A Trip to the Cardiologist, A Lipitor Future, and “Why Doesn’t My Health Insurer Want Me to Know if I’m Likely To Have a Heart Attack?”

I visited with a cardiologist last week. My inadvertent but no less harmful dalliance with two different kinds of drain cleaner having set off an entire chain of long past due check-ups. A little more than two years shy of fifty, I listened intently as I was told that although I had had a good run, a diet composed of grease, chocolate, quick carbs, coffee and unfiltereds was simply not going to cut it as I ventured into the last half of life (last third is more likely, but also more painful to consider– and I suppose for the doctor, harder to say).

I now look forward to a battery of tests. The first, done today, is designed to detect artery calcification: “Coronary calcium is specific for atherosclerotic plaque and can be detected with high sensitivity and accurately quantified by computed tomography (CT) to help predict future cardiac events related to coronary artery disease.” I had to pay for the test out of pocket as it seems my insurance company deems such screening unworthy of coverage– despite the tests highly vaunted predictive power. Quite a few people in this country die each year from heart disease–hard to understand how it wouldn’t be worth the $318 to know who was vulnerable–and if unchecked, destined for the very expensive Intensive Care Unit.

Tomorrow brings an echocardiogram and my first ever stress test. I readily assented to the tests as it is good, I suppose, to know where one stands. But in addition to testing and making dietary changes, the doctor also wants me to start taking Lipitor. A statin prescribed to lower cholesterol. I did not react well.  The prescription it seems is, in more than one sense, a life sentence.

And I am generally suspicious of the pharma zeitgeist. And terribly so as it concerns myself.

The prescription is not, in this instance, a treatment for an acute condition, it treats the endemic. If one has risk factors, it is prophylactic and is prescribed to reduce the risk of heart attack, stroke and other heart diseases. It is doubtful whether once I start taking this drug I will ever stop. There is no foreseeable time (while alive) that I will wish to stop reducing the risk of heart attack or stroke. And that I suppose is the essence of the onset of age– piling up prescriptions. A daily regimen that will follow one to the grave–only the dosages or the brand names changing as each day welcomes a regimen of pills. In short, this prescription feels like the onset of dependence. The forward guard, if you will. A harbinger of a pharmaceutical future.

Seeing my, shall we say, chagrin, the cardiologist told me that, like over 50% of the cardiologists he knows, he takes a statin. “We’ve seen the data.” Another recently told me  “Yeah, I take it. They should put it in the water.”

And so I will take this drug. But I am not happy. I am loath to think of myself in these terms. Only 12 or so years ago I played starting defensive tackle on a semi-pro football team. Soon I will be discussing my cholesterol numbers and God only knows what other numerical health indicators at cocktail parties.

The essence of good health is simply not having to think about it. It is not an issue. I have to think about it now. And I have a sneaking suspicion, that like when I first became a parent, the terms of my existence have just changed.

UPDATE

Photo credit to incurable_hippie.

Access to HIV/AIDS Medicines

The Campaign for Access to Essential Medicines explains why UNITAID’s efforts to develop a patent pool of HIV/AIDS treatments are so important:

Meanwhile, the US health care finance system appears to be getting into a bit of a standoff with HIV/AIDS drug makers:

Without reliable access to the medications, which cost patients in the AIDS Drug Assistance Program an average of $12,000 a year, people with H.I.V. are more likely to develop full-blown AIDS, transmit the virus and require expensive hospitalizations. Eleven states have closed enrollment in the federal program, most recently Florida, which has the nation’s third-largest population of people with H.I.V.

The need for programs like the Health Impact Fund is more urgent than ever.

Veterans, Health Care and the VA

Consider this a follow-up to my Memorial Day post on Veterans & Health Care. There’s an interesting article over at GoozNews regarding health care for veterans at the VA. Goozner writes:

Journalist Phil Longman at the New American Foundation recently updated his book “Best Care Anywhere,” which documents the 1990s rejuvenation of the Veterans Administration’s health care system. Between editions, the wars in Iraq and Afghanistan placed strains on the VA not seen since Vietnam. Here’s his thoughts on the current state of the system, and the lessons its transformation holds for other delivery systems in the U.S.

How does contact with the VA healthcare system compare in terms of
medical outcomes for its patients? How about in other measures of
quality?

In study after study published in peer‐reviewed journals, the VA beats other health care providers on virtually every measure of quality. These include patient safety, adherence to the protocols of evidence medicine, integration of care, cost‐effectiveness, and patient satisfaction. The VA is also on the leading edge of medical research, due to its close affiliation with the nation’s leading medical schools, where many VA doctors have faculty positions. The VA has its problems, but compared to those found elsewhere in the U.S. health care system, it offers “Best Care Anywhere.”

