Heavy Is the Chest that Wears the Gunk

I taught myself to use the GIMP to create this masterpiece:

Well worth it, well worth it.

So why junk up a perfectly good centrist? Because centrism doesn't mean chase money and votes in a completely self-servingly strategic fashion. Here's the NYTimes analysis of why Lieberman voted repeatedly to limit damages that could be awarded to people that sue insurers:

"Many of Mr. Lieberman's friends said he had no alternative but to take this position because it was the one favored by the insurance industry. The industry is important to Connecticut's economy and has generously donated to Mr. Lieberman's campaigns over the years."

Well, you know, everybody has constituents, right? At least he's a continuous and strong supporter of private health insurers, right? Lieberman in 2004, during the Democratic primary:

"LIEBERMAN: There is a morally scandalous fact-that that 43 million Americans don't have health insurance, 2 million more than when George Bush became president. I'm proposing to create a national health insurance pool like the one that members of Congress get our insurance from. If you don't have insurance now, you'll be able to get it, probably free, if you're among the low-income working poor. If you're a child, you will be covered by insurance at birth. If you are fired from your work or lose your job, you will not lose your health insurance."

Sounds great, Joe. People really should have health insurance, and since this is the electoral primary and public options for health care are really popular among Democrats, I'm sure this will really help your primary numbers! But what's this business about "probably free"? Oh, right. It's wiggle room, so that he can crawl back to the insurers that fund his campaigns, tongue lolling like an overheated spaniel:

"I don't favor a public option," Lieberman told Bloomberg News in an interview broadcast this weekend. And I don't favor a public option because I think there's plenty of competition in the private insurance market. We have a unique opportunity, a real opportunity to do this year what we've been trying to do for years, which is to reform American healthcare, I think the one thing that will stop that is pressure on the so-called public option. Let's get something done instead of having a debate,"

So the new message is threefold. One: we are doing GREAT. Helluva job. It is absolutely not true that the senators most likely to oppose the public option come from states with the least competition in health insurance or that Lieberman's home state of Connecticut is dominated by Wellpoint, which commands more than 50% of the state market (although the people of Connecticut are fed up -- their state legislature just overrode a Republican veto to establish universal healthcare statewide). Second: Lieberman is on the side of a nebulously defined 'we' -- which doesn't mean Democrats, exactly (Lieberman is technically an independent) or his constituents (see above state policy, which is overwhelmingly supported by residents of Connecticut). I'm guessing that health insurance companies make up a good bit of this 'we', and it's true -- they've been trying to write health policy for decades. Third: shut up already! Why is everybody debating what's best and not just jumping in with some halfhearted, bandaid-on-a-sucking-chest-wound reform-lite package? This, I think, is a very respectful echo of what we could call the Bush Doctrine.

So all told, until you get on board, Joe, you're going to have a chest full of poorly Photoshopped gunk.

EDIT: Also, there is a rhymey bunch trying to kick you out of the Democratic Party.

Around the World

I'm kind of spinning my wheels trying to figure out what the new legislative direction in Congress will actually look like -- so I thought now would be a good time to figure out how some other industrialized nations structure their health systems. There's been a lot of talk about Canada and the UK, so I'll leave them out and focus on some other nations. This is initial research, and just an attempt to put some summaries side-by-side, so leave a comment if you feel the urge to disagree. Massive oversimplifications to follow:

FRANCE -- The French system is made up generally of private practices for ambulatory care, and public hospitals for acute care; the government provides a national health insurance plan that pays 60-70% of health care costs, and almost 80% of the population supplements that with additional insurance from a private source. Although they've had cost increases similar to (although smaller than) cost increases experienced in the American system, government negotiation with care providers and drug manufacturers have helped limit prices. Because France has three times as many doctors per capita than the US, and because its citizens lead the world in use of prescription medicine (note -- not necessarily a good thing), the WHO called it the world's #1 health care system in 2000, and many Americans who have lived there or studied their policies advocate strongly for their system.

JAPAN -- In Japan, insurers are not allowed to profit from health insurance, and health insurance is guaranteed through one of two national systems, one that covers large employers, and one that covers small employers and the uninsured. While access to basic care is reasonably equitable, the system has considerable problems ranging from overutilization of some services (because doctors are paid by the service) to poor resource allocation (leading many to be turned away from emergency rooms) to insufficient oversight (doctors receive a lifetime medical certificate that requires no re-certification, and many believe they operate at an unacceptably low standard). All this having been said, Japanese citizens are actually some of the world's healthiest -- they lead the UN's list of the nations with the longest lived citizens.

GERMANY -- Germany's first universal guarantee of health care was apparently instituted by Otto von Bismarck, here seen pensive in a pointy helmet. The modern system guarantees insurance for all, paid for through a combination of payroll tax and employer support. Their social insurance system is something like the Japanese, but instead of being assigned a government option, insurance can be purchased from one of over 200 "sickness funds" which are independent, not-for-profit, and which compete with each other for clients. The government does engage in top-down negotiations to decrease costs, and these have been reasonably successful in keeping costs considerably below those in the US.

What do these systems all seem to have in common? First, all industrialized nations I've read about guarantee all their citizens at least a minimal amount of care. Second, the nations above tend to keep electronic or otherwise portable records, like the French carte vitale or the German eHealth card (which has admittedly hit lots of snags). Third, almost all these nations pay their doctors less, but cover medical training of all kinds, often completely. Finally, most of these systems, with some exceptions, were created gradually, using a series of reforms that increased coverage bit by bit.

Ok, last thing, can't resist: Around the World by Daft Punk. The video is intended to metaphorically represent the legislative process of the US Congress.

