healthcare (4)

Numerous have been the predictions that the "Obama" Health care Reform proposals are dead, but others, incl. the President keep saying that something will be achieved as there's 80% agreement on the bills currently debated. I am more pessimistic and have a strong impression that the current process in Congress and the "anti" lobbies and advertising campaigns engage in a whittling down strategy that will postpone the production of a meaningful reform until next year, an election year in which chances of Reform will diminish. THERE IS OF COURSE NO OBAMA-BILL, BUT ONLY AN OBAMA WISH LIST. There are 4 bills in the making in the House and 2 in the Senate; the 4 in the House have a "public option" provision, and one in the Senate does so. According to Senator Harkin, Chair of the Senate Health Committee it is therefore likely that the final bill to be sent to the President will include a "public option." Those who do not want that, but favor a mandatory individual insurance system, are talking about creating something like cooperatives that will lower premiums much like those for large employers. The indigent will be covered by Medicaid and low income groups would be subsidized. ANY STATEMENT OF ANY SPECIFICS OF WHAT IS ACTUALLY IN THE "OBAMA" BILL IS IN FACT NOTHING BUT A RED FLAG FLOATED BY SOME INTEREST GROUP OR IDEOLOGICAL PUNDIT TO GET PEOPLE UPSET ENOUGH TO DEMONSTRATE ETC., MUCH LIKE THE NONSENSE ABOUT "DEATH PANELS."

Meanwhile, since my last entry (Healthcare 3), a lot more water has gone over the dam and much useful information has become available. For example the English, including the Prime Minister and other officials. incl. the Leader of the Conservative Party, David Cameron, have spoken out against the distortion of their medical insurance and care by Republicans and other American opponents to Obama's Reform proposals. THUS THE ENGLISH DEPT OF HEALTH ISSUED AN E-MAIL TO NEWS MEDIAS WITH A 3 PAGE REBUTTAL OF AMERICAN "MISCONCEPTIONS," EACH FOLLOWED BY THE COMMENT "NOT TRUE." In the NYT's News in Review (8-19-09) Sarah Lyall, an American living in England describes her experiences and states that the National Health Service there is great at emergency and pediatric care. A cancer patient was assured of the same care and medicine as an American patient would receive and when she died at last, her family wasn't left with disastrous medical bills. And in spite of public criticism, American misrepresentations have created a Twitter reaction campaign called "We love the NHS." Among the defenders of NHS is Stephen Hawking, the very handicapped scientist, who has received its care since he was 6 years old. But many who can afford it have some supplemental private insurance which helps to speed up medical care or provide better facilities. In the NYT's Sunday Magazine of the same date Sara Paretsky, the mystery writer, relates her experiences in the French system. When on vacation her husband needed emergency care, the got to a small provincial hospital where she explained that the had no reciprocal insurance as is the case with European Union citizens. Her husband receive all the tests and was diagnosed with pneumonia, he receive antibiotics. When she offered to pay with her MasterCard the desk clerk said he would send a bill. This arrived 6 months later. For x-rays, EKG, 10 hours in emergency room, a doctor, a cardiologist, technicians, etc. that bill was for $ 220.

These personal testimonies are used by both sides in the debate and I just received a phone call from my daughter that adds another one showing problems with the current system. Her youngest son (7) broke his fore arm on the school playground. In the emergency room they put on a splint, told her to make an appointment with a doctor (one was recommended) to get a cast put on. She called the doctor's office, gave her insurance information and made an appointment. She had to take a day off from work. When she got to the office and had to give her insurance info, the secretary said this doctor did not accept her insurance (provided by the Am. Libr. Assoc.). She found another doctor who did accept the insurance but could not see him until 3 weeks later; another doctor could see her 3 days later and she made the appointment (for which she has to take off one more day). So much for the doctor of one's choice or the readily available care.