Read more

Veterans & Health Care

As we come upon Memorial Day, it is fitting that we take a moment to consider health care and veterans. We are, after all, a Nation at war. And we have been at war now for closing in on a decade; the casualties mount. As of May 28, 2010 the Department of Defense official number for American deaths is 5,480. My own research experience with official DoD representations in Seton Hall Law’s world renowned GTMO Reports leaves me somewhat skeptical as to the numbers (I cannot tell, for instance, whether post-service and/or inactive reserve veteran suicides are included in this number, but suspect they are not: “There is no epidemic in suicide in VA,” Dr. Ira Katz, the VA’s head of Mental Health told CBS News in November. “But in this e-mail to his top media adviser, written two months ago, Katz appears to be saying something very different, stating: ‘Our suicide prevention coordinators are identifying about 1,000 suicide attempts per month among veterans we see in our medical facilities’” ). Having said that, as in the GTMO reports, we’ll take the government at its word. Not counting civilian contractors, in addition to 5,480 deaths, 37,865 are said to have been wounded. The ratio of wounds to death is approximately 7 to 1.

Such a high ratio of wounded to deaths is a feature of advancing medical technology. More of the injured are kept alive. A quick look at the ratios of deaths to wounded in other American wars witnesses a trend capped off with a precipitous jump.

War	Deaths	Wounded	Approx. Ratio
Civil War (Union only)	281,881	364,511	1 to .8
Spanish-American	2,446	1,662	1 to .7
WWI	116,516	204,002	1 to 1.8
WWII	405,399	671,846	1 to 1.7
Korea	36,913	103,284	1 to 2.8
Viet Nam	58,177	153,301	1 to 2.6
Iraq & Afghanistan	5,480	37,865	1 to 6.9

In modern warfare, through advances in medical technology, more lives are saved, more of the critically injured are kept alive; but it is also true that many of those lives saved have been affected by wartime trauma in often serious and debilitating ways. Many have lost limbs and sight and hearing, experienced traumatic brain injuries, and suffer from grave psychological harm. They do and will require care. We, as a Nation, committed to that care the moment we sent those men and women into harm’s way.

In his Memorial Day address, Secretary of Veterans Affairs, Edward K. Shineski, offered the following quote:

“Poor is the Nation that has no heroes, but beggared is the Nation that has and forgets them.”

This Memorial Day, as we honor those who gave their all in service of their country, let’s not forget our end of the bargain. The care for the families of the fallen and of disabled veterans is perhaps the most sacred contract of all. Men and women who risk their lives for their country have every right to expect that that country will help take care of them –and their families–to the utmost of its ability in the event that they are in some way hurt, disabled or deceased. We simply cannot ask of them to serve and risk if we are not there to help mend.

On May 5, 2005 President Barack Obama signed into law the Caregivers and Veterans Omnibus Health Services Act.

At signing the President said the following:

With this legislation, we’re expanding mental health counseling and services for our veterans from Afghanistan and Iraq, including our National Guardsmen and Reservists. We’re authorizing the VA to utilize hospitals and clinics outside the VA system to serve more wounded warriors like Ted with traumatic brain injury.

We’re increasing support to veterans in rural areas, with the transportation and housing they need to reach VA hospitals and clinics. We’re expanding and improving health care for our women’s veterans, to meet their unique needs, including maternity care for newborn children. And we’ll launch a pilot program to provide child care for veterans receiving intensive medical care.
We’re eliminating co-pays for veterans who are catastrophically disabled. And we’re expanding support to homeless veterans, because in the United States of America, no one who has served this nation in uniform should ever be living on the streets.

Finally, this legislation marks a major step forward in America’s commitment to families and caregivers who tend to our wounded warriors every day. They’re spouses like Sarah. They’re parents, once again caring for their sons and daughters. Sometimes they’re children helping to take care of their mom or dad.

These caregivers put their own lives on hold, their own careers and dreams aside, to care for a loved one. They do it every day, often around the clock. As Sarah can tell you, it’s hard physically and it’s hard emotionally. It’s certainly hard financially. And these tireless caregivers shouldn’t have to do it alone. As of today, they’ll be getting more of the help that they need.

If you’re like Sarah — and caring for a severely injured veteran from Afghanistan or Iraq — you’ll receive a stipend and other assistance, including lodging when you travel for your loved one’s treatment. If you need training to provide specialized services, you’ll get it. If you need counseling, you’ll receive it. If you don’t have health insurance, it will be provided. And if you need a break, it will be arranged — up to 30 days of respite care each year.

So today is a victory for all the veterans’ organizations who fought for this legislation. It’s a tribute to those who led the fight in Congress, including Senator and World War II vet Danny Akaka, and Senator Richard Burr; and in the House, Representatives Mike Michaud and Bob Filner. And I thank all the members of Congress who are joining us here today.

This law looks like a good step in the right direction. I’ve been highly critical in the past regarding the politics first agenda of a bickering and often, it seems, obstructionist Congress. Such was not the case here. As politics has absolutely no place in this discussion, I commend all involved for a job well done.

But if this legislation fails to make available needed services to veterans and their families, and you have experienced such personally, please consider Health Reform Watch open to you as a forum to make systemic shortcomings known to a wider audience.  I can be reached at michael.ricciardelli@shu.edu and I will work with you to publish your thoughts and experience as an article.

May God bless our troops and the families of those who have served.

An Update on the So-Called Young Invincibles: What Health Care Reform Does for Them

Last year I wrote about why the misconceptions about my generation, dubbed “young invincibles” by many, have perpetuated a belief that young people do not care about health insurance.  Thankfully, the health care reform legislators realized that we too, with our superpowers and all, prefer to be healthy and insured.

