Thursday, September 10, 2009

The Straw Man Argument

A "straw man" argument is when you create an opinion that is ridiculous or false, then argue against it. Think of a debate between a congressman and a scarecrow, with the congressman being allowed to tell you what the scarecrow would say if it could talk. The idea is to make one position look stronger by making it appear that the only other choice is untenable.

The straw man in the health care debate is the argument that we shouldn't meddle with the health care system because the majority of Americans already have fine health care. Why risk making things worse for 80% of the country just to try to improve things for the other 20% ( some of whom, admittedly, are choosing to spend as much on cigarettes, alcohol and street drugs each month as it would cost to get health coverage)?

Why is that a specious argument? Well, the fact is that we aren't being given the choice of keeping things just the way they are. Things are changing all by themselves, and not in a good way. Those 80% of people are in for a rude awakening if the American people, through the democratic process, don't take control of their own future.

I spoke to someone recently who works at a big health insurer. Her job is to collect deliquent accounts, the premium money from the employers who are using that company to insure their workers. She's facing a possible layoff.

Who lays off collection agents during a recession? A company that has a lot fewer accounts to collect from, that's who.

Insurers are hemorrhaging subscribers. And the people they are losing are the young healthy people who aren't making high incomes yet -- exactly the low risk people companies prefer to insure. And the more healthy people decide to "go bare," the more premiums have to rise to cover the sick people who "can't afford not to have health coverage." People who are already sick will make sacrifices to continue to pay their premiums that healthy people may not be willing to make. Costs are going up at a steeper and steeper rate. Small companies see it first, because they don't have enough workers to absorb risk if one of their employees get sick. But it's going to spread through the entire market, with entire market sectors suddenly dropping employee health coverage once one big competitor does.

Repeat: You aren't going to have the choice of keeping your current coverage if things don't change. Your insurer will eventually (say in 10 years) make the decision to drop out of the health care market and invest its money in more profitable ways. Insurers are financial institutions at their core. Losing money isn't what they do.

A lot of people assume that "big insurers" and "big pharma" are opposed to health care reform. In fact, they were right there at the table from the beginning this time around. Their futures depend on it. They need to see it happen, and they want to make sure the final product is favorable to their own interests. As we all do.

Give up the notion you can keep things as they are. Understand that if insurers are afraid of competing against a public choice, they are expecting that in the future their coverage will be less attractive than Medicaid is now. If, in the future, your health insurance plan is so bad you're wishing you had the choice of being on Medicaid, you will be very sorry your only participation in the current debate was to wave a teabag and say you're against any change.

Wednesday, September 9, 2009

Covering illegal immigrants

President Obama's speech to a joint session of congress last night was marred by a Republican congressman who seems to have flunked "Raising Your Hand Before Talking in Class" in kindergarten. It was unprecedented in the U.S. Congress, which generally maintains decorum better than a lot of other legislative bodies.

It was particularly unfortunate that his shouted insult was directed to the first African American president of the United States. Many people will conclude, rightly or wrongly, that he would not have behaved that way to a president of his own race. It will just create a distraction by inflaming tensions that are completely off-topic to the health care debate.

But lets look at the substance here. What will health care reform mean in terms of the care given to illegal immigrants?

Probably nothing. I mean, let's get real. Look at what happens now.

Illegal immigrants are not eligible for government health coverage, no matter how ill or how poor. The only assistance the government is offering is a trip back to their own countries to get care there.

So any care they get they must pay for themselves. Few are able to get jobs that pay health benefits. They usually work for the employers whose wages and benefits are too low to attract legal residents.

Those jobs tend to be dirty and dangerous, and they tend to involve long hours. People are going to get sick. But they don't have the time or money to go to a doctor.

So they wait. And they get sicker. And eventually, they go to an emergency room.

Now, emergency rooms by law cannot refuse to treat emergencies. It's a federal crime to turn away women in labor or people with true emergencies because they can't pay. And some bureaucrat in an office thousands of miles away gets to play Monday morning quarterback after the fact to decide what was an emergency. So ER doctors are going to err on the side of caution in treating problems that might conceivably in some rare circumstances actually be symptoms of a true emergency. And they'll tend to avoid even asking about insurance or legal status rather than give someone any reason to suspect their decisions are based on financial considerations. So even those doctors who are so jaded by people who abuse emergency rooms that they have forgotten the compassionate impulses that attracted them to the field of medicine are currently treating illegal immigrants.

They just aren't geting paid.

And that care is costly, both because an ounce of prevention costs less than a pound of cure, but also because the lack of a "medical home" -- a primary care doctor who will coordinate care -- means that a lot of tests will be duplicated each time they show up at a hospital.

