Tuesday, September 29, 2009

No Public Option

The Senate Finance Committee excludes a public option. This really is no surprise. We know that Baucus is in the pockets of insurance companies instead of his constituents, as are many other politicians. It is also blatently apparent that the entire Republican party is united to prevent the Obama administration from accomplishing anything good for America. The Republicans want the Obama administration to fail at improving our country and serving its citizens, just so the Republicans can cite the failure while campaigning for the next elections.

What can we do?
Well, we obviously need some campaign finance reform, for starters. There is an organization working to accomplish this goal. Change-Congress.org, organized by the illustrious Lawrence Lessig, fights against the sway that special interest groups (insurance companies) have over our government. When there is more of an incentive for politicians to work for their constituents, and less of an incentive for them to pander to money-grubbing companies, we will see policy decisions that are better for this country.

Did we need a public option?
Well, the CBO says that various plans proposed would cut the US deficit by tens of billions of dollars over the next ten years, while providing health care to tens of millions of American citizens who currently have no insurance. I've seen other organizations estimate that the deficit would drop by even more, since the CBO did not look at every related variable. There are different plans, though, and different ideas of what the public option would look like. So, there are proposals that include public options that would help many Americans and save our country money, which are both outcomes we need. There are other ways to get these outcomes, such as a single-payer system (HR676, Medicare for All, has hardly been mentioned) or extremely tight regulation on insurance companies, but a public option was the most likely to make it through congress. It just isn't likely enough.

I am confident saying that any politician currently opposing/stalling efforts to increase the government's involvement in health care, either through a public option, marketplace, expanding Medicare, or more strictly controlling private insurance companies, is motivated only by the drive for personal power. These politicians enjoy their campaign contributions and visits from lobbyists, and the Republicans know that sticking with the party line ensures they will keep getting support in future elections. The politicians who are fighting for the health of our citizens are the ones who care about their constituents.

Monday, September 21, 2009

Listen to the Experts

It is terrible that so many politicians make policy decisions to pacify ignorant and misled mobs instead of using the accurate information available to make the best decisions for our country. I cringe when I catch what passes for television news these days, a bunch of polls and tweets from random people presented as if they should be used to guide our government's policies. Those people don't know what they're talking about!

Here's a neat table comparing the opinions of the informed to those of the random. The average person is selfish and ignorant, and wants unlimited care for herself, not understanding the costs, consequences, or relative quality. They care about anecdotes instead of real data on the quality of a doctor or treatment. They don't understand what variance is, let alone its relevance in health care. They trust their heavily biased and marginally informed doctors.

It is hard to explain the details of health care economics to the average person. It is hard to explain why we should have fewer treatments and more tracking of patients and doctors. It is hard to explain why hospitals should have fewer high-tech machines. It is easier to explain why drug companies are evil and doctors shouldn't be so free to refer patients to clinics the doctors own stake in. Overall, the complexity and scope of health care is overwhelming and confusing to the average person who just wants some security.

The convergence of the expert opinions is good for the country. Trust the experts (in aggregate, not just the few who talk on Fox News). We want everyone to have security, just like you want for yourself. We want costs to be low, and quality to be high. We don't want people bankrupted by an illness. We don't want patients exploited. We don't want the nation's deficit to grow. Not only do we have these goals, we have the knowledge and skills to see how to achieve them. We just need everyone else to stop holding us back.

Thursday, September 17, 2009

Obama's Marketplace Plan

Even the famous Ewe Reinhardt agrees with me. Obama's proposed marketplace, where private insurers would compete with a public plan to provide customer-friendly health insurance, is going to be costly. If you're going to give so much care to people, ban rescission, allow pre-existing conditions, and put a low cap on out-of-pocket expenses, then you're going to have an expensive insurance plan.

To keep costs practical, one thing you have to be aggressive about is the chronic diseases that make up the bulk of costs. Encourage and demand more personal responsibility, and be able to cut people off from expensive care caused by their irresponsibility. For example: diabetes is widespread and totally manageable. It is far cheaper to help diabetics follow their treatment regimen than to pay for all the ER visits resulting from improper self-management. Many hospitals offer services that help slower diabetics keep track of their medication, plan their diets, get regular check-ups, and so forth. Not everyone uses those services, though. Some people insist on doing whatever they feel like, and make six trips to the ER each year. That hurts the rest of us. When New York City began a program to call every diabetic regularly to remind them to get check-ups, there was a big outcry about violating their privacy. Well, they violate everyone else each time they avoidably use expensive health care resources. Should everyone pay for a smoker's expensive lung cancer treatment? For a head injury of a motorcyclist who refused to wear a helmet?

