Thursday, October 15, 2009

Harpers Magazine "Understanding Obamacare"

Harpers Magazine, "Understanding Obamacare"

I know that this is a tough audience.  So before I described this article, which is deeply critical of the Health Care Reform pending in Congress, based on the authority of a Magazine, I decided to do a bit of homework.

For as long as I have been reading Harpers, on and of for a half century or so, it has been pretty strongly liberal.  But I have to admit, based on their archives going back to 1850, during the run up to the Civil War, they didn't take a stand against slavery, focusing on short stories and poetry.  Only at the end of the war did they tip their hand, printing a long illustrated article praising Sherman's march through the South. 

I jumped to March 1933, to read an article by Elmer Holmes Davis, "If Roosevelt Fails,"  which is rather uncanny in the similarity between the economic fear that we were facing a year ago as our markets were in collapse.  In reading that article it is less like a monthly magazine than contemporaneous history. It described outgoing President Hoover as a pragmatist, who by forming the Reconstruction Finance Commission, and promoting Unemployment Compensation, was preparing the ground for what was at that time the promises of Roosevelt's New Deal.  I think it's pretty fair to say that Harper's Magazine is the longest established, and most respected, Liberal magazine in the United States.

The news of this essay is not that a writer has criticized what he calls "Obamacare." It is that the institution of Harpers Magazine, the intellectual vehicle of the philosophy of the Democratic party for well over a century, has taken a stand on this pivotal issue of this party.

Unfortunately the article is only available to subscribers, (but anyone can read it, or even buy it, at bookstores) so I will excerpt limited segments based on fair use constraints 

Senior Editor Luke Mitchell sees the pending HCR project as a cynical sellout:

The real battle in Washington is seldom between conservatives and liberals or the right and the left or “red America” and “blue America.” It is nearly always a more local contest, over which politicians will enjoy the privilege of representing the interests of the rich.  

He punctures the illusion that this HCR will impose regulation on Insurers, that government will control the corporate segment, explaining that the actual process is quite the opposite, best explained by the concept of Regulatory Capture. with the byword of the process being "Moderation"

The contemporary form of moderation, however, simply assumes government growth (i.e., intervention), which occurs under both parties, and instead concerns itself with balancing the regulatory interests of various campaign contributors. The interests of the insurance companies are moderated by the interests of the drug manufacturers, which in turn are moderated by the interests of the trial lawyers and perhaps even by the interests of organized labor, and in this way the locus of competition is transported from the marketplace to the legislature. The result is that mediocre trusts secure the blessing of government sanction even as they avoid any obligation to serve the public good. Prices stay high, producers fail to innovate, and social inequities remain in place.

Mitchell describes President Obama's mantra of avoiding drastic change, of building on the present employer based system, of those who like their insurance being able to keep it, with considerable disdain:

With such soothing words, the Democrats have easily surpassed the Republicans in fund-raising from the health-care industry and are even pulling ahead in the overall insurance sector, where Republicans once had a two-to-one fund-raising advantage. The deal Obama presented last year, the deal he was elected on, and the deal that likely will pass in the end is a deal the insurance companies like, because it will save their industry from the scrap heap even as it satisfies the “popular clamor for a government supervision.”

But, Mitchell doesn't have much love for Republicans either, as he closes with this:

Senator Charles Grassley of Iowa explained, “Government is not a fair competitor. It’s a predator.”

Such non sequiturs have opened the way to the darker dream logic that of late has come to dominate G.O.P. rhetoric. Nothing remains but primordial emotion—the fear, rage, and jealousy that have always animated a significant minority of American voters—so Republican congressmen are left to take up concerns about “death panels” and “Soviet-style gulag health care” that will “absolutely kill seniors.” Republicans, having lost their status as the party of business, have become the party of incoherent rage. It is difficult to imagine anything good coming from a system that moderates the will of corporations with the fantasies of hysterics.

I am writing this essay, because I have independently come to the conclusion that this bill, no matter how modified in the Senate or the Conference Committee, will not merely be flawed, but misconceived.  If this were to have an accurate title it would be the "Medical Establishment Perpetual Security Bill" with the subtitle in small type "including an attempt to make health care more affordable and efficient"

I'm convinced that those who support this bill are doing so on faith.  It is a belief that President Obama and the Democrats have a long term plan to use this bill as a wedge, a first step, to eventually transform our health care establishment. I call this faith because it persists in the face of historical empirical evidence that shows that exactly the opposite will happen, as described in the Harpers article. 

