Sunday, January 9, 2011

Preventable Deaths

Of the top five countries, France and Japan provide health care via the Bismarck Model, Australia uses National Health Insurance, and Spain and Italy use the Beveridge Model.


  1. Thanks for your comments on KevinMD reposting my Health train Express blog.

  2. Of the top five countries, France and Japan provide health care via the Bismarck Model, Australia uses National Health Insurance, and Spain and Italy use the Beveridge Model. [end quote]

    There are budgetary problems in these countries though. France's public option means the average worker loses about 25% off their paycheck, then the usual taxes. If someone makes $60,000 they would pay $15,000 for the public option, then more taxes annually. And there are still problems in the system and they are suffering from budgetary problems and either need more money or less care.

    Same with Japan......the average person has to pay almost 1/3 of the bill.....hospitals are not allowed to make a profit....this hurts innovation.

    The domino effect is in place with these recommendations.

    We could keep going.....but in the UK many people are hurt via socialized medicine. I tend to think they are great at boo boo care :) but not catastrophic care. I would prefer to pay Minute Clinic for the minor stuff, and have insurance for the serious stuff. I want to keep innovation at the helm because, ultimately, without America's research countries around the world would not have cheaper medicines (look at what Canada spends in research. They feed off our sacrifice.....we are their rich inheritance...and that's great....we pay so they gain...but if we duplicate them who will pay for the research which is already hard enough to finance?). We run the test kitchen, they get to eat for free.'s a wonderful opportunity we offer the world...we can take pride in the fact that we are helping others....but it will be costly to us.

  3. As we'll see, citizens in many of these countries pay higher overall taxes, although the per capita expense on health care is less than one might think. It's also the case that the people of these countries are generally satisfied with their health care systems, whereas Americans are not.

    Also, the systems of all developed countries -- including the United States -- face budgetary problems because of two common issues: (1) the current state of the economy, and (2) aging populations. But our issue is especially acute because (1) we already spend more per capita on health care than any other country; (2) US government expenditures on health care are surprisingly high: A greater percentage of budget than any of the Beveridge countries; (3) flat income growth since 1980 has not kept pace with medical inflation; this combined with the high number of retirees leaving the work force has placed Medicare in grave danger.

    Certainly the United States offers some of the most technically advanced care in the world. However, the nature of our system places constraints on availability and builds in incentives for overuse.

    The point of all this being that there is no such thing as a perfect system, and we'll always have to accept tradeoffs. The question is, which ones?

  4. I am rushed, but caught your point about the "aging population". I believe the countries you mention do not run up the huge bills we do in the states for end of life care . We know the last six months of a person's life are costly on the system. The admistration's answer....appointed panels that will make life or death decisions. When Nobel winning Paul Krugman said on ABC that we need "death panels" and a "VAT" the outrage on the NY Times blog was interesting.....yes the cyber crowd was aghast over higher taxes via a VAT! Sigh! Liberal minded Krugman was being economically realistic, but it is morally wrong. The repercussions of a mindset set solely on balancing a budget while casting morals aside will come back to bite us. In the UK they can allow viable babies to die. Valuing money above life is not a good matter how much we justify it.

  5. I wanted to bring up lack of covered medicines under the UK model. The expensive ones are not on the list. And paying out of pocket is not always possible. Our cousin just died there (waiting list fatality...stomach cancer). The anti nausea chemo drug was not covered, and either ware some other cancer drugs. You need private insurance to cover that. His end of life morphine was rationed and even with hospice his family was grateful when he died because of rationed pain meds. this why they are called the land of the dirty sheets, and most doctors carry private insurance. We live in terror of getting sick while visiting...not the cost...being a UK citizen means it is free.

  6. Trade offs? How about a small co pay for Medicaid patients who often abuse the system. If half of what is spent in this country on medical payments is from the government it would appear to show we are half way towards a public option already ( that is of you include the VA, Medicaid, Medicare, and State Children's Health). moving in this direction at this rate will move us into socialized medicine for the masses. I, personally, do want single payer or public option like Canada or North Korea.

    I tend to think we do not need more money thrown at the problem just more efficiency...there is vast waste. I think our GDP is just under 20%....but Canada is at half of that....hence why they have waiting lists, lack of new equipment and therapy, rationed care amd denial of claims. I'll take our system over that....but I would like less government amd more free market.

  7. The Affordable Care Act does not call for appointed "death panels." It extends Medicare to end-of-life planning for seniors who desire it. More here.

    I have my doubts about NHI, but am certain that what we have now does not work and is on the brink of collapse.