The most immediate benefit that dependent young people will see under the Patient Protection and Affordable Care Act is the ability to stay on their parents’ insurance until the age of 26; this will take effect in six months. For recent college graduates, and many who have chosen not to pursue a college education, this brings a sigh of relief. The bill also loosens the requirements for who qualifies as a dependent. Even for those who will be approaching 26 soon after the bill passes, the new age limit will afford some time to get coverage through a job with benefits. Marriage status may not necessarily restrict whether or not a child can stay on their parents insurance, as noted by young uninsured expert Sara Collins. Employed children may also qualify for the dependency status as long as they do not have the option of health insurance through their employer. The new bill also applies to all health plans, whether fully insured or self-funded, which was not the case under most state health care extensions to young people.

For those young people that will be 26 before this September, there are other options. The organization that helped esure representation of young people throughout the health care debate, aptly named Young Invincibles, provides a timeline of the other health reform bill measures that will offer help to the young uninsured. It also shows  when these provisions will take effect.

One of the main benefits to consider is that by 2014, more young people will qualify for Medicaid. This will help insure about 9 million young people. Young Invincibles co-founder Ari Matusiak finds that young people will be some of the greatest beneficiaries of the health care reform bill because the young population is currently the poorest of the age demographic groups and because the bill aims to make health care more affordable for those least able to afford it.

One of the other benefits young people will be afforded comes in the form of  tax credits to purchase insurance from the individual market. These are available to those individuals who earn less than $43,320. While the individual market is not the friendliest place to be, new reform measures will ensure that health care prices will not be based on pre-existing conditions and limits the ratio of premiums based upon age (down to 3:1).  The pre-existing condition restriction certainly helps those young people who have chronic conditions (about 15% of us.) Though the age rating restriction benefits older people more than young people, Ari Matusiak rightfully points out that young people are not going to be young forever and can appreciate the idea that we will have security of being able to get insurance without being discriminated against in the future.

Scare tactics are rearing their ugly head again, as many say that the new benefits offered to young people are just increased burdens. Yes, young people will be required to purchase insurance under the new reform bill or they will be subject to a penalty.  The fine will be $95 in 2014 and will gradually increase each year (until 2016, when it tops out at $695 or 2.5% of an individual’s annual income). Given this minimal penalty at the outset, many assume that young people will opt out of purchasing insurance and just pay the fine instead. These are the same people that think young people don’t care about feeling secure with health insurance.  Well, to put this succinctly, we do care. Some may, out of economic desperation, eschew coverage, but so many of us have relatives and friends who have had catastrophic health issues that have left them in debt (or further in debt), that the choice is not likely to be made lightly. We have had our own health issues.  We need prescription medicines and regular checkups. We are not invincible– and we know it.

A majority of us are supportive of the health reform bill.  As young people, we must educate ourselves about the health reform bill so that we know where we stand. We are an integral piece of the reform legislation working as planned.  And while we won’t be duped to do something that harms us more than helps us, we also won’t be beguiled into believing that the new health care legislation is not for us — it is for us– and we should reap its benefits as part of our political patrimony, knowing that in doing so we also help to provide for our posterity.

Who’s the New Guy? – Obama Announces Choice for Next CMS Director

President Obama has announced his choice for the position of director of the Centers for Medicare & Medicaid Services (CMS), Dr. Donald Berwick, a pediatrician, professor, and advocate of improving patient care.  The CMS has been without a permanent administrator since 2006.  Berwick, whose appointment must be approved by the Senate before he may assume the position, certainly has the credentials for the important role the CMS director will surely play in the coming years.  Still, whether Republican Senators will be basing their confirmation decision on credentials or resentment of health care reform’s passage is yet to be seen.

Berwick is best known for founding the Institute for Health Care Improvement.  The Institute for Health Care Improvement is a non-profit think tank that is dedicated to helping hospitals improve their patient care delivery.  As attested to by the Institute’s co-founder Dr. Paul Batalden, Berwick takes incremental approaches to improving patient care that are cost-effective and do not lead to the rationing of care.  For example, Berwick finds that reducing the prevalence of hospital-acquired infections through something as small as keeping medical equipment sterile can help to bring down the rate of medical errors.

Berwick is also a proponent of utilizing medical information sharing, and is often called blunt in regard to how he finds the American health care system inefficient in delivering patient care.  Additionally, Berwick has advocated for patient rights on numerous levels, using a philosophy of patient-centered medicine.  He wants doctors to be rewarded based on the health care outcomes of their patients instead of how many procedures a doctor has performed. Having a leader interested in implementing infrstructural changes which incentivize outcomes as opposed to procedures as paydays without regard to outcome, is, many think, a step in the right direction. It is also worth noting that Berwick himself will be taking more than a 66% pay cut if he is appointed as the director of the CMS.

While Berwick may not have functioned as the head of a health care system in his career, he is not new to the world of national health policy.  In 1998, he was on President Clinton’s advisory commission that recommended ways to reduce medical mistakes and ensure consumer protection in the American health care system.  And also served at that same time as  Chair of the agency that is now known as the Agency for Healthcare Research and Quality. Berwick has also played a part in improving Britain’s National Health Service, for which he was given an honorary knighthood by Queen Elizabeth II.