The NYT also has a "Prescriptions" blog with relevant news items. One of these, printed in the 9/13 paper gives a comparison with some statistics of the French and US health systems. It cites the fact that the World Health Organization ranked the French system as overall the best in the world in 2000. A more recent study affirms this, noting also that the French have the lowest rate of avoidable deaths, while the US was last, in 19th place. (One conservative pundit said the US would do better if you took out all the deaths caused by road accidents or while hunting). The US also has very high rates of "avoidable hospitalizations," i.e. for routinely controllable conditions like asthma, diabetes or bacterial pneumonia that do not require hospitalization. The French system enrolls the entire resident population and like Medicare or Social Security is paid for by compulsory payroll taxes. Doctors work predominantly in private office based and fee for service practices and there's a mix of public and private hospitals. The stats show that the French life expectancy is 3 years more, infant mortality is 4/1000 (US 7/1000), Health spending is 11% (US 15%) of GDP., the percentage of private costs is 20 (US 54) and there are 34 doctors per 1000 inhabitants as opposed to the 26/1000 in the US. The latter figure is revealing as a rebuttal of Obama's opponents who argue that his reforms will cause a decline in doctors.

John Tierney, one of the contributors to the NYT writes articles and maintains a blog at the Times (NYTimes.com/Tierneylab) which regularly summarizes work that questions scientific research supporting for example alarmist environmental developments. On 9-22 he wrote about the findings of 2 (medical) demographers, Samuel H. Preston and Jessica Y. Ho, at the Un. of Pennsylvania that Tierney read as a better than average report card for actual health care (including for the uninsured) in the US in comparison with other industrialized nations. For instance, once you reach the age of 80 you are likely to live longer in the US and life expectancy in general is greater here after one has survived middle age. Americans apparently get ill and die in greater numbers in the US than in the other countries. The fact that one lives longer than average once passed the dangerous age bracket has always seemed to me an axiom of historical demography: even in the dark middle ages there were lots of people who lived to be twice the age of average mortality and some still longer. This situation improved during the so-called "age of discovery" (which increased Europe's food supply as well as healthier foods, but - alas - also tobacco) and the emergence of societies in which wealth and power were no longer based on land ownership but on the production and distribution of manufactured goods which raised the standard of living of more and more people). What remains, after all statistical correlations, including the greater reduction in smoking in the US) have been taken into account, is the question of why middle age is more dangerous here than in other advanced countries. For, even with the better report card the US moves up from the bottom to only the upper half of comparable nations.

In a new book (T.R.Reid. The Healing of America. A Global Quest for Better, Cheaper and Fairer Health Care. Penguin, $25,95), a journalist for the Washington Post uses his chronic (and real) shoulder ailment to investigate the systems in the several countries, including Japan and India) to contrast them with that in the US. In addition to relating his experiences, he also focuses on a careful examination of the philosophic and political history of the different systems. REID THUS ADDRESSES AN ISSUE THAT IS MUCH OVERLOOKED IN THE AMERICAN DEBATE, NAMELY THE DIFFERENCE BETWEEN THE cost OF HEALTH CARE AND ITS quality (which if payment is not an issue, may indeed be - as is often claimed - among the best in the world). He found a variety of systems with the Japanese (and that of some European countries) being most like that of the US, EXCEPT that the private insurers are NON-PROFIT and paid for with payroll deductions, the pay private doctors and hospitals. The M.D. who reviewed the book in the NYT of 9-15-09 draws unfavorable comparisons that indite the US system. Reid's Colorado orthopedist recommended a replacement costing his insurer thousands with unknown co-payments. In India he ends up in a [Y]Ayurvedic hospital (i.e. based on ancient Hindu religious prescriptions) which is private and cost him $42.85 per night. The treatment consisted of meditation, massage, rice and lentils and, he writes, led to "obvious improvement in my frozen joint." In his discussion Reid also notes that one reason for Americans not wanting to adapt for example the Canadian or other model is their insistence on being independent [as if such adaptation shows a weakness]. Reid answers questions of his book's readers on nytimes.com/health.