I've long ago learned that it's impossible to change someone's faith, be it secular or spiritual.  While I'm an atheist, I don't picket outside churches with signs saying, "God is an illusion"  telling congregants that the existence of such a powerful benevolent being is wishful thinking.  I would either be ignored, ridiculed, or attacked....and rightly so.  Life is tough, more so for some than for others. Even if somehow I had the ability, I would never want to disabuse anyone of a belief that provides succor to a difficult existence.

Mitchell doesn't show any special animosity towards Obama, or even the Democrats.  He writes in keeping with the tone of his publication, a document relevant for readers of a century from now, as I am reading about the article about the new F.D.R. administration.  He writes about the nature of our political system, the actual forces that shape our culture and our laws with remorse rather than anger at this manifestation of our debased political culture.  

In some ways, for me it is actually soothing. It gives me absolution that even with what I believe I know, with my own individual and researched insights, I can do no more with my personal blog than he can with his access to the pages of this revered publication to change the course of history.

I hold Harpers Magazine as a shield of protection against apostasy against progressivism. but I am eventually betrayed by the other apostate, Luke Mitchell's own words: "It is difficult to imagine anything good coming from a system that moderates the will of corporations with the fantasies of hysterics"  My arguments against this bill, and ultimately his own, no matter what logic, personal experience or academic endorsements are tainted by the association with "fantasies of hysterics."  

I'll simply close with the words, sonorously remembered by those few who watched the newsreels of momentous events from darkened movie theaters,  "Time Marches On."  



Wednesday, October 14, 2009

Letter to Union Tribune

To the editor:  Re: Grandma pickpocketing the young, 11-26-09-

As a proclamation of the official beginning of the United States Generational Civil War, I would say it's good to have this out in the open, with the caveat that the unfortunate accusational tone, "pickpocketing the young, economic assault on the young by the old"  marks the low point of the dialog rather than setting a standard.  First a correction of this: "Medicaid...primarily dedicated to the elderly."  Not principle or in actuality.   Unlike Medicare, created to address the lack of minimal health care of those beyond working age in a system that merged health insurance with employment; Medicaid was, and still is, designed to aid those in poverty, old and young alike.

Samuelson's ad hominem attack on a generation distorts the serious issues that must be addressed by comprehensive health care reform.  It exists on partly because of the demographic time bomb,  that the birth rate in the early second half of the last century has now created an imbalance between beneficiaries and contributors to Medicare and Social Security. 

While it has been clear for decades that Medicare was on the road to insolvency, our political system refused, or was unable, to tackle the ineffeciecies and inequities of our massive powerful Medical-Industrial complex, that has resulted in health care being unaffordable for so many Americans of all ages.  Sadly, given the evidence of the developing Health Care Reform pending in congress, it still lacks this ability.

As someone approaching 70, the very last thing I want for myself or for my cohorts is a disproportional share of the health care pie, yet the current House passed bill, oblivious to Mr. Samualson apparently, would actually place those on Medicare closer to the back of the new longer line of subsidized claimants for a fixed supply of medical care.  Somehow the powerful "better organized" seniors couldn't prevent both Medicaid and the proposed private option from being able to pay equal or more than they do to providers.

This reform bill, is primarily a rearranging the order by which those in desperate straits can board the life boats, without increasing the number of seats.  Those writing this bill choose to fund token "demonstration projects" that could, perhaps in decades, actually provide the additional capacity to negate needing to  decide  who gets care and who goes without.   Even in the clause that acknowledges an improvement of malpractice, objective certificates of merit being required before court access, the writers of this bill refuse to mandate such efficiencies.

Ultimately for health care in America ever to be affordable, available enough to care for old and young alike, radical changes are necessary.   This means, as much as many may object, actually putting government between a patient and his or her doctor to prevent futile treatment that saps the resources that could be used to meaningfully prolong life.  Far from being "death panels" such entities would ensure the existence of a health care system that can actually enhance and save lives.  These "Life Panels" are the only one thing among other shocking changes to what we have become used to that can difuse the battle between young and old, male and female,  rich and poor, healthy and sick....that is inevitable by ignoring tackling the supply side of health care.  

Blaming our current health care problem on "Grandma," or any single industry or profession is as silly as it is destructive.  We have a health care complex, that is as unique as our own history as a country.   Creation of false villains is no substitute for addressing this social-political issue that is ingrained in who we are as a society, and will only be improved by accepting the pain of major surgery to our body politic.