Since Obama’s health care overhaul “contemplates key roles for both programs in extending insurance coverage to 32 million people at a cost of $938 billion over 10 years,” if selected to be the CMS’s director, Berwick will certainly need to bring his A-game in helping change the way our current health care system consumes Medicare and Medicaid resources.  Many also hope that good Medicare reforms will start a trend, motivating private insurance companies to also make cost-saving changes.  Before that challenge, Berwick will have to get past a Senate confirmation.  Republican Senators are likely going to make the process a rigorous one, where they will grill Berwick on how exactly he plans to effect the new health care reform legislation.

Given the importance of the CMS and the fact that it currently has no director, it would behoove the Senate to quicken the process of Berwick’s selection, considering his credentials and commitment to the rights and needs of American patients.  As the Washington Post said, “supporters and opponents of the new health-care legislation ought to be able to agree that leaving the agency without a confirmed head is not healthy.”  The job needs to be filled, and instead of using political tactics through rehashing the health care reform debate, the Senate should focus on the many qualities that Berwick has to offer.

Health Reform, Women Helped Make It Happen

As I watched C-SPAN last Sunday afternoon, I found it inspiring that the health care legislation was being voted on in the House during Women’s History Month.  And to see the fight to passage being led by two amazingly powerful women, Speaker of the House Nancy Pelosi, and her right-hand woman Representative Louise Slaughter of New York, the milestone of health care reform became even more monumental for me. The commitment to health care reform by women leaders such as Pelosi and Slaughter led to the reconciliation bill’s passage on Sunday.

Nancy Pelosi, who is now being called “Lyndon Johnson in a skirt,” was vital in rallying needed Democratic votes last Sunday.  Pelosi held individual meetings with many of the swing-voters, reminding them of the importance of the bill.  In addition, many cite her persuasive skills in keeping the Obama Administration from ceding more to Republican demands.  Meanwhile on the floor of Capitol Hill, Louise Slaughter, a Congresswoman whose district serves Rochester, Niagara Falls, and Buffalo, NY, added a personal element of to reform as she called on other representatives to share stories of their constituents’ everyday issues with the current health care system.

Though some were said to be uncomfortable with the executive order which essentially reiterated the Hyde Amendment, there are a number of wins that women can point to, regardless of their stance regarding the executive order.  Women will have cheaper premiums since insurance companies can no longer practice gender rating.  They will have coverage for needed preventive care like mammograms and Pap smears.  In 2014, insurance companies will be required to cover maternity care, newborn care, and certain mental health care.  Also by 2014, health insurance companies will no longer be able to discriminate based on pre-existing conditions such as C-sections and past domestic abuse.  Women who are small business owners also stand to gain from the reform.  By 2014, small firms will be allowed to pool together in exchanges to purchase health insurance.

Though neither side was fully satisfied with the final bill, the fact that uninsured Americans will be guaranteed access to quality, affordable health care warrants an applause for those leaders who worked to make health care for all a reality.

Betting on Health Care Reform

At least investors think health care reform will be happening some time soon.  The Wall Street Journal reported that managed care stocks fell after Obama asked Congress to take an up or down vote Wednesday afternoon.  It might be wishful thinking (or dreadful, depending on which way you look at it) for the investors who are moving their investments from managed care plans.  With Congress members still treating health care reform as a game of cat and mouse, whether a vote will happen and whether the vote will be for reform is yet to be determined.

Take for instance Nathan Deal, a Republican from Georgia, who is purposely postponing his resignation from the House until a vote on health care happens so that he can get his nay vote in.  Then, there is the promise from Senate Republican leader Mitch McConnell to repeal health care reform before it has even been passed.  And despite Wall St. estimations to the contrary,  with the complications of reconciliation, the prospect of getting a bill that actually creates a mass exodus out of managed care seems at least somewhat iffy.

Interestingly, as the Washington Post revealed on Wednesday, private insurance companies, such as the infamous WellPoint, will be the primary beneficiaries of a failed health care reform attempt.  As Ezra Klien stated:

The argument is simple: Wellpoint’s business model is uncommonly concentrated in the individual and small-group markets. Those are the exact markets that health-care reform will drastically change. Those are the markets where people get rejected for preexisting conditions, where insurers spend 30 cents of every premium dollar on administration and where rate hikes are volatile and constant. Health-care reform wants to change all of that, and if it does, Wellpoint’s business model will be changed, too.

It would seem, then, that health care reform would not be difficult to carry through in considering who stands to win and who stands to lose if reform is not passed.  One of the major barriers is the Republicans’ animosity towards using reconciliation to pass a final health care bill, an idea they consider foreign to the democratic process.  However, as NPR just reported this past week, reconciliation is not “unprecedented,” and in fact, it has been used many times in the course of our country’s history to pass similar bills.  COBRA, Children’s Health Insurance Program (CHIP), and changes to Medicare have all happened through reconciliation.  Moreover, between 1981 and 2008, 16 out of 21 reconciliation bills were Republican initiatives.

Without a final vote on health care soon, many worry that the momentum will be lost.  Many members of Congress, steadfast in their platform promises, are not helping the process move any quicker.  In the meantime, insurance companies continue to prosper; Americans continue to pay the price.

