Groggy Morning Notes

My brain works in bullet points on mornings I haven’t had enough sleep but, for whatever reason, can’t go back to sleep. Consider this a cleaning session.

• Gross-out: My dog woke me up by vomiting. On my armpit.
• Every time I see the word “Pain” I first think I see “Palin.” Oh, the beautiful irony.
• I said a very stupid thing in yesterday’s blog post. In order to be optimistic and/or happy about a single public issue, I apparently need to block out everything else. Like the banking crisis which, I presumed, didn’t really affect me. Riiiight. What I had was a failure of comprehension. It didn’t really make sense to me at that point, and I didn’t understand that the Fed taking on bad debt (or even the rumor of it) is another example of cronyism and bailing out the big guys. Does the fed step in to save a failing small business, or all those near-mythical family-owned businesses destroyed when a big-box store comes to the neighborhood? No–only when mega-conglomerates implement extremely poor business practices and operate at the edge of a proverbial cliff, and that cliff crumbles beneath them do the feds step in. And yet there’s no consensus about what caused this bubble. Who is running this f-ing government, anyhow? At least Krugman’s article in the Times today shows a basic understanding of the financial system–and the government’s involvement in it–so start there, I guess. I don’t understand!

See? That’s my brain waking up, and there’s typically anger involved in the clearing of the fog. Kind of like learning.

Okay, now I need to edit, edit, edit, work, get hair cut, go to library, go to bank, etc. etc.

Read Full Post »

Read Full Post »

Educate Yourself about Health Care Reform

Health care is the most important domestic issue in the U.S.A.–even for the healthy folks. You need to support reform that curtails rising costs, and prevents insurance plans/companies from denying coverage to the chronically ill and those with pre-existing conditions.

In this country you currently cannot obtain private coverage, and are considered “uninsurable” if you have any of the following conditions:

• Addison’s Disease
• AIDS (HIV Positive)
• ALS (Lou Gehrig’s Disease)
• Alzheimers Disease
• Amyotrophis Lateral Sclerosis
• Angioplasty
• Ankylosing Spondylitis
• Aunria
• ARC ( AIDS Related Complex)
• Arteriosclerosis
• ASD (Atrial Septal Defect)
• Banti’s Disease
• Bi-Polar Disorder (Manic Depressive)
• Bypass Surgery
• Cancer
• Chronic Fatigue Syndrone (Usually within 5 years)
• Colitis
• COPD (Chronic Obstructive Pulmonary Disease)
• Conjestive Heart Failure
• Cirrosis of the Liver
• Collagen Diseases
• Crohn’s Disease
• Cystic Fibrosis
• Cushing’s Disease
• Delirium Tremors (DT’s)
• Dementia
• Depression (Major)
• Diabetes
• Eating Disorders
• Emphysema
• Fanconi’s Syndrome
• Heart Attack
• Hemophilia
• Hemochromatosis
• Hepatitis (Type B, C, Chronic)
• Hodgkins Disease
• Heart Murmur
• Heart Valve Disease or Replacement
• Huntington’s Disease
• Hydocephaly
• Infertility Treatment (Recent)
• Ischemia
• Kaposi’s Sarcoma
• Left Bundle Branch Block
• Leukemia
• Lupus
• Lymphedema
• MS (Multiple Sclerosis)
• Muscular Distrophy
• Myasthenia Gravis
• Narcolepsy
• Organ Transplants
• Pacemaker
• Paralysis / Parapelegia
• Parkinson’s Disease
• Peripheral Vascular Disease
• Porhyria
• Portal or Renal Hypertension
• Pregnancy (Exisiting)
• Psoriatic Arthritis
• Psychoses
• Raynaud’s Phenomenon
• Renal Insufficiency
• Schizophrenia
• Scleroderma
• Silicosis (Black Lung Disease)
• Stroke (TIA, Transient Ischemic Attack)
• Substance Abuse / Dependance
• Suicide Attempt
• Ulcerative Colitis

If you do have any of these conditions, your only option is to obtain employment that offers full group coverage to its employees. Usually that means full-time employment, and if you have any of the above listed conditions, it may be detrimental to your health to work full time. A real conundrum that leaves few options for millions of people.

Here’s an editorial from today’s New York Times that discusses the front-runners’ stances on health care reform. No one favors my personal choice–a single-payer system–but some offer a step in the right direction. Others offer no step, or a wrong-headed step. You guess which is which.

September 23, 2007
Editorial
THE BATTLE OVER HEALTH CARE

One of the enduring frustrations of presidential elections is that candidates and their parties sound like Tweedledum and Tweedledee on many issues. In 2008, when it comes to health care, which is emerging as a defining domestic issue, voters will find stark differences in philosophy and commitment between Democrats and Republicans.

