Sunday, June 10, 2007

A wee bit about health care, and a word on Fineman

I’ve been thinking about health care for a couple of weeks now, and I intend to try to express myself now. But I just went back and looked at some of my previous posts, because I believe I wrote about health care in the past.

Reading my own writing is like hearing your voice on a tape. Ewwww. Am I never coherent?

Before I start on heatlh care, I want to say something about this Howard Fineman article someone found on Newsweek online, and which has spread like wildfire through the Burghosphere ( Now, he does get a lot of things right, we do have good schools and fine museums n’at. I guess we used to be a college town surrounded by an industrial city, now we are a college town surrounded by a retirement community (well, there is still some banking and service around, some boutique steel and a few corporations, or at least their corporate services’ offices – Heinz, Alcoa, Mellon). There is one paragraph, though, which I have to say something about …

“Beside the city, there are 129 other independent municipalities in surrounding Allegheny County. The mayor is in a constant tussle with the county, run by County Executive Dan Onorato. The county has the far bigger tax base, and greater access to state funds. The city and county are sharing 911 and purchasing services, but Ravenstahl and other city officials have little interest in giving up what power they have. A merger of city and county—a move made by many other regions—would extinguish Pittsburgh’s “voice,” Ravenstahl told me. “No one would pay attention to urban issues.””

This Mayor is *not* in a constant tussle with Dan Onorato, quite the opposite. I guess Ravenstahl fed that idea to Fineman, who didn’t bother to check. But opposition to the idea of a city/county merger is interesting. For one thing, a merger was Mark DeSantis’ opening salvo. Now, the Mayor of Pittsburgh does not have authority to create a merger, but his is an important voice in its creation. Would a merger mean that our debt would be shared by the county? Depending on the merger, I would almost think it would have to be if we just dissolved the city. Calling for a merger is a way of being serious about tackling Pittsburgh’s long term debts. State legislators and the governor may be interested in something like that (though our suburban legislators would not be happy, to put it mildly).

So Barack Obama has a health care plan and John Edwards has a health care plan. Hillary, amusingly, does not. Maybe she is keeping 1992’s plan in suitcase, ready to swing into action. Paul Krugman talks about single payer plans in his columns in the NYTimes, and I read them and wonder. The efficiencies he talks about in Medicare and the VA health system, the elimination of the middle man insurance companies, could it be that by eliminating emergency room visits for the uninsured, by eliminating costly overhead from insurance companies and by switching to an emphasis on preventative care that maybe my taxes would go up by no more that the reduction of costs when my employer no longer has to provide health insurance for me?

That is the strawman Krugman dangles in front of us. Get rid of the insurance companies (nationalize them, in effect) and rein in the pharmaceutical companies and the hospitals and doctors (nationalize them, in effect) and all will be right with health care. Well, maybe, but it’s not going to happen anyway. No Congress is going to legislate an industry out of existence, even if we knew for sure the results would be good (and by the way, Krugman is only implying that we should nationalize these industries, kind of a “what a good idea, though I never said that” kind of fing). Pointedly, Edwards’ and Obama’s plans work with the insurance companies.

There was a piece in the NYTimes that captured a different and important piece of the problem. I mean, we have the drain on the system from the uninsured, right, They go to the emergency room, and then can’t pay, so there is pressure on everyone else’s health care costs. Then there are the insurance companies themselves, which employ tactics like guaranteeing hospitals payment from their customers, but in return for the guarantee, the hospital has to accept only 80% of an average of what everybody else is charging for that procedure or hospital stay or whatever. Well, every hospital in the area has an incentive to raise their costs by 5 or 10 percent next year then, to get back what they thought the procedure should have cost anyway. Pretty soon costs are chasing reimbursement all on their own, with their own dynamic. And there are malpractice insurance costs, where the medical associations protect bad doctors to protect their ability to police themselves, and the rest of us pay.

But the piece in the NYTimes (Economx, “Health Care as if Costs Didn’t Matter” 6/7/07) last week was something else again. The essayist commented that Idaho Falls has the highest rate of lumbar fusions per something or other of any city (or something) in the country. Maybe it was Portland, Maine or Oregon that had the smallest number. His point is that there is no real reason for this (though the surgeons in Idaho Falls are surely getting richer), that all the stuff I mentioned before have so knocked medicine from its moorings to science that medical necessity has become at least somewhat variable. I mean, no one’s going to use leeches if you have a cold. The essayist noted that buried in the candidates plans is a call for a national institute to look at what we spend and why on health care procedures. The candidates don’t propose regulating spending or procedure choices, yet. But they may have to.

My wife just had surgery on her foot for plantar fasciitis. Before she had the surgery, there were courses of physical therapy and orthotics, inserts to go in her shoes. Now, she was working a second job as a clerk at a drug store, so she was on her feet for few hours a few times a week. She only quit that job just before the surgery. So there are lots factors going into this, but the bottom line was her feet hurt, particularly her right foot. It still hurts after the surgery, by the way; my wife keeps saying she is overdoing it. (we don’t want to get in the dynamic of how much doing is overdoing).

