As Democrats in Congress push forward THEIR idea of health reform it is becoming clear that the battleground will now move to cost. Cost will become the battle cry along with cost control, savings and eliminating “needless” care. This is a slippery slope America is now going down, one that does not spell a happy ending for the millions of baby boomers, many of whom are embracing this approach as a sort of lingering nostalgia from their 1960’s days of youthful rebellion.
President Obama addressed some of these issues today: “Already, Congress has embraced our proposal to cut hundreds of billions of dollars in unnecessary spending and unwarranted giveaways to insurance companies in Medicare and Medicaid . . . I realize there’s going to be a lot of debate and disagreement on how best to achieve these long-term savings. Our proposal would change incentives so that providers will give patients the best care, not just the most expensive care, which will mean big savings over time.”
WHO DECIDES WHAT IS NECESSARY?
There is much to agree with the President on. However, the concern that many have relates to what is ‘unnecessary and unwarranted’. Who will make those decisions? We know how the National Health Service in England does it. For the most part its process is slow, with new treatments and technologies lagging.
For example, percutaneous endoscopic discectomy. This procedure remains unapproved for NHS patients as of June 2009. The NICE sets rules for what is and is not available to patients under the NHS budgets. In essense, though they do not ration care per se, they DO RATION ACCESS TO TYPES OF CARE. Yet, this same technique is widely reported on in the literature over the past decade and is generally available throughout the United States from specialists in neurosurgery. It is not the only technique available, but is an OPTION for patients seeking a minimally invasive alternative to more traditional open surgery. The American health system has led the way in giving broad access to these types of medical advances. There are many examples of this.
The Canadian system is worse, mainly in that there is no competition at all with the provincial health services. For example, from 1987 to 1995 the Ontario Health Insurance Plan spent more than $1.1 billion for U.S. medical services provided to Ontarians. That is patients who left Ontario to seek treatment in the US as well as patients who happened to be in the US and received medical care. Some Ontarians are crossing the border to seek specific types of medical services that typically are more available in the United States. This is likely the motivation for cross-border care seeking for CABG surgery, residential substance abuse treatment, and experimental cancer therapy. Thus, there is evidence that the United States does serve as a destination for Canadians seeking certain kinds of services that may be less available in Canada. The case of TMJ surgery reinforces the notion that constrained supply in Canada may be less immediately responsive to rapid changes in the demand for highly specialized treatments than in the United States.
The American Recovery and Reinvestment Act of 2009 created the Federal Coordinating Council for Comparative Effectiveness Research to coordinate comparative effectiveness research across the Federal government. The Council will specifically make recommendations for the $400 million allocated to the Office of the Secretary for CER. It is clear, given the calls for cost controls, that this entity will in fact reflect the actions of NICE in England and ration access to technology, drugs and other medical advances in the name of controlling costs.
DEFENSIVE MEDICINE
Regarding waste, at $210 billion annually, defensive medicine is one of the largest contributors to wasteful spending, and it can manifest in many forms: unnecessary CT scans, MRIs, cardiac testing and hospital admissions. A 2005 survey in the Journal of the American Medical Association found that 93% of doctors reported practicing defensive medicine.
Why do doctors order these unnecessary tests? The simple reason is that every physician wants to avoid being sued. Win or lose, the ordeal of a malpractice trial is a devastating experience. The American Academy of Family Physicians, citing a study that interviewed doctors who had fought medical liability cases, said 90% “suffered significant mental effects from the lawsuits” and, disturbingly, 10% contemplated suicide.
A landmark study from The New England Journal of Medicine analyzed more than 1,400 malpractice claims and found that in almost 40% of cases, no medical error was involved. Facing such an unpredictable malpractice climate, a physician’s instinct is to increase testing. When facing jurors and trying to explain a medical catastrophe, who wants to tell them why a specific test wasn’t ordered?
PUBLIC/PATIENT RESPONSIBILITIES
It is also abundantly clear that patients bear a great deal of responsibility as well for rising health care costs. The continual removal of responsibility by employers, health plans and the government has created a perception that health care is free among many. It has now been well shown that placing financial incentives back onto patients, such as the use of HSAs, has led to more discernment among those patients in their choices about use of the health care system as well as options. Removing all financial constraints places the patient in the position of expecting everything and the physician in the untenable position of acting as a cost comptroller . . . which is something physicians should not be forced to do.
Among workers over the age of 65 responding to the National Health Interview Survey [2003-2007], 12% of respondents reported that they are current smokers, 21% are risky drinkers, and 75% are not following recommended leisure-time exercise. Drug and alcohol use was greater among younger workers ages 18-29 years, with more than half of these workers reporting one of the four types of use [illicit drug use only, problem drinking only, heavy drinking only, or both drug use and problem/heavy drinking].