We are all part of a system. If a person is going to renounce their responsibility to the system, their responsibility to take care of themselves so costs to the rest of us are manageable, then they renounce their membership in the system. The system should help those who make good faith efforts to support the system in return, but should not be obligated to help those who selfishly and irresponsibly hurt the system. An arrangement like England's that refuses to pay more than a set amount to keep a person alive for a short time would also be appropriate. We have finite resources to be spread out among everyone in the system. If we focus on an individual at the expense of the group, we cause far more damage that we prevent. In health care matters, we need a teleological utilitarian ethic. Even some modern deontologists allow for a 'Principle of Permissible Harm'. Spend our finite resources first where they will cause the greatest increase in quality-adjusted life-years working. That will make the system much stronger and sustainable for the future. Our current system is not sustainable, and is killing more future life-years than it saves now.

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Friday, September 11, 2009

Obama's Health Care Reform Speech

I'll just try to comment on his speech briefly.

It is a bit overreaching for Obama to be determined to be the last president to try to reform health care. We have no idea what the needs of America will be in fifty years. We will need constant monitoring, evaluation, and reform in order to adapt to future needs.

Over half of US personal bankruptcies are due to medical bills. Employer-provided health insurance (subsidized by the government) has been and is a bad idea. It is hard for US companies to compete internationally, and good American citizens get screwed if they are laid off or self-employed. Small businesses are over-burdened if forced to provide insurance, and the employees suffer either way. Trying to buy insurance individually strips away negotiating leverage and further hurts people.

America takes less care of its citizens than any other major nation. Not only has the government dropped the ball on taking care of everyone, but it lets insurance companies use techniques like rescission to exploit citizens. Obama is calling out our nation, an arrogant nation that likes to believe it is the best, on its cruelty and heartlessness towards its own members.

Obama correctly points out that we all pay more when the uninsured and underinsured end up in the emergency rooms for trivial problems, or major problems that could have been prevented by cheaper basic care. We pay more money as a country for pathetic health outcomes. What he doesn't go into are the details about that: our high payments for cancer treatments and whatnot to extend people's lives just a little instead of focusing on paying for basic and preventative care that would extend more people's lives by a lot. That would raise more "grandma-killing" nonsense, but it really is a great waste that hurts our whole nation. Is baby-killing better? Or worker-killing? Medicare and Medicaid costs are so bad because we provide expensive treatments to people who are going to die anyway, and we enable people with chronic illnesses like diabetes to not minimize their problems. When we can accept the fact of death for the elderly (the private insurance companies actually do have Death Panels, and they're effective at denying care to anyone), and get people to take the barest responsibility for themselves, costs will drastically drop. We also need to cut down on drugs as a whole culture. Pharmaceutical pill-pushing is costly, damaging, and out of control.

Single-payer systems are great, but not the only good solution. Making individuals buy private insurance is a terrible idea. The insurance companies would love that windfall.

The Republican party is united. That is their great strength. Unfortunately, they unite behind terrible ideas. The Democrats, instead of being blind sheep and puppets, like to think for themselves. This strength allows for creativity and progress. This unfortunately leads to many different ideas, such that even when these ideas are good, they split the votes and lead to conflicts that ultimately allow the Party of No to succeed.

Finally, the meat and potatoes.
1) Enrollment in the public plan is optional if you have other insurance.
This is good. It will be healthy for private insurers to have to compete. Right now they have virtual monopolies in most of the country. People get to choose what they like (this is not always good because insurance plans can be hard to understand, and people are manipulated by advertisements). It is great to make health insurance mandatory. This will reduce waste due to ER visits, and reduce financial hardships for those who have sudden medical needs but didn't have insurance. Unfortunately, there is a hardship waiver for people who still can't afford the premiums. This is where the feds should just pay the premium, but later Obama says that he won't allow that. Hopefully Medicaid will take up anyone who can't afford the public plan premium.

2) Rescission is illegal for everyone.
This is good. People can have more security.

3) Federally mandated cap on out-of-pocket expenses.
This is interesting. I assume that the cap will depend on a person's income, and not be the same for everyone. This will raise premiums for everyone.

4) Federally mandated coverage for routine check-ups and preventative care.
This is probably very good. He mentions tests for cancer, and that worries me. Some cancer tests are very expensive and/or have high false-positive rates, leading to much dangerous, expensive, and unnecessary treatment. I'm especially thinking of prostate cancer. Overall, though, it will be good to regularly tell more people that they need to lose weight, eat better, stop smoking, etc... I hope this doesn't just give doctors more opportunities to prescribe unnecessary drugs.

5) Public plan for anyone.
This is great, if it is affordable. COBRA is absurdly expensive, especially since it's offered to people who just became unemployed! This will definitely help small businesses and self-employed persons, too. No one can be denied for existing conditions.

