heathcare (3)

The N.Y.T.s of 6/14, 6/21, 6/23, 6/28 and in between contained several articles on healthcare as well as on factors that affect our health, such as Kristof''s columns (6/21) on industrial agriculture (with nostalgic description of the 0rganic food grown by his farmer parents in Oregon) and (6/28) on endocrine disruptors that are a probable cause for malformation in frogs and fishes as well as in human sexual organs. The argument that modern diets are responsible for such health problems as obesity, diabetes and clogged arteries is an old one, as is the increased cost of these conditions in terms of medical care and lost productivity (not to speak of the suffering of affected individuals and the burden borne by their relatives).

Relevant to the dietary aspects of health is David Kessler's recent The End of Overeating: Taking Control of the Insatiable American Appetite (Rodale Press), which deals with an examination of the food industries successful attempts at creating a combination of fats, sugars and salt that tap into the brain's reward system creating a desire for more. While serving in the Clinton Administration, Dr. Kessler took on the tobacco industry in a drawn out battle during which it emerged that the tobacco companies actually created cigarettes with ingredients that made them addictive and in order to avoid the US' Food and Drug Administration the grew the experimental tobacco in Brazil.

The reluctance of the executives of the food and chemical industries to be active in changing their products as soon as evidence of their negative impact becomes available (or in disregarding/suppressing negative test results in reports to the FDA) is also well documented. The latest case in point is the subject of an article by Morgenstern (6/28) about the producers of Zicam whose first reaction, apart from their denials that have become the automatic commonplace of anybody questioned (no doubt the result of early childhood training by moralistic parents and teachers - in my childhood symbolised by the question "Let me see your forehead" in reference to Cain having been marked by God when he was caught in a lie about the whereabouts of his brother Abel), was to sue the whistleblower who went out of business because of the legal cost of his defense. The offending Zicam was taken of the market after the FDA took action.

Articles in the Business Section of June 14 discussed the overuse of medical care, including the prescribing of too many tests (to protect the physician against malpractice suits for negligence or to help defray the cost of the high tech equipment that every medical group feels it needs - rather than use that already available in the area) received but sparse reaction from healthcare givers. One of these pointed out that it is often the patient who, subject to the pervasive advertising by pharmaceutical and medical equipment industries (and hospitals), insist on the doctor's prescribing new medicines and tests. Doctors may give in because instead of having time to discuss the matter with the patient they know that there are patients waiting not only in the waiting room but in their other consulting rooms. Of course when the doctor is part of a for profit medical system (incl. hospital, labs, etc. referred to in the White House as the McAllen, Tex. syndrome) prescribing hospital stays and test increases the bottom line AND the prescribing physician's share; in case of the elderly the costs are reimbursed by Medicare (i.e. the taxpayer).

One M.D. wrote in a letter to the editor, that physicians see so many patients to pay their bills, afford "college for their children and enjoy the lifestyle rewards of decades of education." There is some remedy for these expenses and not simply by suggesting that teaching Ph.D.s (of which I was one) paid for my own education (by working part time - and full time during the last for years) as well as the private school education of my two children, etc. True, we didn't have (a) luxury car(s) and never lived in the equivalent of a McMansion or belonged to a private golf course etc., but we were not homeless, vacationed in a rental cottage in Maine, went to the theatre in NYC, bought books, drank good wine, i.e. not a life of poverty. There are also the examples of European nations where education is generally free so that the graduates do not have a burden of debt nor the cost of their kids tuition, etc. In addition in Europe there is less of a gap between highest income careers and those of educated professionals so that the "lifestyle rewards" are less subject to inflated expectations.

The B.B.C. World News America had three reports on the Healthcare debate on July 6-8. One of these was on the McAllen, Tx. extravagances and the last one on the system in the Netherlands where two years ago the government decided to institute a moderate free market approach to healthcare, giving a greater role to private insurers (with contributions from those who can afford them (the employed, etc.). One item that caught my attention was the fact that the Netherlands is among the nations that spend much on healthcare for each citizen but only half of what the USA spends and that while in the Netherlands everyone is covered. Another fact emerged from an interview with an M.D. in General Practice who said that she and her colleagues tried to treat their patients without immediate recourse to hospitals and high tech labs, what came across as an anti-McAllen approach. And it is not that Dutch MDs lack in "Lifestyle rewards" but rather, it appears to me, that they lack the prevailing American attitude of "let's get when the getting is good," that parallels pretty much the malpractice indemnities that jack up their own malpractice insurance. [Addendum: In an interview in the NYT (Nov. 11-10-09, p. D5) the Dutch Minister of Health describes the health care system that is being changed to give people yet more choice of improving care that uses transparent "quality indicators" based on electronic records without a "fee for services" system.] Of course, some Dutch doctors are not above committing frauds and I remember that as far back as the 1950s - when I was still there - several individual physicians in two small towns near us submitted false claims; it was a public scandal not in the least because of the high regard in which educated people were then held - they were among the "notables."

On Sunday June 21 '09, the Front Page of the NYT began two healthcare articles, one on an odd case of malpractice, the other on a poll showing widespread national popular support for a greater government role in providing health insurance.

The malpractice case concerned a pysician in the Philadelphia Verterans Hospital who implanted radiactive seeds to attack prostrate cancer. In too many instances these seeds landed not in the prostrate, in one case most of the seeds landed in the bladder of a patient and in a second implant quite a few ended up in the same patient's rectum. The surprising thing is that investigating regulators allowed the physicians to rewrite his surgical plan. It turned out that the entire cancer unit at the hospital was involved in botching 92 of 116 treatments. The entire report makes you wonder, for not only were treating physicians repeatedly at fault but the control system failed as well.

The New York Times/C.B.S. News poll showed that 85% of respondents said that the health care system needed to be fundamentally changed and that 72% backed public health care, including even 50% of Republican respondents. Of those making less than $ 50,000, 65% were willing to pay more taxes and of those with more income 52% percent did so. Fifty percent believed that the government would provide better coverage and 59% that it could do a better job at keeping costs down. All this while there was an awareness that the quality of an individual respondent's care might get worse or that they might have to change doctors.

Apparently those statistics did not change the opposition of conservative members of the House or Senate and one wonders why they would so blatantly disregard public opinion. One reason is possible cynicism about the value of public opinion polls which, they well know, is influenced by advertisements, Presidential speeches, etc. Among those adds are those that warn against the Obama health plan with scare tactics about loss of choice of doctor and decision making federal bureaucrats. But as the poll shows, these scare tactics have some effect, but not on the majority of respondents. A more important reason for continued opposition by conservatives is the American selection system that is based on well defined election units rather than, as in some European countries, on nationwide party lists. It is a given of the American system that incumbents are difficult to defeat in an election, especially in a midterm election (e.g. 2010) when the majority party is likely to loose some seats, which in this case would strengthen the opponents. After all, each member of Congress represents some of the American people all of the time and the American people as a whole only some of the time and that mostly during elelction campaigns.