Wednesday, June 17, 2009
Monday, June 15, 2009
In this clip from the documentary version of Maggie Mahar's truly excellent book Money Driven Medicine, two doctors discuss one of the principle problems facing health care in America, the shortage of primary care physicians (PCP) and the reluctance of those entering the medical profession to track in that direction.
The Money Driven Medicine website is okay but needs a lot of work. So does the propaganda machine. This message is too important to remain in the hands of artists. It's time to put this film into as many places as possible as the health care debate is under way.
I wish I could tell my readers where to order this dvd but I have yet to find out. I have contacted the source and am waiting for a reply.
Posted by Hoots at 12:09 PM
Sunday, June 14, 2009
Last week's presidential election in Iran was both a disappointment and a wake-up call for anyone expecting the incumbent to have a close call or lose to his opponents. Despite whatever negative diplomatic spin official Washington tries to put on the outcome, Mahmoud Ahmadinezhad won in a landslide. Even eyewitnesses and disinterested journalists observing in person may disagree with why and how it happened so the next important question is how will the world outside Iran respond, and specifically, what will be the official and unofficial responses from America?
I put up a background post last week collecting a few links to a few Iranian expats in their deep hope that Iran might select a more moderate leader than the populist demagogue who won reelection. In a different post four years ago I collected a string of links collecting various opinions of observers at that time. Though the issues are complicated I came away with the impression that this man's election was something of a national embarrassment with apathy to blame on the part of people who should know better.
I'm not smart enough to say why Ahmadinejad won with such a lopsided victory but a list of guesses might include a groundswell of populist sentiment that he offers hope for improvements in the lives of a growing number of people trapped in a stressed economy. International sanctions, high inflation and tight credit from the global financial meltdown may be included. And I read somewhere that despite sitting on the world's richest oil reserves, Iran still has no refineries and imports gasoline. If true, this last item strikes me as bizarre.
This photo and comments from an Iranian blog offers a glimpse into the dynamics of the election.
In this picture you see a youngish girl with a modernish appearance selling Ahmadinejad. This is very hard to believe as I have never seen any Iranian girl with her features wearing that kind of make up and highlights. Iranian girls are very smart in knowing what to wear to enhance their beauties. They are extremely aware of not becoming a tableau! This one simply does not know this style of make up is wrong for her features: she would be regarded as tableau and that is very embarrassing by Iranian standards. We all know what has happened to our young girls wanting a bit of freedom with their appearance. Not a single Iranian girl got away with her appearance without being at least cautioned once.
This girl and the driver are both from the Revolutionary Guards (Sepah Pasdaran). She is Khahar(sister) Zynab and he is Baradar(brother) Mohsen. They are just doing a bit of 'taghiyeh' (holey lie) to get Ahmadinejad reelected. They seem to be having some fun doing it too. After the elections she will be back looking like this.
That was June 3. On June 13, as results of the election came clear, he posted this grim little post:
Once again the Iranians were fooled to the polls only and only for one purpose: to show the world that the regime has legitimacy.
The election is over but there seems to be a level of ferment in the population that was missing four years ago. I will be watching next how widespread this year's protests will be commemorating the student massacre of 1988. See last year's post Student Protest in Iran (Additional material).
I don't know how to puzzle together these upcoming events with the results of the election. Perhaps someone else can offer some ideas. My instinct is that Mr. Ahmadi Nezhad may clever enough as a politician to spin many people in the street toward his support but not necessarily students who are a notoriously hard to manipulate bunch in countries all over the world, including ours.
This is a video from last year.
Posted by Hoots at 12:43 PM
Thursday, June 11, 2009
That's misleading. The 119 million figure comes from an analysis of a plan that would mirror Medicare and be open to every individual and business that wanted it. But that's not the type of public plan President Obama has proposed. Nor is such a plan gaining acceptance on Capitol Hill.
The author of the study says that while some have backed the Medicare-like proposal, using the 119 million number "overstates the impact of what now is being considered."
The ad also falsely cites the New York Times as the source of a statement that what's being proposed would leave no consumer choices and "government in control of your health care." The Times didn't say that at all. The newspaper was just quoting claims made by insurance companies and members of Congress.
The ad, which began airing this week on CNN and Fox News, asks viewers to "imagine" that a bulldozer is "the massive, government-run insurance plan some in Congress want." Citing a study by the Lewin Group, it says: "This government-run plan could crush all your other choices, driving them out of existence, resulting in 119 million off their current insurance coverage."
