Health care's weak reforms (HEALTH CARE REFORM, 2009)
Nov 3, 2009
Dr. Bob, I am a student and am currently uninsured. Considering that the fact that there are several people in my position, how can you be so supportive of the democratic party and their weak reforms to the financing of the United States health care system. I recently heard that the estimated impact of the public insurance policy on the financing of health care in this country will equal two percent of the population by 2019. This seems to indicate that if we leave the possibility of creating a national health care program up to the dems it may never occur in our lifetimes. How can you be such an ardent supporter of this party, we need to support real reformers and transformational leaders like Ralph Nader and Bernie Sanders, who would really make the system work for people, not the corporate democrats.
Response from Dr. Frascino
I understand your frustrations and agree the current health care reform bills making their way through Congress are far from ideal. Personally, I would have opted for a single payer system. That said, there is also reality to deal with. No doubt you've seen the fierce opposition by Republicans to any health care reform. And there is the wealthy insurance industry lobby spending millions of dollars to confuse and scare people away from health care reform. With these realities, the current health care reform package is probably the most we can realistically accomplish at this time. It's also a giant step in the right direction. Idealism is fine, but the uninsured need coverage now, even if it's less than ideal. (See below.)
After Reform Passes October 26, 2009 OP-ED COLUMNIST By PAUL KRUGMAN, New YorkTimes
So, how well will health reform work after it passes?
There's a part of me that can't believe I'm asking that question. After all, serious health reform has long seemed like an impossible dream. And it could yet go all wrong.
But the teabaggers have come and gone, as have the cries of "death panels" and the demonstrations by Medicare recipients demanding that the government stay out of health care. And reform is still on track. Right now it looks highly likely that Congress will, indeed, send a health care bill to the president's desk. Then what?
Conservatives insist (and hope) that reform will fail, and that there will be a huge popular backlash. Some progressives worry that they might be right, that the imperfections of reform what we're about to get will be far from ideal will be so severe as to undermine public support. And many critics complain, with some justice, that the planned reform won't do much to contain rising costs.
But the experience in Massachusetts, which passed major health reform back in 2006, should dampen conservative hopes and soothe progressive fears.
Like the bill that will probably emerge from Congress, the Massachusetts reform mainly relies on a combination of regulation and subsidies to chivy a mostly private system into providing near-universal coverage. It is, to be frank, a bit of a Rube Goldberg device a complicated way of achieving something that could have been done much more simply with a Medicare-type program. Yet it has gone a long way toward achieving the goal of health insurance for all, although it's not quite there: according to state estimates, only 2.6 percent of residents remain uninsured.
This expansion of coverage has tremendous significance in human terms. The Kaiser Commission on Medicaid and the Uninsured recently did a focus-group study of Massachusetts residents and reported that "Health reform enabled many of these individuals to take care of their medical needs, to start seeing a doctor, and in some cases to regain their health and control over their lives." Even those who probably would have been insured without reform felt "peace of mind knowing they could obtain health coverage if they lost access to their employer-sponsored coverage."
And reform remains popular. Earlier this year, many conservatives, citing misleading poll results, claimed that public support for the Massachusetts reform had plunged. Newer, more careful polling paints a very different picture. The key finding: an overwhelming 79 percent of the public think the reform should be continued, while only 11 percent think it should be repealed.
Interestingly, another recent poll shows similar support among the state's physicians: 75 percent want to continue the policies; only 7 percent want to see them reversed.
There are, of course, major problems remaining in Massachusetts. In particular, while employers are required to provide a minimum standard of coverage, in a number of cases this standard seems to be too low, with lower-income workers still unable to afford necessary care. And the Massachusetts plan hasn't yet done anything significant to contain costs.
But just as reform advocates predicted, the move to more or less universal care seems to have helped prepare the ground for further reform, with a special state commission recommending changes in the payment system that could contain costs by reducing the incentives for excessive care. And it should be noted that Hawaii, which doesn't have universal coverage but does have a long-standing employer mandate, has been far more successful than the rest of the nation at cost control.
So what does this say about national health reform?
To be sure, Massachusetts isn't fully representative of America as a whole. Even before reform, it had relatively broad insurance coverage, in part because of a large union movement. And the state has a tradition of strong insurance regulation, which has probably made it easier to run a system that depends crucially on having regulators ride herd on insurers.
So national reform's chances will be better if it contains elements lacking in Massachusetts in particular, a real public option to keep insurers honest (and fend off charges that the individual mandate is just an insurance-industry profit grab). We can only hope that reports that the Obama administration is trying to block a public option are overblown.