6) Here Obama talks about an insurance marketplace. It seems like items 2-4 above would only apply to insurance companies who want to participate in the marketplace. Earlier, it sounded like those rules would apply to everyone, but now it seems like they only apply to private insurers who compete for the customers in the public plan pool. That's good incentive for working people to quit their company plan and join the public plan, but maybe only if company plans lose their tax breaks so the true costs are apparent.

7) No coverage for illegal immigrants.
If you want American services, become an American.

8) No federal money for abortions.
Someone said to me that the public plan can still cover abortions because it will be fully funded by premiums, and not federal money. I am not sure about that. It still sounds like the government would pay 900 billion dollars over a decade for the plan, but expects to get that money back from premiums. Obama didn't say he wouldn't spend federal money on the plan. He only said it wouldn't increase the deficit. It is important for the plan to not spend federal money on abortions because the plan would get shot down.

9) Conscience laws still apply.
These are terrible laws that protect health professionals who refuse to do their jobs.

It is not clear to me what incentive insurance companies have to participate in the exchange. This plan says it will have low premiums, but also provide far more services to a group of people likely to have more health problems. Though there is a lot of waste and inefficiency and advertising in other insurance companies, I still do not see how this plan will work. What is offers is going to be expensive. New customers would only be profitable if they pay in more than they cost, and I am skeptical.

If it really would work, I'll sign up. I would love to have the health plan Obama describes. If I felt a need for additional coverage, I am sure a private insurer will have options available to supplement me.

Obama also proposes experimenting (hooray!) in several areas to see if malpractice reform would be helpful. This is something that I already think would be helpful, for the same reasons that Obama wants to try it, and the experimentation would help prove whether it is or not. I am very happy about that.

So, there are some good ideas there, and I am excited about some of them, but I am also skeptical that it will work out as described. We definitely do need reform. Our current system is terrible. Almost any implementation of this plan would be an improvement over what we have, but I think it is likely that it will not meet expectations, and that failure will be used in the future to oppose more needed reform, and against good politicians.

Thursday, September 10, 2009

The Best Plan for America - Part 3

When we've reformed campaign financing, letting us end corn subsidies, we can get to the task of reforming tort laws and malpractice resolution processes.

3) Stop frivolous lawsuits against hospitals and doctors.
Why can suing doctors and hospitals be bad? It leads to doctors running unnecessary tests and performing unnecessary procedures and prescribing unnecessary drugs so that they can't be accused of not trying everything. These unnecessary tests and treatments can cause problems for a patient (side-effects, infections), and increase health costs. When costs go up, people with less money are rationed out of health care. Also, over use of these services creates delays, making people who need them wait, perhaps too long. Where lawsuits are common (Pennsylvania), malpractice insurance rates go up, which also increases the cost of proving care, and drives doctors away, which reduces the availability of good care. Hospitals need to hold larger amounts of money in reserve in case they get sued, which is money that could otherwise be used to improve care for patients.

But what if something bad happens because of a doctor's decision? Well, that's not exactly what malpractice is. We live in a very complex system, and have complex bodies with complex problems. There are hardly any treatments that work 100%, and sometimes bad things happen even when all the correct decisions were made given the available information. Doctors and hospitals should absolutely be protected from lawsuits if they can demonstrate that they followed known best practices. Rogue doctors who make decisions based on their feelings or personal experience instead of the collected empirical data of their fields can go hang.

Even when a doctor does do something wrong, the money involved should be more reasonable. Payouts are sometimes so ridiculously large (which hurts the entire system, remember, and not just the one doctor) that malpractice insurance companies often choose to settle for smaller amounts instead of going to court. This happens even when the doctor is innocent. So, we end up with a bunch of doctors being denied the opportunities to prove their innocence because an insurance company doesn't want to risk a big payout. These settlements are strikes against innocent doctors, and affect their abilities to get jobs, and can even result in licensure problems. If payouts were limited to reasonable amounts, the system would be more conducive to actually determining whether a doctor did something wrong, instead of settling with opportunists who sue at the drop of a hat.

By making it more difficult and less profitable to sue, we improve the entire system. Treatment becomes more accessible to those who need it, costs go down, overall outcomes improve, we can more often actually learn which doctors did something wrong and which were frivolously accused, and we encourage evidence-based medicine instead of defensive medicine. The only people who would really suffer are lawyers.

Wednesday, September 9, 2009

The Best Plan for America - Part 2

So, the first step was campaign finance reform, taking away some of the incentive for politicians to pander to big companies instead of the health of our nation. Once that's out of the way, we can target another big systemic issue.