Narrator: There are hundreds of choices in health care plans today. But imagine this is the massive, government-run insurance plan some in Congress want. This government-run plan could crush all your other choices, driving them out of existence, resulting in 119 million off their current insurance coverage, leaving no choices in health insurance and government in control of your health care.
CPR Chairman Rick Scott: It's not too late. Protect your health care choice. Tell Congress to say no to a government-run plan.
The Lewin Group is part of a subsidiary of UnitedHealth Group, which owns the insurer United Healthcare. It says it operates with "editorial independence," and we've often referred to its studies. This report, published April 6, looked at several options for a public plan, including one that would pay health care providers at Medicare-level rates (i.e., a plan that would pay doctors and hospitals less and have much cheaper premiums than private insurance) and be open to all individuals and all businesses. The Lewin Group said such a plan "would enroll about 131.2 million people (includes some uninsured who become covered). The number of people with private health insurance would decline by about 119.1 million people." Attracted to a less costly insurance plan – premiums would be about 30 percent less than those offered by private insurers – businesses, and individuals, would make the switch first, then some private insurers could go out of business, not the other way around, as the ad says. But the study looked at several variations in how a public plan could be structured – at the low end, one type of plan would cause only 10.4 million to move off their current coverage.
The report prominently notes that the type of public plan President Obama proposed on the campaign trail would be available only to individuals, the self-employed and small employers – not to everyone – and therefore, wouldn't pull anywhere near as many people off private insurance. The Lewin Group estimated that if payment rates were like Medicare, a detail Obama didn't specify in his campaign proposal, 42.9 million would enroll in Obama's type of public plan and 32 million would move off of private coverage. The numbers are lower for plans using different payment rates to medical providers.
The study finds that the more like Medicare a public plan is, the cheaper it would be and the more people and businesses it would attract. Medicare reimbursement rates are significantly lower than what private insurers pay health care providers. Conversely, a public plan that was modeled on private insurance – an idea being pushed by Sen. Charles E. Schumer of New York – wouldn't be that enticing and wouldn't cause much of a shift in the way workers are covered. "That’s an area you might get 10 to 12 million," moving off private insurance, Sheils says.
Sen. Ted Kennedy, meanwhile, has drafted a health care proposal with a public plan that would pay providers at Medicare rates plus 10 percent. The Lewin Group study didn't specifically look at that option, but it did analyze the effects of a plan paying rates midway between Medicare and private coverage. That would be close to Kennedy's idea. (The Lewin Group study notes that Medicare payments to hospitals are 30 percent less than what private insurers pay and payments to doctors are 20 percent less.) Under the midpoint scenario, the number with private insurance would drop by between 21.5 million and 67.5 million, depending on who would be allowed to buy into the public plan.
Conservatives for Patients' Right's ad doesn't make clear that the government would have to institute the most generous public plan in order to have the estimated 119 million move off of their current plans, according to the study.
One final point on the Lewin study: The ad may well give some the impression that the 119 million people that are "off their current insurance coverage" are simply losing their insurance plans altogether. That's not the case, as all would still have coverage through their employer, who decided to switch to the cheaper, public alternative.
It's also worth noting that this number comes from one analysis, and some researchers haven't predicted such a damaging effect on the private insurance market from the introduction of a public plan. A 2008 report by the Urban Institute said in general terms: "We think that a public plan would not drive out private competitors. ... Private plans that offer better services and greater access to providers, even at a somewhat higher cost than the public plans, would survive the competition in this environment. It is also conceivable that private plans offering a lower cost option—for example, lower premiums than the public plan, say by exploiting care management innovations, and network and payment rate limitations—could stake out a separate competitive niche in some markets." The authors said there were constraints on the ability of the government to set very low payment rates.
The ad goes on to say the public plan would "leav[e] no choices in health insurance and government in control of your healthcare," while citing the May 5 New York Times. But that's not the Times' analysis of what a public plan would do.
We've seen this type of newspaper endorsement technique before in political ads, where the credibility of a publication is used to bolster the claims. In this case, the Times didn't say that a public plan would leave "government in control of your healthcare." Rather, a May 5 article by reporter Robert Pear said that this was the view held by Republicans and insurance companies.
Interestingly, the May 5 article is about Schumer's proposal to make a public plan closely resemble private ones. As Sheils told us, if that type of public plan is established, it would mean 10 million to 12 million wouldn't keep their current insurance, according to Sheils' analysis – not the 119 million figure the ad touts.
– by Lori Robertson
Pear, Robert. “Schumer Points to a Middle Ground on Government-Run Health Insurance.” New York Times, 5 May 2009.