Still, if the Massachusetts experience is any guide, health care reform will have broad public support once it's in place and the scare stories are proved false. The new health care system will be criticized; people will demand changes and improvements; but only a small minority will want reform reversed.
This thing is going to work.
OUR HEALTHCARE SYSTEM IS FAIR, DON'T LET OBAMA MESS IT UP!!!!! Sep 20, 2009 Dr. Bob,
I dont trust Obama. Im a red-blooded American and I think our health care system is fair and that insurance companies have the right to make a buck. Folks who need or want insurance should just go out and buy some the way I did. Lets not try to fix a system that isnt broke.
Response from Dr. Frascino
Hello Red Blooded American,
Do you really believe that folks who want or need insurance "should just go out and buy some?"
I'm amazed that you don't trust what Obama is trying to do. What he's trying to do is provide health care for all. This is really a moral issue. Please see the Nicholas Kristof article below. If you still believe our health care system is not broken, then you are choosing to ignore fact and reality. I urge you to rethink your position. It's the moral thing to do.
September 13, 2009 OP-ED COLUMNIST
The Body Count at Home
By NICHOLAS D. KRISTOF, New York Times
In the debate over health care, here's an inequity to ponder: Nikki White would have been far better off if only she had been a convicted bank robber. Nikki was a slim and athletic college graduate who had health insurance, had worked in health care and knew the system. But she had systemic lupus erythematosus, a chronic inflammatory disease that was diagnosed when she was 21 and gradually left her too sick to work. And once she lost her job, she lost her health insurance. In any other rich country, Nikki probably would have been fine, notes T. R. Reid in his important and powerful new book, "The Healing of America." Some 80 percent of lupus patients in the United States live a normal life span. Under a doctor's care, lupus should be manageable. Indeed, if Nikki had been a felon, the problem could have been averted, because courts have ruled that prisoners are entitled to medical care. As Mr. Reid recounts, Nikki tried everything to get medical care, but no insurance company would accept someone with her pre-existing condition. She spent months painfully writing letters to anyone she thought might be able to help. She fought tenaciously for her life. Finally, Nikki collapsed at her home in Tennessee and was rushed to a hospital emergency room, which was then required to treat her without payment until her condition stabilized. Since money was no longer an issue, the hospital performed 25 emergency surgeries on Nikki, and she spent six months in critical care. "When Nikki showed up at the emergency room, she received the best of care, and the hospital spent hundreds of thousands of dollars on her," her step-father, Tony Deal, told me. "But that's not when she needed the care." By then it was too late. In 2006, Nikki White died at age 32. "Nikki didn't die from lupus," her doctor, Amylyn Crawford, told Mr. Reid. "Nikki died from complications of the failing American health care system." "She fell through the cracks," Nikki's mother, Gail Deal, told me grimly. "When you bury a child, it's the worst thing in the world. You never recover." We now have a chance to reform this cruel and capricious system. If we let that chance slip away, there will be another Nikki dying every half-hour. That's how often someone dies in America because of a lack of insurance, according to a study by a branch of the National Academy of Sciences. Over a year, that amounts to 18,000 American deaths. After Al Qaeda killed nearly 3,000 Americans, eight years ago on Friday, we went to war and spent hundreds of billions of dollars ensuring that this would not happen again. Yet every two months, that many people die because of our failure to provide universal insurance and yet many members of Congress want us to do nothing? Mr. Reid's book is a rich tour of health care around the world. Because he has a bum shoulder, he asked doctors in many countries to examine it and make recommendations. His American orthopedist recommended a titanium shoulder replacement that would cost tens of thousands of dollars and might or might not help. Specialists in other countries warned that a sore shoulder didn't justify the risks of such major surgery, although some said it would be available free if Mr. Reid insisted. Instead, they offered physical therapy, acupuncture and other cheap and noninvasive alternatives, some of which worked pretty well. That's a window into the flaws in our health care system: we offer titanium shoulder replacements for those who don't really need them, but we let 32-year-old women die if they lose their health insurance. No wonder we spend so much on medical care, and yet have some health care statistics that are worse than Slovenia's. My suggestion for anyone in Nikki's situation: commit a crime and get locked up. In Washington State, a 20-year-old inmate named Melissa Matthews chose to turn down parole and stay in prison because that was the only way she could get treatment for her cervical cancer. "If I'm out, I'm going to die from this cancer," she told a television station. Mr. and Mrs. Deal say they are speaking out because Nikki wouldn't want anyone to endure what she did. "Nikki was a college-educated, middle-class woman, and if it could happen to her, it can happen to anyone," Mr. Deal said. "This should not be happening in our country." Struggling to get out the words, Mrs. Deal added: "The loss of a child is the greatest hurt anyone will ever suffer. Because of the circumstances she endured with the health care system, I lost my daughter." Complex arguments are being batted around in this health care debate, but the central issue isn't technical but moral. The first question is simply this: Do we wish to be the only rich nation in the world that lets a 32-year-old woman die because she can't get health insurance? Is that really us?