2) Stop subsidizing corn.
A big reason that America has such bad health outcomes compared to all those other industrialized countries that pay less for health care is that Americans are fat. Fat, lazy Americans eating lots of meat and drinking soda get those really expensive chronic illnesses like diabetes and hypertension. This raises costs for everyone, since we're in this system together. A major reason that so many people eat meat and sweets is that those foods are so cheap. An apple costs more than a candy bar. Juice costs more than soda (juice is also high in calories, but fructose is easier on your pancreas than dextrose). Also, impulsive and ignorant people would rather get fast food or some other form of processed junk than take half an hour to cook. Cooking healthy food can actually be very inexpensive, but it takes a little time, and most Americans would rather do something else.

So, how would ending corn subsidies lead to healthier eating? American corn is produced in far greater quantities than needed because the feds pay the big farm conglomerates to do it. There is so much unnecessary corn that the price is very low to buy it. Since it's so cheap, it gets fed to chickens, pigs, and cows to get them big and fat at a low cost. It also gets turned into corn syrup to keep our sodas and candy cheap (the price of sugar is artificially increased in America by federal tariffs on sugar imports, keeping down competition with corn). So, heavily because of this one crop subsidy, meat and sweets are very cheap and plentiful in the US.

There are other consequences. Since so many fields get devoted to corn (which does not require crop rotation like some other crops), less of other crops are grown that are not subsidized. More corn for animals and sweets (and fuel) results in fewer carrots and spinach and peas for humans. A smaller supply of those healthy foods for people means that they cost more.

So, ending the corn subsidy would make meat and sweets more expensive, and probably other healthy foods cheaper and more prevalent. There would be an economic incentive for people to eat food that is better for them, and restaurants would serve smaller portions of meat to keep costs low. Diabetes and heart disease rates, etc..., would fall, and life spans would increase again.

Animals might get switched to a different food, which would then be taken from humans, but I don't know what that would be. There would be other effects of the change, as well.

If the price of corn went up to the same level as that of other countries that do not subsidize (Mexico), those countries would stop importing the poor-tasting, standardized, potentially dangerous American corn that is wiping out their indigenous corn strains and making them slaves to the entirely unethical Monsanto. More expensive American corn would lead to more preservation of genetically diverse corn, which would protect our global supply from disease or insect. It would also let "heirloom" corn strains compete, which taste better and are safer to eat.

Tuesday, September 8, 2009

The Best Plan for America - Part 1

When I walk down the street, people often ask me, "Hey, old man, why aren't you wearing any pants?" Only slightly less often than that, they ask me what the best health care plan would be for America. The best plan is complicated, but not as complicated as many people think. Unfortunately, the best plan requires many changes to other aspects of our government and culture. Over time, I will gradually explain what would be the best health care plan for our country, and what it would take to get it.

1) Campaign Finance Reform
The necessary first step would be campaign finance reform. What does campaign finance reform have to do with health care? Very simply, the current system lets big companies control our nation's policies via legalized bribes to congressmen. The average citizen is practically unable to voice his or her needs to representatives. Our voices are drowned out by the sound of money getting transferred from corporations to politicians' campaign chests.

As we can see right now, it is nearly impossible to get enough politicians to serve the interests of the country instead of the interests of their financiers. If politicians could no longer be bought by corporations, we could have a government that serves the people. Instead of looking out for the interests of only Aetna's and Pfizer's shareholders, congress would look out for the other 300,000,000 of us.

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Tuesday, September 1, 2009

Grab Bag 1

Here's just a bunch of topics I've pulled aside and not gotten around to posting.

Teen pregnancy and STD rates got worse under G.W.Bush's watch, especially in the South. No surprises, there. When you take money away from programs that work and give it to programs that don't work, the outcomes suffer. When you have a culture that uses evidence-based practices, you see returns on your investments.

Putting stents in arteries may be unnecessarily done 240,000 times per year. Dr. Teirstein is an obvious example of the big problem with many doctors. He is biased towards something he has experience with and makes a fortune from, which leads him to discount real research. He doesn't care what really works best for people. He doesn't want to be told what to do. He wants to do what he likes and effectively defraud insurers. Fee for service is a terrible way to pay doctors. We need fee for outcomes. They need to be accountable.

Stupid Americans will not vote for politicians who would actually make the best decisions for our country. Rationing is not bad. Every health system has rationing. In fact, every system that involves money or resources has rationing. It's a fact of life. Get over it. Right now, insurance companies ration the Hell out of people's health care, and the uninsured get nothing at all. The British system is brilliant. The British try to make sure they get the most pop for the pound. With finite resources, they try to do the most good that they can for everyone. Only complete idiots would take the American route and deprive children and workers from basic care while spending the bulk of resources on people who are going to die soon. Also in this article is the idea that we should find out what treatments work best in which situations, then NOT require doctors to use that information. I sure as Hell want my doctors to do what's been shown most effective instead of whatever else they feel like.

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