Al Rodbell
Encinitas California

  Editor:  I know this is long, but if you need to edit, give me a shot at trying to select what can be removed.   Or if you want to feature this as an OpEd, my education is a M.Phil from Columbia University in Social Psychology and Public Health.


Tuesday, October 13, 2009

Fungibility-or Perspective in Health Care Dialogue

Since the word has it's root in contract law, its importance as a broader concept is not even included in most definitions.  Here's Wikipedia's discusion.

The word fungible is best explained by example:

Purchasing a ton, or even a pound, of Bituminous Grade A Coal means that the individual chunks of coal are interchangeable. They are given no individual identity even though each is different.

Let's look at historical images of the concept.  During Viet Nam the metric of success of combat used by the U.S. forces was "Body Count."  Each dead Viet Cong troop was part of a mass, without a live history or all that made them human beings.  Going back further, fungibilty is a quality that used to apply when the wholesaler purchased the entire cargo of slave ships.  Only when auctioned off did the slaves lose their fungibility, not be become full human beings, but individual units of production.

Medicare patients are treated as fungible when they are analyzed as having an aggregate life expectancy, an average cost per year, and a total demand on medical care resources.  A recent report shows the difference in cost of such patients in Miami county which is twice as much as the average county in the United States.

With the magic of Fungibility, this additional cost becomes "waste," something that can be eliminated and fund one third of the cost of Universal Health Care. Medicare expenses in fungible form here.  .  But as in my examples above, Fungibility, aggregation whether of dead soldiers, slaves, or medicare patients is only a metaphor. 

When it comes to deciding how to bring down the cost of those Miami Medicare patients, in an instant they become actual individuals, in pain, in despair, fearing death and begging, or demanding, succor in the form of medical treatment....that happens to cost money.  Or when it comes down to cutting waste from the other direction, the suppliers of medical care, all of a sudden these amorphous entities become real doctors, nurses, hospital administrators, Health Care investors......and all of them have lobbyists, very powerful effective lobbyists, as discussed in today's N.Y. Times front page article.

Clients of Private Insurers are never fungible.  The sales department may be under pressure to sign up their quota, but the underwriting department has the job of individuating, of evaluating each applicant to determine whether they will insure them. 

Under the existing system (no universal mandate) this is required, since their expected cost to the insurer will depend on whether they are going to be paying for medical care for Grade A (Health) people, or Grade B, who can be expected to cost them more. 

How they do this sorting happens to be major issue. Unlike coal where there are laboratory tests of random samples to determine categories of quality, no exact tests exist for all the ailments humans are heir to.  And every state has developed it's own unique regulations that define how an insurance company can evaluate applicants, and their options once they have done so.

The two largest states are illustrative.  In N.Y. everyone must be accepted for individual insurance, but treatment for given existing conditions may be excluded.  In California an insurer may not exclude caring for a pre-existing condition, but they can refuse to insure an individual.

Unlike the example of Fungible Bituminous Grade A Coal, a lump of coal is not an active agent with an interest in joining a given category.  In the world of private insurance we all want the best value, simplified to the equation of(care/cost)from an insurer, and we will flock to the one who offers it. When this occurs in excess one of the elements of the value equation must change, care must decline or costs must rise, in order to for a given insurer to function.

This process works through adverse selection.  If you go through the excellent Wikipedia article, you will note it only applies to private insurers, not to single payer, national health care, or to medicare.

Let me try to share what I see as the root of the inability to improve our Health Care System.  This is our not looking at the organic verities that underlie it, but assume that legislation, if done right, will cure the problem.  

"Law" is interesting word.  It can mean the product of democratic legislatures, or the edicts of autocracies, that impose rules on constituent entities- individuals, agencies, corporations etc.   But there is another meaning of Law.  That is the discovered relationships of natural forces, as in Law of Supply and Demand, or Law of Gravity. 

Our National Health Care system is shaped by both of these types of laws.  Somehow, we have pretended that the former, "imposed law" will prevail over the later, "discovered law"  We assume that imposed law requiring affordable care, will prevail over the law of supply and demand.  A belief that black markets past and present belie.

While we eagerly try to refine the imposed law in a comprehensive Federal Health Care Reform Act, we have barely even thought about the discovered laws of interactions, economic or psychological.  If this diary has been too arcane, this one, Health Care in the World of Tomorrow, may give an example of a problem that must be addressed before any Health Care Reform will be effective.