HOW CAN YOU SUPPORT SOCIALIZED MEDICINE?????? Sep 5, 2009
How can you of all people support socialized medicine. It scares the hell out of me.
Response from Dr. Frascino
"Socialized medicine" is a propaganda term dreamed-up by insurance companies and right-wing lunatics to try and scare folks into rejecting any kind of healthcare reform. If your house was on fire would you be worried about "socialized firefighters" coming to put out the blaze? Or if you are the victim of a violent crime, will you shun "socialized policemen" who come to your rescue? These programs are government run! The government also runs part of our current healthcare system: Medicare and the Veterans Affairs Medical Program. See the columns by Nicholas Kristof from the New York Times below. Hopefully, you'll find them enlightening!
September 3, 2009, OP-ED COLUMNIST
Health Care That Works
By NICHOLAS D. KRISTOF, New York Times
Here's a paradox.
Health care reform may be defeated this year in part because so many Americans believe the government can't do anything right and fear that a doctor will come to resemble an I.R.S. agent with a scalpel. Yet the part of America's health care system that consumers like best is the government-run part. Fifty-six to 60 percent of people in government-run Medicare rate it a 9 or 10 on a 10-point scale. In contrast, only 40 percent of those enrolled in private insurance rank their plans that high. Multiple surveys back that up. For example, 68 percent of those in Medicare feel that their own interests are the priority, compared with only 48 percent of those enrolled in private insurance. In truth, despite the deeply ingrained American conviction that government is bumbling when it is not evil, government intervention has been a step up in some areas from the private sector. Until the mid-19th century, firefighting was left mostly to a mishmash of volunteer crews and private fire insurance companies. In New York City, according to accounts in The New York Times in the 1850s and 1860s, firefighting often descended into chaos, with drunkenness and looting. So almost every country moved to what today's health insurance lobbyists might label "socialized firefighting." In effect, we have a single-payer system of public fire departments. We have the same for policing. If the security guard business were as powerful as the health insurance industry, then it would be denouncing "government takeovers" and "socialized police work." Throughout the industrialized world, there are a handful of these areas where governments fill needs better than free markets: fire protection, police work, education, postal service, libraries, health care. The United States goes along with this international trend in every area but one: health care. The truth is that government, for all its flaws, manages to do some things right, so that today few people doubt the wisdom of public police or firefighters. And the government has a particularly good record in medical care. Take the hospital system run by the Department of Veterans Affairs, the largest integrated health system in the United States. It is fully government run, much more "socialized medicine" than is Canadian health care with its private doctors and hospitals. And the system for veterans is by all accounts one of the best-performing and most cost-effective elements in the American medical establishment. A study by the Rand Corporation concluded that compared with a national sample, Americans treated in veterans hospitals "received consistently better care across the board, including screening, diagnosis, treatment and follow-up." The difference was particularly large in preventive medicine: veterans were nearly 50 percent more likely to receive recommended care than Americans as a whole. "If other health care providers followed the V.A.'s lead, it would be a major step toward improving the quality of care across the U.S. health care system," Rand reported. As for the other big government-run health care system in the United States, Medicare spends perhaps one-sixth as much on administration as private health insurers, although the comparison is imperfect and controversial. But the biggest weakness of private industry is not inefficiency but unfairness. The business model of private insurance has become, in part, to collect premiums from healthy people and reject those likely to get sick or, if they start out healthy and then get sick, to find a way to cancel their coverage. A reader wrote in this week to tell me about a colleague of hers who had health insurance through her company. The woman received a cancer diagnosis a few weeks ago, and she now faces chemotherapy co-payments that she cannot afford. Worse, because she is now unable to work and has to focus on treatment, she has been shifted to short-term disability for 90 days and after that, she will lose her employer health insurance. She can keep her insurance if she makes Cobra payments on her own, but she can't afford this. In her case, her company will voluntarily help her but I just don't understand why we may be about to reject health reform and stick with a dysfunctional system that takes away the health coverage of hard-working Americans when they become too sick with cancer to work. On my blog, foreigners regularly express bewilderment that America may reject reform and stick with a system that drives families into bankruptcy when they get sick. That's what they expect from the Central African Republic, not the United States. Let's hope we won't miss this chance. A public role in health care shouldn't be any scarier or more repugnant than a public fire department.