What will change in the new system? Like I said, probably nothing. No one ever lost an election because he lacked compassion for undocumented immigrants. And since the government doesn't need to worry about trying to get this population cared for more cheaply when it can already get doctors to provide this care for free, why would politicians or either side of the aisle bother to try to change things?

Everybody needs to chill. There are more important details to argue over than the one everyone already agrees on.

Saturday, August 29, 2009

Co-ops vs. the Public Option

One of the ideas floating around Washington is to promote "co-ops" -- organizations of patients/providers who would join together and be chartered to provide their own healthcare coverage, rather than purchasing it from insurance companies.

Well, God bless 'em if they can pull it off. Here in Philadelphia, where there are a small number of powerful commercial insurers, each controlling a large portion of the market, doctors and hospitals tried to do something like that, too. It failed.

One problem is that such a group is assuming a lot of risk for the future cost of care. Assessing risk is something insurers do very well. You're going to be hard pressed to do a better job.

As far as the idea that the co-op would have less overhead, what really would happen would be that the co-op would have a huge amount of initial overhead with the costs of setting themselves up as a legal entity, creating a plan for what employees they need and hiring those people, creating the data management structures to make sure their premiums are collected and their claims are paid, etc.

And as far as the idea that the individual co-op members would be more likely to control their own healthcare costs if they were at some financial risk for the company's claim experience: You're still going to have to deal with selfish people who join the co-op in the expectation that there will be less restrictions on the health care they demand, and who are happy to let the costs be shared among the other members.

In addition, the co-op model doesn't address the problem of large insurers using their clout to demand discounts from providers, suppliers, and drug manufacturers, and the effect of those demands on raising prices for individuals. Those insurers can use those deals as a weapon to keep the co-ops from being able to compete on equal ground, just as the Wal-marts of the world demand that suppliers not give the same discounts to their competitors.

The only co-op that could hope to survive would have to be large enough to eat the start up costs and to negotiate discounts on an even footing with existing insurers. They would in effect be a mutual insurance company themselves. We already have such companies, and they aren't in any hurry to get into the health care business. If health care reform changes their incentives, great. I'm interested to see how it plays out.

If people want the option of co-ops: Let's do it, and I wish you the best. But they are not an alternative to providing a public option, because they will not be strong enough to provide competition for established health insurers. Conservatives complain that a single payer model would not be under pressure to maintain quality or control costs. We need competition (a good conservative value) to do that. I agree. And if private insurers can't compete with some government-run healthcare plan everyone says they're afraid of, those insurers need to reconsider their business model.

Friday, August 28, 2009

Ad hominem political arguments and health care reform

My clock radio went off the last two mornings playing audio clips of people praising the recently deceased U.S. Senator Ted Kennedy. No one trotted out those people for comment while conservatives had been heaping contempt on him for as many years as I am old enough to remember. But that's how things go when you die.

To be sure, he was an easy political target. He was the poster boy for why drinking, driving and philandering are a bad combination. And he was politically powerful enough to survive what would normally have been a career-ending scandal. His satisfied constituents reliably sent him back to Washington for term after term.

He passed a lot of bills to protect the powerless in society -- the sick, the disabled, the children. But he never lived to see universal health care passed. It had literally been his life's ambition.

And conservatives used that fact to try to inflame opposition to universal health care. Just call something "Teddy Kennedy's (fill in the blank)" and the Ditto-Heads (their own term for themselves!) would line up against it without understanding anything more.

In rhetoric, the study of the use of language for persuasion, it's called an "ad hominem" argument -- an argument "against the person." Rather than arguing the facts of someone's point of view, you attack the person holding that point of view.

It's reminiscent of a quote from Adm. Hyman Rickover: "Great minds discuss ideas, average minds discuss events, small minds discuss people." (Adm. Rickover actually attributed it to an "unknown sage," but no one has been able to trace it definitively to anyone earlier.)

Politicians and the marketers creating their political ads have studied rhetoric, and they know exactly what they're doing and why they're doing it. They think you're stupid.

Since Sen. Kennedy was diagnosed with a brain tumor, he'd been dragging himself into Washington long after it became unwise to do so, even collapsing at an event during President Obama's inauguration. He saw the light at the end of the tunnel. Had a bill been passed by the original August deadline, he would have lived to see his dream fulfilled. A lot of conservatives would have hated to have had that happen.