The three leading Democratic candidates all want to achieve universal or near universal health insurance coverage. The four leading Republican candidates espouse no such goal and barely mention the uninsured. The Democrats are willing to put substantial federal money into health care reform. The Republicans are not. The Democrats would expand government health insurance programs and give the federal government a greater role in regulating the insurance industry. The Republicans generally want to shrink federal programs and free the insurance industry from what they consider regulatory shackles.

Compared with these sharp differences between the two parties, the distinctions between leading candidates within each party are small, mostly a matter of tactics to achieve comparable goals. We far prefer the Democrats’ approach to health insurance, since at least they want to address an issue that must be resolved for reasons of economics, public health and fairness. Sadly, none of the leading candidates, in either party, has the vision or the political courage to propose radical solutions for the big underlying problem behind America’s health care crisis: the inexorably rising costs.

THE REPUBLICAN CANDIDATES

Two Republican candidates have yet to grapple seriously with health care reform. John McCain, running largely on Iraq and national security, has not said anything substantial about health care, nor has he even included it among issues listed on his campaign Web site. Fred Thompson has only a brief paragraph on his Web site in which he opposes new mandates, higher taxes or a Washington-controlled program, and calls for free-market solutions. He has also called for reduced spending on entitlements and says he would have opposed the new Medicare prescription drug benefit.

Rudolph Giuliani, who leads the Republican field in national polls, has only sketchy plans but has made it clear that he favors free-market approaches and is strongly opposed to what he mislabels as the Democrats’ push for socialized medicine. Borrowing from President Bush, he proposes a tax deduction of up to $15,000 to help families buy private health insurance instead of getting it through their employers. He believes millions of people might choose that option, creating a market in which insurance companies would rush in with affordable policies to cover them, and the nation would begin to move away from the employer-based system that the Democrats are trying to bolster. For the poor, he envisions some combination of vouchers and tax refunds to help buy policies but has given no indication of how much that program would cost or how he would pay for it.

His proposals are not likely to make much of a dent in the ranks of the uninsured. Tax deductions are of little use to low-income people who pay little or no income tax, and insurers are notorious for refusing individual policies to high-risk or chronically ill people. Given Mr. Giuliani’s eagerness to ease regulation of insurance companies it is hard to see how he could make that market work better.

Mitt Romney has the most developed health plan among the Republicans, as one might expect given his prominent role in spurring health care reform in Massachusetts. As governor of that left-leaning state, he helped make Massachusetts a leader in providing universal coverage, mostly by mandating that everyone must buy health insurance or pay a financial penalty. But as a candidate in the Republican primaries he has changed course, disavowing any need for mandates and contending that what was right for Massachusetts would not be right for the country.

Instead of a national reform effort, he wants the 50 states to devise their own plans, but without much financial help from the federal government. He promises federal incentives to help states deregulate their health insurance markets to encourage cheaper policies.

His key proposal at the national level centers on tax deductions to help people pay for health care. He would allow individuals to deduct their out-of-pocket expenditures — and any premiums paid for insurance policies they bought on their own rather than through their employer — from their taxable income. For those who still cannot afford coverage, he would encourage states to redirect money now used for charity care to help low-income people buy private health insurance. There would be no new federal money for this purpose. His advisers estimate the proposals would cost a modest $10 billion a year in reduced revenues to the United States Treasury.

The problem of relying on tax deductions to increase insurance coverage is that they mostly favor the better off. The problem with relying on the states to enact the needed reforms is that the plight of the uninsured would be left to the whims of geography. Few states have the financial resources that allowed Massachusetts to move to universal coverage, and many states lack the expertise to mount a sophisticated program.

THE DEMOCRATIC CANDIDATES

Although Republicans routinely lambaste the Democrats for supporting socialized medicine or government programs in which bureaucrats would dictate your health coverage, the plans put forth by the three leading Democratic candidates — Hillary Clinton, Barack Obama and John Edwards — are all very careful to build on the existing system of employer-based coverage supplemented by government programs like Medicare, Medicaid and the State Children’s Health Insurance Program.

None of them is proposing a “single payer” system run by the government. And all bend over backward to reassure people that they can maintain their current coverage if they like it. Their political goal is to head off opposition from those who fear that their own coverage might suffer in the course of covering some 47 million uninsured people.

The Democratic plans have far more similarities than differences. All three would move toward universal coverage and would rely heavily on mandates to do so. Mrs. Clinton and Mr. Edwards would require everyone to take out health insurance. That would bring young and healthy people into the system to help subsidize coverage for the more sickly, and would eliminate the problem of “free riders,” who show up uninsured at the emergency room and get very expensive care without paying. Mr. Obama would require parents to get insurance for their children but has no mandate for adults.