Considering the recommendations of Reid's Oklahoma orthopedist and the oft cited costly practice of "defensive medicine," i.e. doctors prescribing tests not only for preventive care (e.g. blood tests as part of regular check ups or to confirm their diagnosis, but rather to avoid malpractice suits or just to make sure that their medical group's expensive diagnostic equipment gets its uses, I am reminded of the fact that when I still worked and had dental insurance, one dentist talked about implants and other expensive procedures. I never had those and now that I no longer have dental insurance, only necessary maintenance (3x/year) appears enough. Admittedly, after all those years with the same dentists I receive excellent care.

Meanwhile the Kaiser Family Foundation reported on 9/15/09 that the average cost of employer/employee insurance has doubled from 1999 to 2009 to $13,000 (op from 5,800), while employee expenses have also gone up to $3,515 on average in addition to higher co-pays and annual deductibles. Most of these increases occurred between 2000 and 2006 (though the smaller percentages for the last three years may be somewhat misleading as a smaller % on a higher premium may translate into more money than it seems). Of the 13,000 the average employer pays 9,800, an amount that is paid for by all consumers in the price of the services or products they buy from that employer/company; presumable an individual consumer has some choice of not buying (but not the consumer in aggregate and if the services or products were not bought, the employer goes out of business).

Some of the current opposition is based on the question of who will be paying for whom (illegal immigrants are the big bugaboo). All the emloyed people pay for the care of the poor though Medicaid and all employed people pay into the Medicare fund according to their income. (One problem is caused by the voluntarily underemployed: they do not contribute to Social Security or Medicare (or to the wellbeing of society), but they will eventually get the benefits. This is still a serious issue in the Netherlands with its generous social service laws). In any of the established insurance systems, be they Medicare or private, all of the members pay the cost of any member's care. Thus I paid into Medicare (and even now a contribution is withheld from my social security payments each month) and the College continues to pay for my supplemental private insurance (which is actually in lieu of salary). I do not anywhere near use the prescription costs that most 78-year olds use and my insurance, including my personal contributions, thus contributes to the cost of the medicine of others. One of these is a Harvard economics professor who wrote that he takes one statin pill a day at an estimated cost (including pharmaceutical research etc.) of $150.000 for an estimated additional year of life. Whatever Harvard provides in medical insurance and whatever the Professor pays for a supplemental clearly doesn't pay for his statin (and, a cynic might add - having taken note of the social usefulness of economics as a science for the common good - may be his additional year isn't a good exchange). The issue here is not whether he should get his medicine, but whether this expensive statin is necessary. What would the physician, if he were an old-fashioned caring type, prescribe instead if the Professor had no insurance or a less generous one?

Additionally several articles, for example the cover reportage in Time (8-31-09) on "The Real Cost of Food" or the N.Y.T.'s lengthy reportage on infractions and poor enforcement of the 1972 Clean Water Act (9-13-09, followed by a second one on 10-13-09 that reports on coal burning plants reducing their air pollution by dumping some chimney residues into local rivers!) make it clear that health care would be cheaper if the cause for many illnesses were eliminated. At least 2 factors may work against this solution. In the case of food, people may not heed the warnings because newspapers etc., have been crying wolf too often and where the fault lies with the production of foods, the consumer is likely to feel powerless against the "powerful." This last factor also plays a role in the lack of enforcement of the Clean Water Act, which although a Federal law is dependent on local enforcement and local courts in the sense that enforcers are under pressure by local interests, e.g. a federal prosecutor may be afraid to lose his job if a local Representative or Senator needs local votes. (One thinks of former Senator Pete Dominici from New Mexico who put pressure on the Federal prosecutor to bring voter fraud cases against Democrats just before the election of 2006 and then had him fired when he refused). The water pollution article is especially alarming as it shows a photo of the damage done to a child's dentures by certain chemicals in the ground water in West Virginia. These instances bring to mind the old saying about "an ounce of prevention", in particular if one thinks of the costs that will be borne by the taxpayer for enforcement and clean up of the pollution or the illnesses resulting from food related illnesses (E.coli, salmonella) or obesity (diabetes).