But they've now turned their vile towards Speaker of the House of Representatives Nancy Pelosi. She is singled out for their scorn among all the people backing reform. Her sin seems to be simply being a woman in a position of power, which to a lot of people means "a shrew." People who have no idea what she actually stands for or has accomplished are distanced from health care reform by ads calling it "Nancy Pelosi's plan." (Reform opponents at least had the good sense to realize it would have looked bad for an ad calling it "Teddy Kennedy's plan" to be running when he finally died.)

Health care reform is an important issue, too important to be argued through ad hominem attacks, either against Nancy Pelosi or against any of the congresspeople on the conservative side. We live in a country where no one without health insurance would ever be left to die on the side of the road after a car accident, yet there may be little assistance forthcoming to pay the hospitals and medical providers who stepped forward to care for that uninsured person. If you want to live in a civilized society, to know that you can get care in a disaster and that you won't have to look at people lying on the street dying in front of you if they suffer a catastrophic illness, you have to share the cost of being in a civilized society.

Let's keep the arguments civilized, too, shall we?

Tuesday, August 25, 2009

Report from the White House Conference Call Briefing for Physicians, August 25, 2009

The White House Office of Health Reform hosted a conference call for physicians last evening. 2,700 physicians joined in the conference call, and 400 submitted questions in advance, evidence of how serious physicians are about trying to make sure this is done right. It was not open to the press, and the idea was that doctors could speak freely, though there wasn't much time for open questions.

Much of the conference was a general overview of the goals of reform as well as addressing the most common questions that had been submitted. They wanted to reassure physicians that they "get it:" Doctors are spending too much time on paperwork and bureaucracy, and that hurts patients by reducing the time we can spend with them. It's not what we went to medical school for. Keeping the current system isn't an option anymore, as the costs are spiraling out of control. Malpractice costs have to be reduced, although a simple cap on non-economic awards has had unintended consequences in some jurisdictions. The payment system is broken, and it's insane that we have to endure the annual handwringing ritual while we wait for congress to come up with another band-aid fix for the automatic pay cuts created by the "sustainable growth rate" formula (SGR).

Some of the features of the new system they wanted to highlight:

-- Insurance companies will no longer be able to exclude pre-existing conditions, nor can they limit coverage or terminate policies once people are sick.

-- There will be limits on out-of-pocket expenses, so that high deductibles and co-pays don't prevent patients from being able to obtain services that are otherwise supposed to be covered by their plans

-- Annual and lifetime caps on coverage will be prohibited, so catastrophically ill people won't suddenly find themselves with no coverage because they've passed some arbitrary maximum amount of expenses

-- Preventive services that can be shown to save money for taxpayers will be completely free to patients, with no copays or deductibles. The assessment of cost effectiveness will include not only what such preventive services save in future medical costs -- the impact that insurers already look at, although their focus may be on short term cost-effectiveness only -- but will also include the overall cost to society in non-medical costs and lost productivity. It's a big shift from Medicare's current policy of not paying for preventive care except in a very limited number of procedures.

-- There will be more emphasis on "global payment formulas" rather than paying per procedure. If you find that spending more time on one visit keeps your patients healthier than five short visits, go for it. Under the current system, Medicare and most other insurers significantly underpay for long visits, but short ones tend to be paperwork-intense and unsatisfying for doctors and patients. The idea is to reward quality rather than quantity of service.

-- There will be money to increase the numbers of primary care physicians, both through loan forgiveness with programs like the National Health Service Corps and through medical school scholarships

-- The planning already includes an "SGR fix" -- no more pretending that expenditure won't exist and acting surprised when it has to be added to the budget.

Obviously, whether these lovely promises will work will depend on the details of implementation. For those of us working with managed care in the 80's and 90's, we know that a well-run capitated health plan can reduce paperwork overhead, provide superior results in patient care, and allow physicians the choice of how best to budget their time to keep their patients healthy. We also know that in recent years capitation has been used by commercial insurers as a means to dump more of the insurer's costly bureaucratic tasks on physicians and their staff while keeping reimbursements stagnant, making a government-run option actually look like a better alternative.

It will be important to have flexibility to reward mini-centers of excellence, so physicians who become particularly competent in managing a particular illness aren't penalized by having large numbers of sicker, more time-consuming patients without being compensated for it. (Currently, insurers usually have programs for a small number of common, costly diseases like asthma, heart failure, and diabetes, but they have nothing for less common conditions like deafness or paraplegia that could be better managed if a few primary care doctors had a significant number of similar patients and could justify special equipment and services for them.)

It will be important to resist the urge to micromanage quality control, creating a whole new mountain of paperwork to suck up time and money. Whenever possible, quality control should flow from patients being educated about how to recognize quality, and then letting them make choices for themselves and their family members that reflect their personal experience with health care providers.