While Medicaid Enrollment Rates Increase, States Face Financial Pressure to Decrease State Medicaid Spending

Last week, the Kaiser Family Foundation released a report indicating a large jump in state Medicaid enrollment from June 2008 to June 2009.  The report said that the 7.5 percent increase was the greatest one-year jump in enrollment rates ever, with over 3 million people joining the public health program funded jointly by the federal government and individual state governments.  The reason for the increase  is thought to be that because more people became unemployed due to the economic crash, more individuals turned to Medicaid for health coverage.  However, because the economic downturn meant less revenue entering into state budgets, state Medicaid programs have not been able to keep up with the rise in new enrollees.

During a convening of state governors at the White House this week, state officials will likely raise the issue of Medicaid spending. The issue is pressing in light of the impending funding cut when stimulus money from the American Recovery and Reinvestment Act of 2009 will expire in December of this year.  The governors will likely ask that the stimulus funding be continued until states can somehow make up for their large current budget deficits.  In addition to asking for more money, the governors will also likely discuss the feasibility of health care reform efforts.  With both House and Senate versions of health care reform proposing increases to state Medicaid programs to ensure the coverage of more uninsured individuals, the state governors would, understandably, like to know where the money for such expansion would come from.

The National Association of State Medicaid Directors estimates that states’ budgets will fall  short  $140 billion in the next fiscal year.  This means even less money for the likely further increase in Medicaid enrollment to come this year, as Medicaid enrollment generally lags behind unemployment.  To account for the deficit, many states are planning to reduce their Medicaid programs. USA Today finds that three categories of such reductions exist:

• California, Arizona and Virginia propose reducing who’s eligible. In Arizona, 310,000 people would lose coverage. California also wants to increase premiums.
• Michigan, Tennessee, Massachusetts and others propose eliminating benefits. Masachusetts’ elimination of restorative dental services would save $56 million, says Medicaid director Terry Dougherty.
• Texas, Pennsylvania, Louisiana and others propose cutting payments to hospitals, doctors or nursing homes. Several states are considering new taxes on hospitals as a way to avoid cutting these payments.

States that accepted stimulus money to expand their Medicaid programs in 2009 are restricted from any such cuts that would affect low-income enrollment.  However, if the stimulus funding is not extended, some states are planning on heightening eligibility requirements.  For other states, while decreasing hospital and doctor reimbursement seems like the worst possible option– given that many doctors have already stopped accepting  Medicaid patients due to what they deem to be an insufficient rate of reimbursement– many states’ officials find that the only other viable option they have is raising taxes.  Many state leaders refuse to increase taxes in fear of the political backlash come November.

Realizing the need for health care reform to help manage the burden of paying for health care, state governors have stated a desire to be part of the health care reform conversation.  Many have already expressed their dislike for individual mandates, which they believe will drive more individuals to state Medicaid programs.  For the most part, however, the governors want reform and they want it now, finding that they simply can’t afford to wait another year.

It is also worth noting that an underlying issue from these new numbers is whether the Medicaid program is actually a good prototype for expanding health care coverage.  Drew Altman, President and CEO of Kaiser, put in perspective Kaiser’s report as well as the concerns of public spending that were sparked by the Centers for Medicare and Medicaid Services’ projections for 2009-2019– which forecast that public spending on health care will surpass private spending.  He noted that while spending in public health insurance programs would increase, the cost-benefit would be better, since per capita costs on health care were lower in government-run programs than in private insurance programs.  According to Altman, such numbers did not undermine health reform efforts, but instead denoted “the need to control health care costs in the public and the private sectors alike.”

Obama’s Plan for a Health Care Summit and the Unenthusiastic Response

Last week, President Obama announced plans to hold a bipartisan health care summit to push forward on health care reform and to give both sides an opportunity to discuss ideas for health reform legislation that will be able to garner enough votes for passage.  While President Obama and Democratic Congressional leaders want to use the health care proposals that have already passed in the House and in the Senate, Republicans say that they are unlikely to vote for a bill unless the current proposals are scrapped and the process is started afresh.  It seems like Americans, once again, may be left watching the theatrics of the health care reform debate without actually being the focal point of it.

Some conservative Congress members have already responded to the President’s invitation publicly to make their steadfast positions known.  Representative Eric Cantor (R-Va.) said this past week that he was not willing to discuss a “health reform package that spends money we don’t have.”  He added that “House Republicans have offered the only plan that will lower health care costs.”  If that is true, it is likely attributable to the fact that the House Republican bill would cover only 3 million uninsured Americans, compared to the Democratic House bill which would  insure an additional 36 million Americans.

On Monday night, House Minority Leader John A. Boehner (R-Oh.) joined Cantor in submitting a letter to White House Chief of Staff, Rahm Emanuel, which said that the Republicans were not willing to come to the table unless certain prerequisite questions were answered.  You can see the whole letter here.  In the letter, Cantor and Boehner express their non-support for reform that the American people themselves are not supporting; the basis for such being the recent Republican Senate win in Massachusetts.