People who adopt four healthy behaviors — not smoking; taking exercise; moderate alcohol intake; and eating five servings of fruit and vegetables a day — live on average an additional fourteen years of life compared with people who adopt none of these behaviors, according to a new study. So it is clear that a combination of bad habits, bad diet, lack of exercise and open ended expectations of the health system are also playing a major role in driving system wide costs, both in terms of unecessary tests and procedures, but also in terms of health consequences of detrimental behaviors.
DEMOGRAPHICS
Seventy-six million American babies were born between 1946 and 1960, representing cohorts that would be significant on account of its size alone. This cohort shares characteristics like higher rates of participation in higher education than previous generations and an assumption of lifelong prosperity and entitlement developed during their childhood in the 1950s.
In the 1985 study of US generational cohorts by Schuman and Scott, a broad sample of adults was asked, “What world events over the past 50 years were especially important to them?”For the baby boomers the results were:
Baby Boomer cohort #1 (born from circa 1946 to 1955), the young cohort who epitomized the cultural change of the sixties
Memorable events: assassinations of JFK, Robert Kennedy, and Martin Luther King, Jr., political unrest, walk on the moon, risk of the draft into the Vietnam War, anti-war protests, social experimentation, sexual freedom, drug experimentation, civil rights movement, environmental movement, women’s movement, protests and riots,Woodstock, mainstream rock from the Beatles to Jimi Hendrix experimentation with various intoxicating recreational substances
Key characteristics: experimental, individualism, free spirited, social cause oriented
Key members: Former UK Prime Minister Tony Blair, U.S. Presidents Bill Clinton and George W. BushBaby Boomer cohort #2 or Generation Jones (born from circa 1956 to 1964)
Memorable events: Watergate, Nixon resigns, the Cold War, lowered drinking age in many states 1970-1976 (followed by raising), the oil embargo, raging inflation, gasoline shortages, Jimmy Carter’s imposition of registration for the draft, punk or new wave from Deborah Harry and techno pop to Annie Lennox and MTV
Key characteristics: less optimistic, distrust of government, general cynicism
Key members: Douglas Coupland who initially was called a Gen Xer but now rejects it and Barack Obama who many national observers have recently called a post-Boomer, and more specifically part of Generation Jones57.8 million- Number of baby boomers living in 2030, according to projections; 54.9 percent would be female. That year, boomers would be between ages 66 and 84.
2.1 – The number of workers for each Social Security beneficiary in 2031, when all baby boomers will be over age 65. Currently, there are 3.3 workers for each Social Security beneficiary.
To be sure, demograhics are playing a VERY LARGE ROLE in the exacerbations of cost issues related to health care we are now facing. However, this is no different than the challenges faced by the educational system during the 1950’s, 1960’s and 1970’s. We met those challenges. We can meet these. However, we must remain vigilent that as this baby boom generation ages, and health care costs become an ever greater concern, that we do not edge toward solutions that would be morally questionable . . . limiting care, limiting care choices, encouraging a more rapid embrace of end of life options and similar troublesome paths. Caring for our aged, in all aspects is a moral imperative that we can all agree on admist this debate . . . obi jo
Obama Addresses Concerns Over Health-Care Costs – http://www.washingtonpost.com/wp-dyn/content/article/2009/07/17/AR2009071702665.html
Canadians’ Use Of U.S.Medical Services – http://content.healthaffairs.org/cgi/reprint/17/1/225.pdf
Percutaneous endoscopic laser cervical discectomy – http://www.nice.org.uk/nicemedia/pdf/IPG303Guidance.pdf
Comparative Effectiveness Research Funding Federal Coordinating Council for Comparative Effectiveness Research – http://www.hhs.gov/recovery/programs/cer/index.html
Defensive medicine – http://en.wikipedia.org/wiki/Defensive_medicine
Wasted medical dollars – http://blogs.usatoday.com/oped/2008/04/wasted-medical.html
Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment – http://jama.ama-assn.org/cgi/content/short/293/21/2609
Claims, Errors, and Compensation Payments in Medical Malpractice Litigation – http://content.nejm.org/cgi/content/abstract/354/19/2024
Health Savings Accounts Boost Consumerism in Medicine: Increased Patient Responsibility Inevitable – http://www.medscape.com/viewarticle/496154_4
Health Savings Accounts Boost Consumerism in Medicine: Early Adopters Report High Satisfaction – http://www.medscape.com/viewarticle/496154_2
Health behaviors and health care costs in the multigenerational workforce – http://agingandwork.bc.edu/documents/FS23_HealthBehaviors_2009-06-10.pdf
Four Health Behaviors Can Add 14 Extra Years Of Life – http://www.sciencedaily.com/releases/2008/01/080108083001.htm
Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study – http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050012
Baby Boomer – http://en.wikipedia.org/wiki/Baby_Boomer
U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin: 2000-2050 – http://www.census.gov/population/www/projections/usinterimproj/
Social Security Basic Facts – http://www.ssa.gov/pressoffice/basicfact.htm
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It is a shame that some Americans are so gullible, to the outlandish propaganda and lies spat in the newspapers, television and radio about Obama’s health care agenda. They have demonized the British, Canadian and other worthy plans. Hidden under a disguise cover, these radical entities are determined to keep the special interest organizations in absolute power. Comprising of the money-draining profitable insurance companies and their rich stockholders. They don’t want any changes to the broken system of medical care, because it will hurt the status quo. I was born in England, in the county of Sussex and until the inception of the European Union and the European Parliament dictating to Britain. That they must accept millions of foreign workers, the nations medical system was exemplary. I never had to wonder if I would have to file bankruptcy, to pay my medical bills, or listen to the incessant ring of debt collectors on the phone.