EDIT: Worst health care systems in the world. We made the list! Wooo.

Melting to the Money

Dr. Rob left this comment a few days ago, and this was the most thought-provoking part to me: "[I] hope the congress will avoid melting to the money and actually push primary care." I agree with him -- I hope that primary care is a priority in the new system (and since the legislation is still being debated, it's not certain that the final draft of the reform bill will prioritize primary care), but it took me a while to figure out why ignoring primary care would be "melting to the money."

Here's what I figured out: since we have, excepting Medicare and Medicaid, a largely for-profit health care and insurance system, the most profitable parts of the health economy become larger, and the less profitable parts shrink in size -- the system flows towards the money. Examples:

1) Notice how you never see television advertisements for prescription drugs that cure disease or fix a problem? The drugs worth advertising -- the most profitable ones -- are new treatments for chronic disease like irritable bowel syndrome, fibromyalgia, erectile dysfunction, etc. These are treatments one has to take over and over again, and the reason only new drugs are advertised is because the profit margin is highest on drugs that are still under patent. This book puts it particularly well:

Jurgen Drews, a physician who has been the research director of a major global pharmaceutical company...argues that in recent years an obsessive, and ultimately self-defeating, focus on the bottom line, and the increasing costs of launching a new product, have led pharmaceutical companies to devote their research efforts increasingly to so called "me too" remedies for conditions such as high cholesterol and hypertension for which useful therapies already exist.

Because it's quicker, and more profitable, to seize control of a market that already exists than it is to undertake the long process of truly improving public health.

2) Why is it that a trip to the dermatologist, even a very simple one, is likely to cost three times as much as a trip to a general practitioner? Supply and demand -- there are fewer dermatologists, and they can demand a higher price, even though their specialty is no more complicated than general practice medicine, and they don't have more training, just different training. It is weird that we have plastic surgeons driving around in Benzes while some rural counties with obvious need have a crisis-level doctor shortage. I'm not arguing that people should be stopped from paying for health care, I'm just pointing out that under the current system, the most profitable branch of medicine is cardiology, followed by radiology, orthopedic surgery, ophthalmology, anesthesiology, and dermatology. Those are all great, and deeply necessary for good health care, but they're not the medical care that we need most. They're the kind of care that is most specialized -- when you need a specific surgery on your eye, there's a very limited number of people who can do it, and they can charge whatever they like. Meanwhile, your primary care physician is deeply involved in saving your life in a number of ways (monitoring your blood pressure, providing early cancer diagnoses, catching diabetes before serious symptoms set in) but they're not paid a premium for it -- because there's lots of general practitioners.

3) Public health initiatives -- education and availability of the most simple, most effective health interventions -- make zero profit (because they address a need before the point of crisis) for private industry and provide measureless profit to the community. So we leave it to non-profit, often non-medical groups to do things like encourage HIV prevention, provide flu shots (which are organized in my neighborhood by the LA County government), educate expecting mothers (a service of the March of Dimes), etc. etc. Resources -- money -- literally melts away from these needs, because they don't fit into our current profit-based model. This is not cost-effective -- if we had an organized, national health care system that could ensure that folic acid was provided for every pregnant mother, we would pay less in emergency room visits, government-sponsored care for premature newborns, lost work and wages, etc. etc. etc. The problem is that it's not profitable to tell women to take a multivitamin in the first weeks of pregnancy -- at least not profitable in the narrow, free-market sense.

I probably come off sounding a little bit critical of the free market in the examples above, and I'm really not -- private companies can be, under certain conditions, terrifically helpful. Unfortunately, too much money has melted to the shape of that free market, and we're missing all the benefits that can be had from a not-for-profit, community option for health care. That's the public option -- and to get it, we're going to have to overcome the entrenched interests (and the money they've accumulated) that profit from the current system -- namely, insurance companies and the politicians they support.

The Invisible Hand

Some of the resistance to a national public health option that I've seen goes like this: free competition naturally makes services cheaper and more effective, and government interference ends incentives to excel (because nobody has to compete to succeed -- they just line up for free government money). This, I think, is true for transistor radios, furniture, cars, etc. But what about health care?

Unmoderated, unrestrained free-market competition is the last thing we want for health care. Can you imagine what would happen if one corporation gained a majority share in all the nation's hospitals? What would it be like if there was only one company (something like Microsoft in its heyday) that you had to deal with every time you needed an MRI or an X-ray? Compared to furniture, medical treatment is not a luxury -- when one of your feet goes numb and stays that way, it's likely that you'll pay whatever you have to.

We allow this kind of competition -- i.e. we allow insurance companies to grow until they have an unacceptable level of power over us and our lives -- right now. The AMA released an analysis (here) that says that two insurance companies -- WellPoint and United -- control 36% of the national market for health insurance. With mergers taking place faster than ever before, this amount could easily increase.

That's the national scene, though -- it gets worse in the cities. 16% of American metropolitan areas are dominated by an insurance company with a market share over 90% -- so if you want to get insurance in Texarkana, TX, or Battle Creek, MI you can pretty much only deal with Blue Cross/ Blue Shield. And if they don't want you? Tough!

Republicans and Democrats alike love to talk about the free market and free competition as if it is a basic American belief. It's not. Our innovations and our competition -- from cars to computers -- are built on a system of government-maintained roads and railways, protected by a government-run military, and managed by laws that we all agree upon. For some parts of our economy, this is the best choice -- to have government intervention. Health care is one of those parts!

But the insurance companies, greedy as all hell, hang outside our window -- don't you want free trade, they say? Don't you believe in the invisible hand?