Exactly what are the citizens of American thinking about health care reform anyway?  CNN reported on Tuesday that nearly two-thirds of Americans want Congress to persist in passing health care reform legislation.  The poll, an ABC News/Washington Post survey, also indicates that Americans blame both Democrats and Republicans on their unwillingness to compromise.  HHS Secretary Kathleen Sebelius herself is quoted as saying, “When people look up close at the personal activities of Congress they are confused and disgusted with the whole process and too afraid that whatever is going on can’t possibly be good for them or their families.”

Many believe that the idea for the health care summit was to address the back-door processes that led to American distrust and to make it all more transparent.  Still, there appear to be more differences between the conservative version of reform and the liberal version than points of reconciliation.  Though the prolonged tug-of-war between both sides does not seem like one that might be resolved in a day of convening, the summit is, perhaps, at least a start.

And, while the political contenders decide what to do about the summit, the health reform stalemate has presently-occurring repercussions. Many hospitals, which were holding on to the hope of reform, are now at the point where downsizing their health systems is thought to be the only step left.  Hospitals all around the country have been seeing more and more uninsured patients, and with no one to cover the full cost of services, the hospitals providing unreimbursed care are said to be further sinking into debt– and must therefore cut staff as well as services.  On the individual level, Americans are also finding it difficult to  keep up with the costs of health care, and while many forgo insurance, those that cannot due to chronic illness or necessity of care are finding the cost further prohibitive.

It would make sense, then, that Americans do want reform.  Andrew Rubin, Vice President for Medical Center Clinical Affairs for NYU Langone Medical Center and radio show host for HealthCare Connect, says that one of the underlying reasons why Americans are reluctant to give support for legislation is their lack of understanding of what is happening, not because they do not want to see change.  Let’s hope that the proposed health care summit will be used to clarify issues for Americans who do need and want health care, instead of for just another political brouhaha.

Medical Experts Say Haitians Will Need Health Care Help for Years to Come

The BBC recently reported that medical organizations with members serving the Haitian communities affected by the earthquake on January 12^th warn that one of the larger issues for Haitians will likely be the need for increased medical supplies, such as prosthetic devices and rehabilitation services.

Concerned about infection, doctors in Haiti have had to amputate the limbs of a great many injured patients.  In addition to the need for such resources as medical devices and prosthetic equipment, doctors are also still in need of simple medications.  Antibiotics are needed to prevent the spread of infections and painkillers to help damaged patients simply make it through the day.

Because many of the country’s hospitals were also destroyed by the earthquake, doctors in Haiti are performing most care in makeshift open areas.  And in such environments, infection spreads fast.  Though the few hospitals that are running are reported to be in relatively well-organized condition, many of the patients in those hospitals are not leaving as they have nowhere else to go, except perhaps the streets– where infections await their open wounds. So they stay,  Doctors are left with fewer and fewer areas to treat, and the number of patients increases. To remedy the situation, there are plans at present to quickly build a convalescent center.

The present medical needs are only the beginning.  The concerns of some medical experts extend to the years after the media eye has turned away from Haiti, after the NGOs have left the country, and after foreign doctors have returned to their home-countries.  These experts worry about how the Haitians that are being treated today will be able to continue with one less leg or one less arm in the future.  Without proper rehabilitation services or necessary follow-up medical care, many Haitians will lack the physical capabilities to rebuild their lives.  Mark Hyman, a doctor and volunteer with Partners In Health, calls these future medical needs of the injured Haitian community the “third wave,” and he finds that such aid is not yet realized:

Soon, very soon, there is the need for rehabilitation, helping the thousands with lost or broken limbs get back on their feet or foot again. There are no physical therapists, no facilities, and no place for them to go for care. As the immediate surgical needs are slowly addressed, the psychological needs explode magnified by each minor aftershock.

Some medical device companies have already donated supplies to aid the doctors’ efforts as well as money to support the other necessary aid efforts in Haiti.  While such donations are helping address an urgent need, they are being outpaced by the number of amputations being performed.  Hope lies in the idea that health care systems will be put in place before the external help exits; that prosthetic devices will ultimately be made available to the patients that need them; and that Haitian medical workers are trained to be able to properly care for those who cannot care for themselves.

The needs of the Haitian people are great, and the impact of this disaster will be felt for years to come.  Please give to help those who are working hard towards rebuilding Haiti.  Click here to find a list of the different organizations through which you can donate. And if you happen to be a part of a prosthetic device company which wants to do something amazing, we’d love to write the story.

Intersecting Issues: Immigration Reform and Health Care Reform

The LA Times reported this past week that the pending health care reform would negatively affect rather than improve the health of California’s citizens.  Why would this be the case?  Nearly thirty percent of the state’s population consists of immigrants.  In L.A. County itself, there are more uninsured residents than any other U.S. county; as the L.A. Times calculates, the majority of that uninsured population are likely immigrants:

It’s a safe bet that the majority of those people are immigrants, because health officials say that 40% of all the patients treated at county hospitals are undocumented. In recognition of that fact and of the hospitals’ legal and ethical responsibilities to treat the uninsured ill and injured — regardless of their immigration status — Washington currently subsidizes their care at facilities, like L.A. County’s, with “disproportionate” numbers of such patients.