  8. Collapse? Could you expound! Do you think government involvement will cause collapse? Or help?

  9. From

    JANUARY 6, 2011 9:47PM
    Afraid Of Death Panels? They Already Exist!
    RATE: 0 Flag

    By Jillian Barclay  
    Death Panels Already Exist! They Are Called Utilization Management!
    Death panels! Oh, No! That over-reaching and intrusive Federal Government! Trying to get between a doctor and patient! How dare they? Decide who lives or dies? Well, guess what? Death panels are already a reality and not just paying for end of life discussions with your doctor as was proposed in the Health Care Affordability Act. People need to realize that death panels exist at every private insurance company in this country! They are called utilization management or utilization review departments. They are the insurance company employees that decide, based on medical information submitted by your doctor, whether you will receive a certain treatment or not. They make these decisions based on cost versus probable outcome. How many days are you allowed to stay in the hospital? Are you allowed to have a surgery suggested by your doctor? Is your chemotherapy going to be approved? Will you be allowed to have a CT scan or MRI? How about that liver transplant?

  10. I think you may be in agreement with this short, well done video? That I disagree with:). I do not view health care as a right, although I see a responsibility to provide care to those who truly need it. For that matter I think the government has done a poor job with education, providing food, etc., etc. and created a lot of unproductive facets and programs. We expect more than the government was ever set up to provide.

  11. The government has done barely any job at all in the areas you refer to because public health has never been much of a priority in this country. But it's a matter of funding, not ability.

    There are two areas (at least) in my lifetime where government attention to public health has been spectacularly successful: anti-smoking programs and regulations, and seat belts. Public and private anti-smoking efforts (many of the private ones are publicly funded) have paid off so well that they almost cancel out the fattening of America, relative to other countries.

    Building up the national, state, and local public health infrastructure would save billions (perhaps trillions) of dollars via preventive measures. And not just in sickness: Kaiser Permanente conducted a pilot program in California that educated on how to avoid falls. The control group had a statistically significant greater number of fall and broken bones.

  12. "Collapse? Could you expound! Do you think government involvement will cause collapse? Or help?"

    Alice, you're much too focused on government involvement. It's a tool, but it had better not be the only one. Similarly, there's no point in not taking advantage of all available tools.

    "Implode" might be a better word than "collapse." Some economists (Laurence Kotlikoff, to name one) believe that it has already begun. This is anecdotal, but I have spoken with physicians who believe it is a matter of time. The source is the fragmented nature of the delivery of health care, which comes from the government (Medicare/Medicaid); employer insurance of a wide variety of quality, depending on the size and nature of the employer (let's just say that it's good to work for Microsoft or Google); self-insurance; and out-of-pocket payment (the uninsured).

    This has resulted in an apparatus (it's not really system) that

    *has not controlled and has in places exacerbated medical inflation;
    *has been unable to respond effectively or efficiently chronic disease; *incents treatment instead of wellness;
    *is supply driven instead of value driven;
    *rewards effective marketing over effective care;
    *encourages both overtreatment and undertreatment
    *for those under 65, is most open to those who need it least and least open to those who need it most

    Underlying all of this is a rapidly increasing pool of uninsured (60M at any one time) and underinsured (15M and rising) because employers are increasingly unable to provide insurance and a Medicare system in serious financial trouble. We baby boomers are swelling the ranks of the retired and aren't being replaced because we had fewer children than our parents. Meanwhile, income -- which finances Medicare -- has remained flat in real terms since 1980 while medical inflation has averaged about 5% annually since then.

    The ACA buys time and provides badly needed consumer protections, but that's about it. If we don't get everybody into a single program -- and economists and health policy analysts across the political spectrum agree on this point -- the supply of health care will dry up as it serves fewer and fewer people and may well not be able to guarantee adequate health care to the elderly.

    Even a single program won't be enough without a robust commitment to public health and primary care, containing chronic disease, and an IT infrastructure that measures and reports quality and that reduces administrative overhead.

    That's what I mean by "collapse."

  13. I am trying to find the truth on this matter....and it sure ain't easy!:). Just asking questions at kevinmd got me muted, so I went to The Huffington Post.....over 3,000 posts there about an article covering this with some patches filled in.  It is riveting on the level of what isn't being told about Deer.  

    I am finding doctors are just too eager to believe this, under the guise that will support their own...often faulty logic.   They are too quick to proclaim anti vaccinationers as deluded nuts.  I went to the  site and read Wakefield's own words....they were so different than I anticipated.  Refreshing on a level because they lacked the pride I usually hear.  Basically, I just want the medical community to give me all the facts...then let me decide...but, the more I delve the more I see ignorance displayed....most doctors want a blind form of trust in them.  I can find out the ingredients of the foods I buy, but the average doctor knows not what is in the shot yet expects the good patient to obediently offer up their precious child's arm just because they claim it is safe.  Yet...ask you to sign a waiver.  Odd!  One wonders who is really ignorant in this debate? disagree with you....we are leaning on the government to do what we should be doing.  Do you read David Brooks from The New York Times!  Great article recently.  At 3 a.m. God knows what my mind is thinking, but I believe the title is something about the Achievement Test.  It is not a lack of funds in education or medicine...with education we have oodles of funds but not enough good...really good teachers (when you get tenure after two years for just showing up few will feel the incentive to go above and beyond.  Did you see Waiting for Superman?  The maker of the film is a liberal, but it is really revealing.  We have the money and supplies...we do not have commitment in huge numbers.  There is much the medical establishment could learn from this film.  One problem is the teacher's union wouldn't allow their members to vote on an intriguing offer.  They offered to double the pay of good teachers in exchange for the two year tenure.  Na da..said the union....while kids languish...same with medicine).