I have mentioned the problem of E.coli in an earlier blog on hygiene in the fields. But another of those horrifying tales, a front page article in the 10-4-09 NYT, about the suffering caused by greed must be mentioned here. It relates the suffering of a young woman who, in 2007, was infected with the severe strain of E.coli from eating a grilled hamburger that had been frozen; her nervous system was affected and she can no longer walk. The article goes on to discuss the origin of the products that go into a hamburger. It turns out that slaughter houses do some testing but "few grinders test ingredients, citing costs and and the fear of recalls."(italics provided) The woman was one of 940 people that were sickened and the company, Cargill, recalled 844,812 pounds of ground beef. The components (various types of scraps) of this beef came from 4 different processing plants in three different states and Uruguay. Two of these plants had earlier been found to have failed USDA or other inspections. After the recall, a spate of inspections showed that 55% of plants did not follow their own safety protocols. In a reaction to this article, the president of the American Meat Institute wrote a letter to the NYT (10/7/09) in which he stated that the incident of E.coli now occurs at a rate of less than one half of one percent, having declined 45% since 2000. This raises questions in my mind: 1) did the decline occur mostly after 2007; 2) does it mean that there's still 55% left; 3) one percent of what?

On the radio this morning a correspondent was interviewing the president of a fancy "longevity" resort on Turnberry Isle in Florida that aims at improving health by way of stringent dietary requirements, among which fruit and vegetables are dominant, in order to reduce high blood pressure and obesity related illnesses. Here I am reminded of the 1970s food revolution in France that introduced the nouvelle cuisine with one chef creating a cuisine minceur (a reducing diet of a 3-star cuisine) in a resort in Eugenie-les-Bains (SW France). For those who can afford it.
In my own daily living I have also adopted a regime of no smoking (without withdrawal problems), normally 5 meatless (and mostly organic) days (restricting red meat in particular) and when birding selecting usually a large salad for lunch with 2 glasses of wine rather than beer.
We use, almost always, only extra virgin (Italian) olive oil and very rarely (saltless) butter and cubed bacon (fat removed afterwards) only when making a stew.

At home I have on average less than 2 glasses of wine per day with the main meal and on days that I have no wine I may have a shot of Calvados. Instead of breakfast I have a large glass of orange juice (with pulp) and otherwise I drink a small can of tomato juice and San Pellegrino. I try to avoid having two meals a day. I must admit that vegetarian meals leave me with an unsatisfied feeling at the end of the day. My doctor finds my vital organs in good shape, probably because until my retirement and especially before coming to America in 1957 (at 27). As a kid my daily routine consisted of walking to school (4x 15 minutes in primary school and 2x45 to secondary school), bicycling to work (2x30+ minutes/day, depending on the always present Dutch winds). And at school there were twice weekly calisthenics as well as, voluntary, school sports; I was on the soccer and handball (a sort of soccer played with the hands). In addition there were long bicycling trips on the weekend or hikes in the dunes. As a teenager I had also a series of kayaks and spent days (incl schooldays!) exploring nature in the fields in our canal-rich region. As a merchant mariner (approx. for 1 1/2 year spread over 5 years) I played soccer whenever we were in a port with another ship that could produce a team and during a 7 month period in France I played soccer (all Dutch players are assumed to be good!) as a semi-professional in a small town. I was provided odd jobs (gardener, goatherd and what have you) by sponsors of the team and we got some pay whenever we did not loose. It was an often harrowing experience. In my early years, as a result of the Great Depression of 1930/31 and because of a long tradition of thrift our family had meat only 2x and fish 1x per week, while during the German occupation (1940-45) there might not be any meat and all food quantities were gradually severely limited (which gave the name "hungerwinter" to 1944/5). Underweight when I arrived in the US in November 1957, I rapidly gained too much weight, mostly as a result of ice cream and fast food. It could have been worse but for the fact that, living in the city of Philadelphia, I walked everywhere and hiked whenever out in nature. From 1983 to 1999, when I lived on campus I walked everywhere, climbed stairs to my classes (and toilet on the 2nd floor of my house). Though gradually adopting a less physical way of living, I have maintained the same weight ever since 1960, even when after my knee replacement in 2000 (at 70) and other muscle problems I have become more sedentary. Maintaining our hilly 2 acres and (organic) gardening helps.