The House bill for health care reform would reduce the funding for such subsidies modestly, while the Senate bill would significantly decrease payments towards the subsidies.  Whatever the outcome of the compromise bill, L.A. County will be left worse off.

As we know, neither the House nor the Senate bill would cover undocumented immigrants, or allow them to receive subsidies or tax credits for purchasing insurance.  However, even if the country will not be paying for the health coverage of such immigrants, it will be and already is paying for the high costs of having immigrants treated in emergency rooms, since many hospitals, such as those mentioned in the L.A. Times piece above, treat patients regardless of their immigration status.  Hospitals that provide emergency services and participate in Medicare are required to treat all who come to them for emergency services by the Emergency Medical Treatment and Active Labor Act; some of the costs for the emergency care are covered through Medicaid, while others result in expenditures that the hospitals incur as debt.  The effects of the debt can result in higher hospital fees for other patients.  But greater hospital charge rates for the uninsured are a matter of contention, and tend to obscure the actual value of services rendered and unpaid for. Having said that, it is not unimaginable to think that provisions in the health care bills may actually drive up medical expenses for some segments of the population–and that such increased expenses will have significant adverse affect upon the whole.

Again, the House bill does a better job than the Senate version does at addressing the issue of immigrant health, as the House would allow for undocumented immigrants to participate in the health insurance exchange by permitting them to purchase insurance policies. While the House bill would require immigrants to pay for the policies entirely, the Senate bill does not allow for immigrants to participate whatsoever.  It is worth considering that the immigrant community consists largely of young, healthy individuals; the impact upon the risk pool of their inclusion is no small thing.

Some health care advocates believe that resolution lies in immigration reform, so that immigrants can become citizens of the United States.  An LA Times story about a UCLA study released this last week is also worth considering:

The report said that legalization, along with a program that allows for future immigration based on the labor market, would create jobs, increase wages and generate more tax revenue. Comprehensive immigration reform would add an estimated $1.5 trillion to the U.S. gross domestic product over 10 years, according to the report.

Though many Americans seem to feel that immigrants are taking jobs away from unemployed American citizens, CNN writer Ruben Navarrette, Jr. points out that much of the labor immigrants participate in is in areas of work that Americans themselves have shunned.

Behind the politics of both health and immigration reforms lies the compelling stories of immigrants who have labored in our county and who are in desperate need of health care.  While data and numbers can show the cost-benefits of allowing immigrants to participate in health care, the issue of treating ill humans seems an ethical one– not something to be justified by statistics alone.  But at the heart of this is the simple question, is healthcare a  human right? Or is it a luxury–a “treat,” if you will,  to be dispensed according to the rules of carrots and sticks? and not just a luxury.

What about the Kids? Health Care Reform and Children

During the reconciliation process of the House and Senate bills, one of the issues likely to be raised is what to do with the Children’s Health Insurance Program, commonly known as CHIP.  Under the Senate bill, federal financing for CHIP would be extended for another 2 years past the current expiration date of 2013.  The House bill, on the other hand, would allow CHIP to come to a close in 2013 since the bill plans to expand coverage for children through Medicaid and through the health insurance exchange– where subsidized health insurance would be available.  Whether or not these health reform initiatives will be able to meet the medical needs of children is a matter of debate.

CHIP is a “state-federal partnership” that was created in 1997 under the Balanced Budget Act to help insure those children who are from families that earned too much to qualify for Medicaid.  Similar to Medicaid, the federal government matches state dollars spent on CHIP (average of 57% federal responsibility for Medicaid spending, 70% for CHIP), but unlike Medicaid, the allocations to states for CHIP is capped.  CHIP also places greater discretion in  individual state’s hands regarding eligibility requirements.

One of the first bills Obama signed as President was the Children’s Health Insurance Program Reauthorization Act, or CHIPRA, in February 2009.  CHIPRA added $33 billion in federal funds to use towards providing coverage to 4.1 million children via Medicaid and CHIP through the year 2013.

In 2007, over 80% of eligible children nationwide participated in Medicaid or CHIP. Currently, 29 million children are enrolled in Medicaid, 7 million in CHIP. If CHIP were to be allowed to expire and absorbed (at least partially) by an expansion of Medicaid, however, the lower reimbursement rates for Medicaid could mean that those children transferred would not have access to as many health care providers as they would have had under CHIP.  While Medicaid might seem to be a sufficient substitute, it would still leave gaps that CHIP had filled if the reform does not include higher reimbursement rates for Medicaid and automatic enrollment provisions, as proposed by the House. In addition, as it stands, because of the relatively low reimbursement rates from Medicaid, many doctors have ceased to accept either new or all Medicaid patients.

The alternate option of funneling children to the insurance exchange does not seem promising either.  Many children currently enrolled in CHIP could become uninsured if their families cannot afford the plans offered in the exchange, which is a concern– as many families will still have a hard time meeting the premiums– even after the proposed subsidies from the government.  Senators Jay Rockefeller of West Virginia and Bob Casey of Pennsylvania have proposed to avoid some of these issues by expanding CHIP until 2019, a move that they say would benefit our country’s children by ensuring their access to health coverage.