On several occasions I ended up in the cottage hospital and their was never a cost applied to it, never a ream of paperwork. Incidentally, I choose my own doctor where I Lived. The longest I waited for surgery was three months, as it was not an emergency. No doctor, no hospital or specialist asking me for my Social Security number, drivers license or if I was covered by a predatory for-profit insurer. No premiums, no-cops and pre-existing condition clauses. Yes! Didn’t have a private room, but who cares? Today the British Isles is being submerged under a barrage of legal and illegal immigrants, who have never paid into the system, have caused some rationing. Prior to the importation of foreign labor my trips to doctor, to hospital, the eye or a dentist was paid from my taxation. Unless we pass a national health care agenda, Americans will never know what it’s like to breeze through their lives, without worrying about paying for health care? Tell your Senators and Congressman you want an alternative to the–GET RICH– insurance companies, before a Universal health care is killed. 202-224-312 REMEMBER THE INVESTORS AND STOCKHOLDERS DON’T WANT THEIR PIECE OF THE $$$TRILLION$$$ DOLLAR PIE DISTURBED. EVEN SOME POLITICIANS HAVE THEIR DIRTY FINGERS IN THE PIE?
AS AN ALTERNATIVE TO THE PRIVATE HEALTH CARE, A GOVERNMENT SINGLE PAYER SYSTEM WILL ASSIST IN REVITALIZING THE WILTING US ECONOMY.
Brittancus, thanks for your input. Unfortunately, the comparisons between what was (and you describe it) a relatively homogeneous population in England post-WWII has become increasingly heterogeneous and swelled to nearly 61 million. The comparisons fade when you talk about a nation the size of the United States, with perhaps the most heterogeneous population in the world and total number in excess of 300 million. America does not need to copy the British or Canadian plans. America has its own system. It is flawed, as are the British and Canadian systems. We can build on OUR system and make it better. We agree that insurance reform is the key, but eliminating COMPETITION, the key element that has made American society advance is NOT the way to do it. We seek reform and common sense regulation, read “the plan” and “details of the plan” on this blog. But scuttling the entire system in favor of a nationalized, federally controlled system is NOT the way to go.
So the US is to big and complicated to have a system like the UK.
How about India? As the world’s largest democracy, more people actually voted in their last election than the entire populations of the US, Canada, New Zealand and the UK. That’s a lot.
I asked the Indian attendant at the convenience food store who is from india about health care in his country. He said it was good. But what about doctors, I asked. Are there enough? Sure, he said, ticking off the stats that India has more doctors, engineers, scientists and other specialists than any other country. But what about the poor people? Do they get medical care? Of course, he said. There are plenty of places they can go.
Well who pays for medical care? It depends on who you are, he said. Those who work for the government have a separate system of pay. But there are lots of different insurance plans for those outside of government.
But what about those who cannot afford insurance? Well, they don’t pay. If you cannot afford to pay,l then there is no charge.
I could see he was not an expert, but as a layman he was really mystified bt my questions. The idea that health care would be a problem seemed to be a totally strange concern for him. He’s a healthy young man with a pretty good job in
America while he finishes grad school, working toward a degree in engineering. I guess he hasn’t got sick yet bad enough to find out how the system works here.
Lord, I hope he never does. If he does, he’s in for a rude awakening.
John, thanks for the comment. To suggest that India has in some way, a model health care system, is, well, hard to fathom. Mother Theresa of Calcutta became famous caring for the dying outcasts of Indian society who had no treatment of any kind at all. Not even an emergency room that has to take all comers regardless of ability to pay . . . as we do here in the United States. Unfortunately, it would appear that many are “drinking the koolaid” that is being dished out by this administration on health care. There is a health insurance problem which has been building for some time. However, when one looks at the causes of this, in many cases, the fault lies at the feet of politicians who continually substitute rhetoric and political posturing for common sense regulation and reform that is consistent with American ideals and principles. Sorry, I think most citizens of the sub-continent would be very happy to have American medicine . . . perhaps that is why so many of their physicians work here, in America and not in India.