    I am focused on how to help people best.  I have one child with cancer, and my oldest had an inoperable brain tumor.  The healthcare bill is of high interest when you have two children with pre existing conditions.  

    I believe, deeply, in human rights....but precedents based on emotions are dangerous.  David Brooks made a good comment.  He said that during the horrible snow storm a few weeks ago everyone sat around complaining about when the city would shovel them out.  His answer...get a shovel.  Let's help ourselves instead of the entitlement....non productivity and dissatisfaction we get from reliance on the government.

  14. What do you think of this portion from The Washington Examiner today?


    Well, not with the new healthcare law, as Avik Roy nimbly points out in his point-by-point takedown of the DNC's pro-ACA talking points. Rather than a heavily regulated, heavily subsidized corporatist healthcare reform bill that takes many of the worst aspects of the status quo and entrenches them further, what American healthcare needs is free market reforms that put more choice into consumers' hands while lowering government involvement in the industry across the board.

    Government can still be a part of the solution - indeed, government will need to be a part of the solution, if only to repeal decades of bad healthcare legislation.

    Low-income insurance vouchers or catastrophic insurance vouchers could empower low-income Americans to purchase their insurance on the market. Meanwhile, forcing insurers to compete across state lines - and reforming the insurance regulations to apply to the state of the insurance carrier rather than insurer - could drive competition and lower cost across the board.

    ACA represents a failure of imagination - and while I was genuinely torn during the debate over reform between, on the one hand, my awareness that our current system is horribly broken and that a lot of people are unfairly left out in the cold, and on the other hand my dislike for what has ended up becoming a huge, expensive subsidy for insurers, drug companies, and the middle class - I think I can firmly say that the new law is a mistake. It may be a mistake that really does benefit a number of Americans, but a mistake nonetheless, and one that will end up costing the American taxpayer a hell of a lot more than the very conservative - one might say absurdly conservative - cost estimates put out by the CBO. And there's no way Republicans will be able to repeal it in time {snip}.

  15. One man's failure of imagination is another man's political miracle. Roy, to me, is the most articulate of the privatizers. But he places ideology ahead of pragmatism, and true health care reform needs the latter. Like many health care analysts (left or right) devoted to a particular approach, he underestimates the political heavy lifting required for systemic reform. In the case of health care, I see at least two preconditions:

    * Severe external pressure on the political system from patients (i.e., voters), the medical community, and the business community to reform the health care apparatus in a way that relieves economic pressure on them and that is based on -- however it's expressed -- value-driven care;
    * A willingness on the part of Congress to pursue a bipartisan solution.

    I don't like voucher-based health care because it will result in a two-tier system in which the most at-risk groups -- low income people and the elderly -- receive lesser care. It won't change the fundamental problem that exists now: Health care is most available to people who need it least, and least available to people who need it most.

    Philosophically, I don't share Roy's conviction that the market/profit motive is best positioned to deliver value-driven health care on a population basis. I have no reason to share it, as the profit motive has failed us so far and as no other developed political economy has drawn that conclusion.

    The privatizers have drawn one essential conclusion and spread another beyond the academe. The first is the importance of health literacy; the second is the recognition that health care has become supply driven, which has created genuinely perverse incentives. They also promoted the concept of Health Savings Accounts, which are now a standard part of any medical benefits package. All of these should be of systemic reform, but not in the way the privatizers insist is the One True God.

    BTW, no one will talk about it, but a voucher-based program implies mandates. Affordability is only one barrier to health care access; insurance companies screen applicants on the basis of health and will continue to do so unless forced otherwise. If they are mandated to sell and people aren't mandated to buy, premiums will skyrocket and the vouchers will be worthless. Massachusetts discovered that, which is why they instituted the double mandate. Five or six other states have tried single mandates and dropped them because of soaring premiums.

  16. It's not a matter of people asking the government to do for them what they should be doing themselves. Health care is a 15T dollar business and the second-largest sector of the economy. The likelihood of individual behavior influencing that is nonexistent.

    Say you want to reduce the number of ED readmissions of pediatric asthma cases by half, an accomplishment that would pay for at least ten years of earmarks in twelve months and that would greatly relieve pressure of EDs (and taxpayers). But the problem isn't rooted in individual negligence: It's because there's no public health campaign geared at this, because there are not enough primary care physicians, and because ED personnel are only intermittently trained in pediatric asthma diagnostic techniques. I don't know of any way to accomplish this goal without a government commitment at the federal, state, and community levels.

    Same goes for containing adult asthma, cancer, depression, diabetes, and heart disease. Why these five? Because they consume 75% of health care expenditures. The effects of all could be reduced -- there are plenty of sensible policy measures out there -- but not without a public commitment. The market won't because the incentives there are to not contain them. And in a nation of 311M people, uncoordinated individual measures can't accomplish much.