In considering the options, it would behoove us to remember that “a stitch in time saves nine,” and that the regular health maintenance of children– much more likely for those children who have insurance– will pay dividends in the form of less of those costly visits to the emergency room and hospital stays. We would also be advised to remember that uninsured children in the hospital have bbeen shown to face a 60% greater risk of death than those children who have either private or government health insurance.

Ringing in a New Year in Health Reform: For Whom the Bell –Still– Tolls

As we come upon this new year and the prospect of House and Senate Bill reconciliation,  I find myself taken by the process. The length of it–the depth of it–or perhaps more precisely, the lack of depth thereof. Back in the dog days of summer I wrote this:

The debate wandering to and fro and fueled by hyperbole, the desire for “victory” (whatever that may mean), and lobbyist dollars descending upon the corridors of Washington until they have become, in the words of T.S. Eliot,  ”Streets that follow like a tedious argument / of insidious intent.”

The words, unfortunately, seem as apt now as they did then. The passage of time harboring more of the same as the process “followed” into the need for 6o votes and the compromises (if not betrayals) necessary to garner the same.

“Had we but world enough and time/ This coyness, Lady, were no crime”

This article published back in September is worth considering

Research released this week in the American Journal of Public Health estimates that 45,000 deaths per year in the United States are associated with the lack of health insurance. If a person is uninsured, “it means you’re at mortal risk,” said one of the authors, Dr. David Himmelstein, an associate professor of medicine at Harvard Medical School.

The researchers…determined that the uninsured have a 40 percent higher risk of death than those with private health insurance as a result of being unable to obtain necessary medical care. The researchers then extrapolated the results to census data from 2005 and calculated there were 44,789 deaths associated with lack of health insurance.

Last New Year’s Day I wrote this in anticipation of the continued economic meltdown as it regarded Health Reform:

As we ring in the New Year and begin to contemplate the inter-relatedness of the macro-economy and commence what may well be the “fall into a ‘death spiral’ of unemployment, disfiguring ailments, and a tendency to be underemployed due to such ailments,” it might be worth a moment to consider the often sudden and unexpected nature of both job loss and catastrophic illness– and John Donne.

The bell which John Donne refers to in his most famous quote is “the passing bell,” tolled by the Church for those who are dying. As Donne lay very ill in his bed and heard this bell being tolled, he wondered if he were, in fact, sicker than he thought. And that perhaps that bell was being rung for him personally. He came to realize, however, that whether that was the case or not was largely irrelevant because

“No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were. Any man’s death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”

In the midst of the year long “tedious argument / of insidious intent,” that bell tolled for thee another 45,000 times.

Dollars and Sense & Health Care Reform

With health care reform approaching its culmination point, like all things most memorable of the past year, the overarching question remains, “How much will this cost us?”  As it currently stands, the House version of health reform will cost an estimated $1 trillion over a decade, while the Senate version comes in at $871 billion.  Next, comes the obvious second question, “How will the government pay for it?”  As Kaiser Health News summarizes in its recently released guide to health reform:

Both bills hit up the wealthy, but in different ways. The House would impose a 5.4 percent income tax surtax on individuals who earn more than $500,000 a year and couples that earn more than $1 million. The Senate would increase the Medicare payroll tax rate from 1.45 percent to 2.35 percent for people who earn more than $200,000 a year and families that earn more than $250,000.

To raise money to pay for the legislation, the Senate would impose a 40 percent tax on the portion of most employer-sponsored health coverage that exceeds $8,500 a year for individuals and $23,000 for families. The Senate also would raise the threshold for deducting medical expenses to 10 percent of income, up from 7.5 percent.

Overall, the financing provisions could spur a pitched battle; the House hates the Senate tax on high-cost policies, while the Senate opposes the House’s income-tax surcharge.

In addition, many Americans worry that efforts to contain costs within the bills will lead to decreased standards of care.  As a New York Times piece reveals, however, this may not be the case.  The article examines the health system in Richmond, Virginia, where there are stringent state infrastructural expansion guidelines placed on health care practices and hospitals to contain costs.  The state requires large medical infrastructural expenditures by health care providing institutions– in the form of hospital expansion or even major equipment purchases– to be approved by the state through a “certificate of need.”  Neither of the House or Senate bills  includes such a provision, but there is a great deal of speculation that the oversight and cost-cutting measures in both will have a deleterious impact on the quality of health care.

While Richmond spends less than average per capita on Medicare than other metropolitan areas, patient outcomes are better than average. The Times reports

The quality of care in Richmond is better than in most American metropolitan areas, according to various measures, and it continues to improve. Medicare data, for example, shows that Richmond hospitals do a better-than-average job of treating heart attacks, heart failure and pneumonia.

But perhaps the most interesting aspect of the Times’ analysis relates to those states that do not police their health care infrastructure expenditures– or, as in South Dakota, had done so formerly, but ceased to do so.  When South Dakota “scrapped” its certificate of need program, one chief operating officer reported going on an expansion binge. In such cases, the number of patients that providers treat is said to correspond proportionally to the level of health care resources available.  One medical officer found this “supply-sensitive” phenomenon to mean that the more hospital beds a hospital has, the more patients it is likely to see.  Build it and they will come– or perhaps more to the point– they will be sent. At our expense.

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