires serious cost control measures in 4 major areas: 1) Ins. industry waste, 2) provider system waste, 3) pharma waste and abusively high prices, 4) disease prevention and chronic illness management. Some of these cost controls challenge special interests so now you get a glimpse at why these weren't done as part of state health reform.  Pathetic.

Current opportunities for hc cost control required for affordable hc:

1. Various bills that have been filed allowing private employers, municipalities, and individuals to opt-in to the GIC, MassHealth or Commonwealth Care as coverage options.
(Kaprelian is lead sponsor of the GIC/municipalities bill)

2. Jehlen bill requiring health insurers to spend 90% on health care services (what a novel idea, hc dollars spent on hc!!)

3. Tolman bill to establish uniform billing - creates one standard form for all hc billing in the state

4. Montigney bill to start the long overdue state bulk purchasing of pharmaceuticals, maybe at first just for Masshealth and GIC (that are funded with our taxpayer dollars) then expand it

5. Hynes/Tolman bill to establish a Mass. Health Care Trust for Universal HC with streamlined single payer financing [to bring about fundamental reforms of both the financinng and the delivery system components of our hc system].

In addition to suggesting some answers I also make the effort to provide links to organizations that run Action Alert listserves and provide other ways for people to get involved with making positive change.
For state level reform visit ADHC and MassCare

For national level reform visit HealthCare-Now

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by: AnnEM @ Mon Apr 16, 2007 at 14:21:54 PM CDT

[ Parent ]