All three would require big employers to provide health insurance or contribute to the cost of covering their employees outside the workplace. But they differ in the treatment of small businesses, whose opposition helped derail the last big reform effort in 1993. Mr. Edwards is the toughest. He would require small businesses to provide insurance coverage or help pay for coverage elsewhere. Mr. Obama would exempt them from any mandate. Mrs. Clinton, in what looks suspiciously like a bribe to buy small business support, promises them a tax credit for providing coverage.

The Clinton plan would cost an estimated $110 billion a year, the Edwards plan $90 billion to $120 billion, the Obama plan $50 billion to $65 billion. All three would finance their programs partly by rolling back Bush-era tax cuts for those making more than $250,000 a year and partly with debatable savings they would get through cost-cutting.

All three would require insurers to accept everyone without regard to pre-existing conditions, would provide tax subsidies to low-income people, and would establish purchasing pools to help individuals get low group rates.

There would be a menu of options for people dissatisfied with their current policies because of high costs or limited benefits, including both private health plans and a public program that would compete alongside them. That would provide an interesting test of whether government or private plans are more effective and popular, a matchup that critics of “government-run” programs seem determined to avoid.

The Clinton plan has an innovative proposal to limit the premiums that families have to pay to a certain percentage of their income, as yet undefined. That is a welcome protection for consumers but could cause problems if medical costs continue to rise far faster than wages.

WHAT’S MISSING

All of the plans, both Republican and Democratic, fail to provide a plausible solution to the problem that has driven health care reform to the fore as a political issue: the inexorably rising costs that drive up insurance rates and force employers to cut back on coverage or charge higher premiums. All of the plans acknowledge the need to restrain costs, but most of the remedies they offer are not likely to do much.

Electronic medical records to eliminate errors and increase efficiency, more preventive care to head off serious diseases, and better coordination of patients suffering multiple, chronic illnesses are all worthy proposals, but there is scant evidence they will reduce costs. Proposals to import drugs from abroad, allow Medicare to negotiate drug prices, restrain malpractice expenses, increase competition among health plans, and empower consumers to shop more wisely for medical care might help a bit. But many experts doubt that any of this will truly put the brakes on escalating health care costs.

No top candidate in either party has broached more drastic remedies, like limiting the use of expensive new technologies, cutting reimbursements to doctors and hospitals, or forcing people to use health maintenance organizations. And no one has suggested imposing higher taxes on everyone, not just the wealthy, to finance universal coverage. These solutions are not even discussed on the campaign trail lest they alienate voters and interest groups.

At this stage, the various plans should be considered as broad outlines of where the candidates want to go, with details to be worked out later. Voters who put a high priority on covering all or most of the uninsured will prefer the Democrats’ approach, as we do. The chief danger is that the Democrats have a tendency to imply that everyone can be covered with good benefit packages without inconveniencing anyone but the wealthy. Their cost and savings assumptions will need thorough analysis when more detailed plans emerge.

Voters who put a higher priority on reshaping the health care system along free-market lines than on achieving universal coverage will prefer the Republican plans. Those plans’ likely impact on costs will also need to be analyzed when more details emerge. The “magic of the market” may be less than magical.

Given the wide split between Republican and Democratic approaches, the polarized politics in Washington, and the overriding need to find a way out of the morass in Iraq, it will be an uphill battle to achieve consensus on health care any time soon. But at least voters will have a clear choice of which way the candidates are headed.

Read Full Post »

World’s Best Medical Care?

A must-read editorial from today’s Times…

August 12, 2007
Editorial
New York Times

World’s Best Medical Care?

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.
That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

•

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.

Read Full Post »

Movie Week: Day # 6

Almost there…

Yet another classic that I just saw for the first time, and–in my opinion–the best Jack Nicholson movie. It was nice to see Jack before he became a parody of himself, before his signature grin became a signature, and when he performed with a touch of insecurity–not performed insecurity. And Faye Dunnaway is gorgeous.

The movie is great, and could’ve been made yesterday, with the exception of a line like “L.A.’s a small town.” I had a tough time believing the setting was the 1940s for some reason; the movie looked too much like the 1970s, if that makes any sense. Yet this was not a major distraction, just a personal twinge. And I’m still naive enough to feel unsettled about how ultimately little has changed since…well, the turn of the (20th) century, I guess. How the century of the corporation–and its manipulation of the government for its own profit–continues, perhaps stronger than ever. How the line (also mentioned here) “As little as possible” is the motto for “free-market capitalism” (the “free-market” part is a myth) and for about half of the American population–whether they understand its implications or not.

A down-home, country boy villain that really is purely evil (Sound like anyone? Oh, right.) caps the trio of excellent performances. Loved the scene where he and Jack eat fish–with the heads still on. Loved the movie.

Read Full Post »