Sheils, John. Interview with FactCheck.org, 11 June 2009.
Holahan, John and Linda Blumberg. "Can a Public Insurance Plan Increase Competition and Lower the Costs of Health Reform?" Urban Institute, 2008.
Posted by Hoots at 4:38 PM
Tuesday, June 09, 2009
Monday, June 08, 2009
Via Common Deams/ Denver Post / Ron Beasley
As America comes to grips with the reality that changes are desperately needed within its health care infrastructure, it might prove useful to first debunk some myths about the Canadian system.
Myth: Taxes in Canada are extremely high, mostly because of national health care.
In actuality, taxes are nearly equal on both sides of the border. Overall, Canada's taxes are slightly higher than those in the U.S. However, Canadians are afforded many benefits for their tax dollars, even beyond health care (e.g., tax credits, family allowance, cheaper higher education), so the end result is a wash. At the end of the day, the average after-tax income of Canadian workers is equal to about 82 percent of their gross pay. In the U.S., that average is 81.9 percent.
Myth: Canada's health care system is a cumbersome bureaucracy.
The U.S. has the most bureaucratic health care system in the world. More than 31 percent of every dollar spent on health care in the U.S. goes to paperwork, overhead, CEO salaries, profits, etc. The provincial single-payer system in Canada operates with just a 1 percent overhead. Think about it. It is not necessary to spend a huge amount of money to decide who gets care and who doesn't when everybody is covered.
Myth: The Canadian system is significantly more expensive than that of the U.S.
Ten percent of Canada's GDP is spent on health care for 100 percent of the population. The U.S. spends 17 percent of its GDP but 15 percent of its population has no coverage whatsoever and millions of others have inadequate coverage. In essence, the U.S. system is considerably more expensive than Canada's. Part of the reason for this is uninsured and underinsured people in the U.S. still get sick and eventually seek care. People who cannot afford care wait until advanced stages of an illness to see a doctor and then do so through emergency rooms, which cost considerably more than primary care services.
What the American taxpayer may not realize is that such care costs about $45 billion per year, and someone has to pay it. This is why insurance premiums increase every year for insured patients while co-pays and deductibles also rise rapidly.
Myth: Canada's government decides who gets health care and when they get it.
While HMOs and other private medical insurers in the U.S. do indeed make such decisions, the only people in Canada to do so are physicians. In Canada, the government has absolutely no say in who gets care or how they get it. Medical decisions are left entirely up to doctors, as they should be.
There are no requirements for pre-authorization whatsoever. If your family doctor says you need an MRI, you get one. In the U.S., if an insurance administrator says you are not getting an MRI, you don't get one no matter what your doctor thinks - unless, of course, you have the money to cover the cost.
Myth: There are long waits for care, which compromise access to care.
There are no waits for urgent or primary care in Canada. There are reasonable waits for most specialists' care, and much longer waits for elective surgery. Yes, there are those instances where a patient can wait up to a month for radiation therapy for breast cancer or prostate cancer, for example. However, the wait has nothing to do with money per se, but everything to do with the lack of radiation therapists. Despite such waits, however, it is noteworthy that Canada boasts lower incident and mortality rates than the U.S. for all cancers combined, according to the U.S. Cancer Statistics Working Group and the Canadian Cancer Society. Moreover, fewer Canadians (11.3 percent) than Americans (14.4 percent) admit unmet health care needs.
Myth: Canadians are paying out of pocket to come to the U.S. for medical care.
Most patients who come from Canada to the U.S. for health care are those whose costs are covered by the Canadian governments. If a Canadian goes outside of the country to get services that are deemed medically necessary, not experimental, and are not available at home for whatever reason (e.g., shortage or absence of high tech medical equipment; a longer wait for service than is medically prudent; or lack of physician expertise), the provincial government where you live fully funds your care. Those patients who do come to the U.S. for care and pay out of pocket are those who perceive their care to be more urgent than it likely is.
Myth: Canada is a socialized health care system in which the government runs hospitals and where doctors work for the government.
Princeton University health economist Uwe Reinhardt says single-payer systems are not "socialized medicine" but "social insurance" systems because doctors work in the private sector while their pay comes from a public source. Most physicians in Canada are self-employed. They are not employees of the government nor are they accountable to the government. Doctors are accountable to their patients only. More than 90 percent of physicians in Canada are paid on a fee-for-service basis. Claims are submitted to a single provincial health care plan for reimbursement, whereas in the U.S., claims are submitted to a multitude of insurance providers. Moreover, Canadian hospitals are controlled by private boards and/or regional health authorities rather than being part of or run by the government.