Monday, August 24, 2009

End of Life Counseling vs. "Death Panels"

"...there are no 'death panels' in the Democratic healthcare bills, and to say that there are is to debase the debate." -- Charles Krauthammer

Thank you, Mr. Krauthammer, for bringing a bit of sanity to this discussion from the conservative point of view. As has been pointed out, this part of the health care reform bill only included incentives that had previously been non-controversial and which had bipartisan support -- before people started looking for any shred of evidence to back up their assertion that the purpose of healthcare reform was to pull the plug on Granny.

Krauthammer goes on to say, however, that living wills are of no value (though he has one himself), that ill people will change their minds anyway when the time comes, that family members will just ignore the living wills and use their own judgment, and that just bringing up the topic pressures patients to choose to forgo care.

It's true that a lot of people think there should be only one "right" answer to the question of using heroic measures to keep a terminally ill or vegetative person alive. But that's exactly why such documents are useful. If you happen to want to be kept alive at all costs, it's a good idea to put it on paper rather than assume that if the situation arises, people will know that's how you feel.

In fact, there are a lot of misconceptions about the whole topic. With the limitations on Medicare funding, nobody would be offering to hand out extra money to doctors unless they felt the need were very strong.

Counseling about advanced directives should start with young adults. After all, anyone could end up in a coma from a car accident, pregnancy complication, or other sudden event. It may even just be a temporary situation where decisions must be made about emergency procedures. But someone will have to make those decisions, and in those situations, it's especially hard on loved ones to bear that responsibility without any guidance or confirmation of their authority to do so.

Leaving the discussion until people are diagnosed with terminal illnesses certainly would imply that patients are really just expected to gracefully give up on life support. And often, the first time the issue is raised is at the time of a terminal diagnosis. That's why an incentive to move the discussion out of the oncologist's office and into the primary care doctor's office is an excellent idea.

The most important thing you can include in your advanced directive is the choice of a person to make decisions for you. No piece of paper can ever anticipate all the possible situations that could occur that might require slightly different decisions. Usually, the most appropriate decisions will first try to bring the person through what may be a reversible process, then -- when it becomes apparent that medical science can't make him better but can make him worse -- to change the focus to measures that make sure the person is not in physical or emotional discomfort. We can't always cure people, but that doesn't mean physicians no longer have any treatment to offer at that point.

While hospital personnel will informally use the legal next of kin as a spokesperson if there is no one designated, legally, they have no grounds to do this. The courts consistently rule that such a person should be appointed by the courts, not the doctors. Should there be any disagreement about the decisions being made for you, especially among family members who may be equally closely related to you, it can end up as a nasty court battle. That can exhaust your family's financial resources (that are needed to care for YOU) and can permanently destroy the bonds among family members (who would otherwise be cooperating to help care for YOU). If you have designated one surrogate decision maker (as well as a backup person), if you have informed your family members of your choice, and if you have discussed your preferences with your surrogates, it takes a lot of the pressure off them and everyone else.

What's more, you may happen to know that your legal next of kin does not see eye to eye with you on these matters. You may know he/she may be prone to faint in hospitals. You may have different religious beliefs than your family members. You may have a friend or life partner your family doesn't get along with but who you want to be with you if you are ill. You make even decide the best choice of surrogate should be someone outside the family. The best time to make these decisions is when you're feeling well and still have plenty of time ahead of you. Once you've created your advanced directive, you will continue to communicate your feelings and opinions with your surrogates and other family members. You may even re-do the document as you get older or in response to other people's experiences. That's why the law paid for periodic discussions of end of life issues rather than pressuring people to sign their lives away on some document, as if it might be used to override their own wishes later.

Most people don't think about end of life issues unless they are nudged. That's why the incentives to have doctors do some nudging could help.

Now what about the objection (such as was raised by Betsy McCaughey on The Daily Show) that having the law have a very specific list of topics that should be discussed would be a financial incentive for doctors to get people to agree to forgo care? Well, let's be realistic here, folks. If the law offers to pay people without specifying what has to be included, especially for a topic many of us are uncomfortable talking about in the first place, you're going to have doctors handing out brochures and calling it a discussion, just as you currently have pharmacists asking you to sign a log form and calling it counseling. If anyone objects to particular items in the list, sure, let's discuss that, but do Republicans really want to say that patients should be kept ignorant about any of those items?