My mother in law recently went into an assisted living facility. Without getting into how she is doing there (which is its own nightmare and contributes to my wife’s overdoing it), what put her there is interesting. A few months ago she developed pain in knees, bad enough that she found she was unable to get out of bed. It was precipitated by her going up and down the stairs a couple of times in her apartment building. A couple of days later she couldn’t get out of bed, at least, not upright (she crawled to a phone to call us). Now, she was on a pain medication for arthritis, and her doctor prescribed an increased dosage. That was a problem, though, because with her decreased mobility she couldn’t get to the kitchen to take them, and the new pills were too large for her to swallow. They were cut in half, which yielded sharp edges, a new problem, and meanwhile she was not moving much, losing what mobility she had, and not eating (she had not been eating much anyway, but now she was eating less). She didn’t want new pain medications because she was afraid they would make her “loopy”. I should mention she has other issues, like Macular Degeneration and hearing loss (she doesn’t think her ancient hearing aids work, so she doesn’t try them).Eventually, we had to put her in the hospital, so that she could have tests to determine the cause of the pain. A couple of theories were advanced; arthritis in her knees or crumbled discs in her spine. Meanwhile, though, her decreased mobility and inability to take care of herself became issues in and of themselves. She left the hospital and was sent home, but she lived on a third floor apartment in a building with no elevator, so that was a concern. She got a visiting nurse and occupational therapist people coming in, but it turned out that would only be for a month. When she starting leaving the door open and calling to people in the hall to get her a drink of water, back to the hospital she went, and then into the assisted living facility. As far as I know her pain has not ever really been addressed, but the facility has stopped trying to get her to use a walker (a few months ago she wasn’t using anything) in part because she is still in pain and in part because she is slow to follow instructions because she can’t see or hear well. They now cart her around in a wheelchair all the time. All of which is to say that medicine is its own dynamic. Maybe if her doctor could have hit on the right medication and “gotten out in front of the pain”, a lot of this could have been avoided, or maybe it was unavoidable. The fact I could ask the question is, in and of itself, disturbing.

People opposed to a more universal form of health care coverage often say that we have a Cadillac level of coverage now. We have the best science, the best doctors, hospitals, etc. Of course, the people who say this have insurance coverage. Those without coverage, well, like people on the minimum wage, they are going through a transitional phase, they simply need to get training for a better job (they are probably young and healthy anyway). Except that people still don’t get better jobs, and those without coverage get sick and put off getting treatment , and the US still has a higher infant mortality rate and we die sooner that than the people in other industrialized countries.

But universal health care is going to have to tackle doctor’s wages. Those doctors, who engage in more lumbar fusions in Idaho Falls get paid more. Should they? The hospital and now an assisted living facility are getting paid well from my mother in law’s situation, yet she has not been well served by the result. Health care reform is going to have to address physician wages, hospital charges, insurance rates, and how good the care is.

Another columnist in the NYTimes commented (Gawande, “The Obama Health Care Plan”, 05/31/07) on the Edwards and Obama plans. In his view, either one would be an improvement over what we have now. The problem is, we might keep what we have now. That’s what happened in 1992, and the interests opposed to change have, if anything, gotten more powerful. If you think change is inevitable, think again. Read for yourself, study the plans, choose one to support or just rail against the drug and insurance companies and the hospitals and doctors who complain and threaten.

So I don’t know if taxes are going to go up with a more universal health care. Supposedly we will get new efficiencies to offset new costs of coverage. Preventative care would make a big difference, but libertarian opponents of the nanny state may want us all to suffer. Certainly doctors are going to want us to pay higher taxes, to keep them well paid.

Lots to think about.


Anonymous said...

No need to raise taxes. If we redistributed the taxes already collected we could be living in a socialist paradise. I say that with up most respect for what Chavez is doing to save the sight of thousands
of South Americans and what Fidel Castro is able to do with one arm tied behind his back by our economic blockade. When you see the new Michael Moore film "Sicko" you'll know what I mean. Moore takes 911 first responders to Cuba for treatment that is better than what they've received so far here in our country, and all on a very strictly limited budget. Makes me wonder what we could do by just shifting all that war money over, to benefit Americans and rebuild the infrastructure. I hope your wife and mother in law come through this alright.

EdHeath said...

Well, of course the world is a complicated place, and the problems of inequity between rich and poorer probably mean that redistributing revenue collected in a different way than it is distributed now would be next to impossible. I think we will be punished (taxed) for health care reform.

I have to say about "Sicko", apparently the hospital Moore went to was a better facility than usual in Cuba (so said a Cuban in the NYTimes). But the Cubans certainly have made quite a bit in terms of health with very little. I would not, in fact, want to go there for health care, but I can imagine many Americans would prefer the Cuban level of care to none at all. Of course, the issue is how to provide an approximation of an American level of care to at least most Amercians.

My wife, by the way, is doing well (thank you for asking). My mother-in-law is not doing so well, but we are taking what steps we can (by we I mean my wife).

EdHeath said...

The examination of "Sicko" I referenced is here: "", for what it is worth.

When I say it would be difficult to change the way tax revenue is spent, I mean that vested interests would resist changes. But I agree with the notion that there is still a lot of waste in our government as a whole and in health care spending in particular. A lot of waste and a lot of deprivation.