Myth: There aren't enough doctors in Canada.
From a purely statistical standpoint, there are enough physicians in Canada to meet the health care needs of its people. But most doctors practice in large urban areas, leaving rural areas with bona fide shortages. This situation is no different than that being experienced in the U.S. Simply training and employing more doctors is not likely to have any significant impact on this specific problem. Whatever issues there are with having an adequate number of doctors in any one geographical area, they have nothing to do with the single-payer system.
And these are just some of the myths about the Canadian health care system. While emulating the Canadian system will likely not fix U.S. health care, it probably isn't the big bad "socialist" bogeyman it has been made out to be.
It is not a perfect system, but it has its merits. For people like my 55-year-old Aunt Betty, who has been waiting for 14 months for knee-replacement surgery due to a long history of arthritis, it is the superior system. Her $35,000-plus surgery is finally scheduled for next month. She has been in pain, and her quality of life has been compromised. However, there is a light at the end of the tunnel. Aunt Betty - who lives on a fixed income and could never afford private health insurance, much less the cost of the surgery and requisite follow-up care - will soon sport a new, high-tech knee. Waiting 14 months for the procedure is easy when the alternative is living in pain for the rest of your life.
Posted by Hoots at 7:21 AM
Lebanese politics is a form of representative democracy, but nothing like what Americans imagine when they read those words. I have been following events in that part of the world since before I started blogging and it seems the more I learn the less I know. Americans hear the term Hisbollah and rarely stop to think that it is neither a country nor a tribe, and most have no idea that it's geographic location is inside Lebanon. It is puzzling, then, that there can be a war between Israel and Hisbollah that does not involve the whole of Lebanon. This is because various political interests there are not under a single control and command center. Each group has its own militia which protects and retains whatever power is possible under the Lebanese constitution.
Via the Arabist I just watched a four part documentary about the Gemayyel clan which as Maronite Christians is the dominant family which controls the presidency of Lebanon by constitutional authority.
That sentence calls for an explanation.
Lebanon's constitution is modeled around what is called a consociational principle. When I first came across that word several years ago I thought it was a typographical error. Nothing in my schooling had referred to anything consociational so I had to look it up. In plain language it refers to a political system insuring that certain interests that could be pushed out of power if mathematical results of voting are left unchecked are afforded constitutional protection. Variations of this idea are also practiced in Switzerland and the Netherlands.
When we speak carelessly of "democracy" we forget that one of the downsides of the idea is what political scientists call the "tyranny of the majority." We like to say that everyone has to go along with whatever the majority decides, but in many instances that is impossible, not because the minority won't "just go along" but because by doing so they would be violating deeply held beliefs that if abandoned would mean they would simply vanish. In America we deal with this problem by allowing certain groups to be exempt from whatever the majority holds. The Amish, for example, are not expected to pay taxes or allow their children to be recruited into the military. Various religious groups routinely are allowed to observe certain days as holidays, often paid. Sometimes these exceptions are mandated by law. More often they are simply extensions of cultural courtesy.
When the Lebanese constitution was drawn up a background of bloodshed and bad feelings made "cultural courtesy" an unrealistic ideal. So by law certain components of the political control of the country were designated for various groups. The president will always be a Christian (which in Lebanon means a Maronite Christian), Speaker of Parliament will be a Shiite Muslim, Prime Minister will be a Sunni Muslim, and other parts of the government will be similarly divided, including not only these three main sectarian groups but Druze and others as well. (Druze refers to a Muslim offshoot group that can be though of as "Muslim unitarians.") For this reason the presence of Palestinian refugees is tolerated, even though they have little or no political influence, and Hisbollah, which is a remnant (and revolutionary) Sunni group, is also able to control part of the country. (For Americans, one of the bright spots of yesterday's elections in Lebanon was that Hesbollah did not do as well as they had hoped. Nevertheless, the group is very much a reality in the Lebanese political scheme of things.)
Short sentence. Long explanation.
Anyway, for the reader who had half an hour and is willing to click through four different videos I recommend this series.
I learned more in half an hour of watching than I have been able to grasp after five years of reading and studying. It helps that I have put in that five years, of course, but even without knowing that much background an uninitiated American can get a lot out of the series. Disclosure: Yes, this is an Al Jezeera production, so for those who have already decided that anything from that source is taboo, I suppose you may simply keep moving in your bigoted ignorance. For everyone else, here is Part One.
Posted by Hoots at 6:21 AM