There is also the idea that people will be pushed to have living wills in hopes it will be a big money saver for Medicare. And I'm sure there are people outside of medicine who feel that way. After all, there are statistics that 50% of Medicare expenditures are during the last year of a person's life. But the reality is that it usually isn't anything as clear cut as a comatose person being kept alive on a ventilator for months.

The more common situation is something like this: A person who has been holding up well with a chronic illness or who is advancing in age gets hospitalized with a urinary tract infection. That's not hard to treat, and she comes home from the hospital within a few days. But a month or so later she's got pneumonia. Again, it's easy to treat, but maybe she's not functioning as well as she was when she comes home. Maybe she falls and breaks a hip, and it's back to the hospital for a hip replacement, then to rehab. But while she's at rehab she gets confused at night from all the room changes in strange environments, so it's back to the hospital for a cat scan to make sure she didn't get a bleed in her brain from the blood thinner she's getting. Maybe she goes back to rehab after getting some tests for her delerium, or maybe she goes back home. She's getting nursing visits, multiple medications for her usual illnesses plus a few extra to tie up loose ends from the hospitalization. There are follow up visits with the primary care doctor, the orthopedist, the neurologist, and whoever else. Little things continue to come up. And eventually some event occurs that causes death, maybe in a hospitalization for something that doesn't respond to treatment so well, or perhaps the person will simply be found to have died in her sleep at home.

You see it often: Death doesn't always come because of some untreatable illness. Even people with cancer don't necessarily die of the cancer itself. People really do die of old age, and people naturally approaching death just become more susceptible to all kinds of simple illnesses, all of which require money to treat. But you're only going to see that in retrospect. A living will wouldn't change what you're doing or save that much money. None of these hospitalizations would be considered aggressive life support, because you aren't going to know it's the last year of someone's life until they do die.

You have an advanced directive because it makes an inevitable part of life more civilized for you and for the people you love. It's a tool to serve your needs in whichever way you feel best suits you. It's a document to provide guidelines for your caregivers to encourage them to respect your wishes, not a contract to bind you to youthful ideas you might abandon when you're closer to death.

If after hearing all this information, you want to complete an advanced directive form for yourself, there are sample forms at for each state. Your own advanced directive may be more personal, but these forms will help guide you through your own state's legal requirements. Take it to your doctor to learn about what all the terms mean. (I can't tell you how many people don't want to be kept alive on a ventilator but don't realize that being put on a ventilator is usually part of getting CPR.) Then talk to your family and chosen surrogate decision makers. The piece of paper is to make things easier on you and your family, but it's only the beginning of the discussion.

Saturday, August 22, 2009

Abortion and Health Care Reform

Coverage for abortions has been raised as a point of contention in the planning for a new national health care system. It needn't be.

The U.S. government traditionally has not paid for abortions or services related to abortions. There are a large percentage of U.S. citizens who feel abortion is immoral and don't want their taxes used for it. There are a large percentage of people who don't want their taxes used for nuclear weapons, land mines, cluster bombs, torture in secret prisons, the Iraq invasion, etc., but once the horse is out of the barn and something has been paid for once, it's hard to change those policies. The anti-abortion movement doesn't want to end up in the same position.

However, when the issue is payment for abortion in the context of payment for ALL medical services, it becomes a non-issue. Most employer health plans cover abortions, and no one is quitting their jobs over it. The fact is that abortion is much cheaper than pregnancy, childbirth and neonatal care, with all their potential medical disasters. A health plan that excludes coverage for abortion isn't going to cost any less than one that includes it. It could even cost more, if you were to assume that none of the people who lacked health insurance coverage went ahead with their abortions by paying out of pocket.

Any national health plan that includes the choice of employer plans does not need to address the issue. People who choose a private health plan can simply privately contract with the same plan for an additional rider to cover abortions. It would probably have a nominal cost or be free.

People who chose a public option for coverage would not have the possibility of purchasing the rider, so they would have to get it from a private company or continue to pay cash for the procedure. Since private companies would not be on the line for the cost of those people's pregnancy complications or premature babies in ICN's, they would rightly charge them extra for the abortion coverage. Charitable organizations which support abortion options might set up private funds for low income women, which people could support with private donations (which would be tax deductible so long as that division of the charitable organization did not engage in any political activity).

It's interesting that the people opposed to including a public option for health coverage, and who are aghast at the idea of a single-payer health plan, are by and large the same ones who don't want abortions covered with federal funds. By excluding any public option, they're actually making it much easier for everyone to have full coverage for abortions. By supporting the status quo (for the length of time the status quo continues to be tenable without reform), they are in effect continuing to give the majority of women coverage for abortion services.

Maybe they ought to think this through a little more?