Saturday, October 10, 2009

Transforming Malpractice Procedure

Malpractice Policy is a window on this Bill
It can be found in a single section 2531. It acknowledges the defects in the current system, by appropriating funds for states that require a "certificate of merit" before a case can even be brought to court. However boldly mandating universal care is defined in this bill by the federal government, it is strangely diffident in addressing this hot button issue of malpractice.

It does not even require such a certificate of merit, acknowledged in the bill to be advantageous, to precede any tort by preemptive federal mandate. One of the hopes, the justifications of this bill is that it will shift our country's health care to more effective, evidence based procedures. A powerful tool to reach this end would be providing safe harbors for any doctor who follows such procedures.

Malpractice policy is more than limiting high doctor's insurance for this, or preventing excess "defensive practice," it could be a tool for promoting the practice of evidence based medicine that acknowledges the limits of any practice and the potential for bad outcomes even give proper procedure.

This article, Is "No-Fault" the Cure for the Medical Liability Crisis?, by David E. Seubert, MD, JD published by the AMA shows how a replacement for the current judicial based system can promote the long range goals of Health care reform.

A no-fault system of compensation for medical injury similar to the workers’ compensation and automobile insurance models may be the answer to the medical malpractice crisis omnipresent in the United States today. Allowing physicians to come forward when an error occurs and join forces with their patient(s) and the hospital system could improve the entire network of health care. The current conspiracy of silence carries great risks for society. Suppose the error that has harmed a patient lies in a faulty system and has potential to do much more damage? Silence and lack of investigation of the problem can have greatly deleterious consequences.

A no-fault system encourages health care professionals to identify the system malfunction and take a proactive approach to fixing it. At the same time, where a patient has suffered harm, the no-fault system must assure appropriate compensation. Such an approach accomplishes two goals: first the patient is compensated for the injury, and, secondly, society’s health care is upgraded and enhanced by fixing an error in the system. Such an error may in fact be a physician with a deficit. The no-fault process can identify this deficit and allow for physician retraining and rehabilitation.

It is interesting that the long articulate refutation of the above article by a malpractice litigation firm at the end of the link above, includes this:

Reforms to the existing system, such as fostering increased communication of errors, limiting the use of juries for determinations of fault but not for determination of damages or using neutral medical experts, may prove more advantageous to both patients and physicians.

This happens to express my proposal pretty exactly. Yet, this pending bill ignores the opportunity to transform this politically defined system, in this case protecting the constituency of plaintiff's lawyers, thus impeding the very goals that are used to justify this comprehensive reform.

Friday, October 9, 2009

"Bending the cost curve of health care"

"Bending the cost curve of health care" the ultimate goal of this reform

While universal coverage is the goal, President Obama and all experts agree that this will only be possible if costs are lowered from the current rate of twice the general inflation rate. Here's what the report has to say on this vital point (pg 10):

Comparative Effectiveness Research

We reviewed literature and consulted experts to determine the potential cost savings that could be derived from comparative effectiveness research (CER), We found that the magnitude of potential savings varies widely depending upon the scope and influence of comparative effectiveness efforts. Small savings could be achieved through the wide availability of non-binding research, while substantial savings could be generated by a comparative effectiveness board with authority over payment and coverage policies.

Such a board with authority over policy, even as a possibility, has been explicitly excluded by President Obama, as this is exactly what he meant by promising that "nothing will come between you and your doctor"

The report continues giving the estimate based on two important measures, one is the important aggregate of all Medical expenses, both individual and all levels of government called "National Health Expenditures or NHE, the other is the savings in Federal Outlay, which is represented by the national deficit:

Our interpretation of the CER provisions in H.R. 3962 is consistent with the least stringent of these levels of influence (AR note, as promised by the President and in the law that was passed) translating into an estimated total reduction in national health expenditures of $8 billion for calendar years 2010 through 2019......

Thus, according to this report, the centerpiece of this Health Reform Effort, "bending the cost curve" for the first decade will amount to $8 billion dollars. While that may sound like a considerable amount, the total of NHE for this period will be approximately $20,000 billion. To put it in everyday terms that's like someone offering a rebate on a purchase, saying that it will be sizable and make a difference in its affordability; and after you paid a thousand dollars, the rebate, the savings, came to 40 cents. This is the same ratio of "bending the cost curve of medical expense" that is reasonable to expect from all of the cost savings in the Health Care Reform bill as represented by the version passed by the House of Representatives.