HEALTH CARE REFORM, WON'T IT BE BAD FOR HIV POSITIVE PEOPLE? Sep 2, 2009
Dr. Bob, Why are you pushing Obama's health care reform? They are going to take over medical care, cut care to elderly folks like grandmothers and have panels to decide who lives and dies. I'm sure they will cut care to those of us with HIV cause it is expensive to treat us. Shouldn't we try to block such rationing of health care? Zelda
Response from Dr. Frascino
Health care reform will not throw your granny off a cliff, nor will it cut off care to HIVers! In many ways we already have health care rationing that is not only unfair; it's morally reprehensible. (See Nicholas Kristof's article from the New York Times below.) It's time you turned off Fox News and stopped listening to the scare tactics of the insurance companies and rightwing wingnuts. Democrats, like Obama, have had to fight for every dollar in the AIDS Drug Assistance Plan (ADAP) and Ryan White Fund. Don't be fooled by the myths, lies and hype. Health care reform is desperately needed.
Until Medical Bills Do Us Part
By NICHOLAS D. KRISTOF, Op-Ed Columnist New York Times, August 30, 2009
Critics fret that health care reform would undermine American family values, not least by convening somber death panels to wheel away Grandma as if she were Old Yeller.
But peel away the emotions and fearmongering, and in fact it is the existing system that unnecessarily takes lives and breaks apart families.
My friend M. you'll understand in a moment why she's terrified of my using her name had to make a searing decision a year ago. She was married to a sweet, gentle man whom she loved, but who had become increasingly absent-minded. Finally, he was diagnosed with early-onset dementia.
The disease is degenerative, and he will become steadily less able to care for himself. At some point, as his medical needs multiply, he will probably need to be institutionalized.
The hospital arranged a conference call with a social worker, who outlined how the dementia and its financial toll on the family would progress, and then added, out of the blue: "Maybe you should divorce."
"I was blown away," M. told me. But, she said, the hospital staff members explained that they had seen it all before, many times. If M.'s husband required long-term care, the costs would be catastrophic even for a middle-class family with savings.
Eventually, after the expenses whittled away their combined assets, her husband could go on Medicaid but by then their children's nest egg would be gone, along with her 401(k) plan. She would face a bleak retirement with neither her husband nor her savings.
A complicating factor was that this was a second marriage. M.'s first husband had died, leaving an inheritance that he had intended for their children. She and her second husband had a prenuptial agreement, but that would not protect her assets from his medical expenses.
The hospital told M. not to waste time in dissolving the marriage. For five years after any divorce, her assets could be seized precisely because the government knows that people sometimes divorce husbands or wives to escape their medical bills.
"How could I divorce him? I loved him," she told me.
"I explored a lot of options with an attorney here in town," she added. "The attorney said, 'I don't see any other options for you.' It took about a year for me to do the divorce, it was so hard."
So M. divorced the man she loves. I asked him what he thought of this. He can still speak, albeit not always coherently, and he paused a long, long time. All he could manage was: "It's hard to say."
Long-term care constitutes a difficult and expensive challenge in any health system. But the American patchwork, full of cracks through which people fall, has a special problem with medical expenses of all kinds bankrupting couples.
A study reported in The American Journal of Medicine this month found that 62 percent of American bankruptcies are linked to medical bills. These medical bankruptcies had increased nearly 50 percent in just six years. Astonishingly, 78 percent of these people actually had health insurance, but the gaps and inadequacies left them unprotected when they were hit by devastating bills.
M. still helps her husband and, quietly, continues to live with him and care for him. But she worries that the authorities will come after her if they realize that they divorced not because of irreconcilable differences but because of irreconcilable medical bills. There were awkward questions from friends who saw the divorce announcement in the newspaper.
"It's just crazy," she said. "It twists people like pretzels."
The existing system doesn't just break up families, it also costs lives. A 2004 study by the Institute of Medicine, a branch of the National Academy of Sciences, found that lack of health insurance causes 18,000 unnecessary deaths a year. That's one person slipping through the cracks and dying every half an hour.
In short, it's a good bet that our existing dysfunctional health system knocks off far more people than an army of "death panels" could even if they existed, worked 24/7 and got around in a fleet of black helicopters.
So, for those of you inclined to believe the worst about President Obama, think it through. Suppose he is indeed a secret, foreign-born Muslim agent who is scheming to undermine American family values while killing off as many grandmothers as possible.
If all that were true, why on earth would he be trying so hard to reform our health care system? We already know how to prod families into divorce and take a life unnecessarily every 30 minutes all we need to do is reject reform and stick with exactly what we have.
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