The New Zealand Way

It seems that patient dissatisfaction is not unique to the US. Last week in New Zealand’s third- largest city, Christchurch, a middle-aged family man named Neville Toohey, decided to go on protest-mode after a long simmering feud regarding a claim with New Zealand’s ACC (Accident Compensation Corporation) for back problems. His public demonstration consisted of climbing the Christchurch Cathedral steeple, barricading himself inside, and unfurling a banner stating how he felt he had been mistreated by ACC (he used a less genteel word) and then directing further inquiries to his website. Probably more germane to my previous blog posts is not so much the detail of the disagreement, but how the New Zealand authorities dealt with this act of civil disobedience. The predictable appeals to Mr. Toohey to abandon his protest were made both by church authorities and the police. He declined to obey. Eventually, it was negotiated that Mr. Toohey would descend the cathedral tower at noon on the following day. He complied with this, was arrested for trespass and bail was immediately posted pending a hearing. He was released to go home. Mr. Toohey expressed remorse at lost revenues for the Cathedral (the tower climb is a fee-based tourist activity ) and made a contribution to the church to offset these losses. Most notable was what didn’t happen: there were no SWAT teams, teargas, snipers, or any of the other increasingly militarized tactics employed by police in the US in lieu of rational discussion. This outcome, to me, seems to mirror the reasonable civility and rational approaches to problem solving I’ve seen here so far--even in the face of substantive disagreements.

But just what is the ACC?

The ACC is one of several pillars on which the New Zealand health care system is based. It is a no-fault national insurance program funded directly by the government to cover medical expenses stemming from any accident that occurs in New Zealand. In addition, the rules of the ACC preclude further litigation because both medical expenses and subsequent compensation are provided for. Thus, the absurdities and excesses of an adversarial litigation-driven system of compensation such as that found in United States are simply rendered irrelevant. And even though health policy academicians--frequently law school professors and economists rather than medical clinicians-- downplay the impact of litigation on costs to the US health care system, the corrosive effect of this lawyer-driven adversarial system is pervasive. Just ask any clinician. In a future blog I will address this issue more comprehensively, but for now let’s continue to look at what else makes the New Zealand health care system tick.

As we discussed earlier,a well-organized and well trained primary care base is vital to the rational utilization of healthcare resources. Surprisingly, at the initial point of access, which is often a physician-owned practice, the patient is expected to pay some or even most of the cost of the encounter. Many patients, however, are able to obtain a community health services card so that the co-pays are on a sliding scale based on income. There are also further subsidies available for patients with chronic illness who have more than 12 visits per year.They are granted a high user health card, or HUHC. Despite these subsidies, I was rather surprised to see computer prompts linked to patient accounts which commented on bad debts and previous payment status, but this seems to be generally accepted as a necessary evil to maintain financial viability and overall fairness in the system.This is the only part of the system that requires out-of-pocket payment. And despite the potential barrier to access posed by these copays, my experience thus far is that it doesn’t seem to be a problem--at least in the sites I saw so far. I do want to continue to observe the potential effects of this system. But that’s where the potential financial barriers end.

After being seen by a primary care doctor, all laboratory investigations, radiology tests, emergency hospital evaluations, hospitalizations and surgery are paid for. No deductibles, no co-pays, no maximums.

Recent changes in subsidies have further included “free care under six”, full prenatal and obstetrical care, and recently a nationwide capitation scheme for the state’s share of primary fees. These costs are administered through primary health organizations, or PHOs. PHO’s are one of the primary conduits of the annual national health budget which directly pay GPs and other primary providers.

Another recipient of government funding is the District Health Board, or DHB, which pays for hospital and laboratory services. (This is a simple mandate on paper, but as with hospital systems everywhere, efficient, fair allocation of these funds is an enormous and politically charged task. In fact, the Health Minister Mr. Ryall, recently announced significant budget cuts to the DHBs, stating that more funds are to be devoted to clinical care.)

A third entity that makes up the foundation of the health system is PHARMAC, the Pharmacy Management Corporation. PHARMAC is the national formulary and pharmaceutical supplier. It negotiates directly with pharmaceutical manufacturers for supply and pricing of essential pharmaceuticals. All covered drugs are $3.00 NZ ($2.10 USD) per prescription.This includes at least one, if not more, representative drugs from virtually every modern therapeutic class of medications utilized in modern medical practice. In my three weeks of prescribing in New Zealand, I have yet to feel constrained by the PHARMAC formulary. Labeled on-patent drugs are still available, but at substantially more cost to the patient--just like the situation virtually every patient faces in the US who does not benefit from the advantage of collective bargaining.

Finally, there is a private sector. Occasionally, patients feel that wait times are excessive for elective surgery such as joint replacements. They can then opt to be treated through the private sector, and frequently the wait times are indeed shorter for such elective procedures. The general perception is that there is no quality difference between the private and public sectors, just differences in timing. The spector of a two tiered health system doesn’t seem to have arisen. Not surprisingly, there is a growing health insurance industry for those who seek their care in the private sector. In general, the insurance industry is better regulated here than in the US, but I have heard stories of the usual limitations, asterisks, exclusions, fine print, etc., etc. that have become the stock in trade and major source of profitability of the Health Insurance Industry in the US.

So to summarize, a medical patient in New Zealand can expect the following:

• some amount of copayment, if not full payment to access the GP.
• If lab tests, investigations, emergency treatment, hospitalization, or surgery are required it is free.
• If the patient is pregnant, prenatal care and delivery are free.
• If the patient is injured in an accident, the care is free (and subsequent compensation is provided for).
• if medications are required, each prescription covered by the formulary is $3.00.

Is everyone in New Zealand happy with this scheme? Obviously not ---at least Neville Toohey isn’t--- but by and large people seem to be satisfied with the basic provisions available to them. There is occasional grumbling, but when I ask New Zealanders if they would rather have a system like that in the United States, the response is a unanimous and unequivocal “NO”.

The New Zealand health system is not socialism. This is an example of an intelligent educated population and leadership understanding that one of the cornerstones of a human rights-based society, as well as, incidentally, a healthy productive creative society, is the social provision of healthcare.

I see words like “landmark” and “historic” used to describe the recent health care legislation signed by Pres. Obama. Compared to the NZ system these legislative reforms are functionally inadequate and morally lacking.

I hope to gain deeper insight into this system as I continue to work here for the next two months. As I do I’ll share them with you. This includes problems and shortcomings, but also the kind of problem-solving that is taking place to keep the citizens of this country healthy and productive.

The Political Thuggery Of Health Care Reform Opponents Continues

I know I said I would foreswear political commentary and get on with describing the New Zealand Health Care system after having experienced it first hand for 2 weeks, but I am increasingly incredulous as I continue to read the news from home. The sorts of political intolerance I described in my last post have apparently increased and the role of the Republican Party in tacitly approving this outrageous behavior (and even perpetrating some of it themselves) appears to be escalating. First, the latest:

• Louise Slaughter, D-NY Had a brick thrown through her district office window in upstate New York. She also received telephone threats of a future sniper attack.

• Gabrielle Giffords, D-Arizona. A window was smashed in her office.

• Bart Stupak, D-Michigan. Telephone death threats. (And since he pushed through anti-abortion language included in the bill’s final version, we should assume it couldn’t be the “pro life” activists, even though in the past they seem to have had no qualms about supporting the murder of doctors they disagree with).

• James Clyburn, D-South Carolina. Sent a faxed picture of a noose, a time-honored Southern symbol of racial intimidation...and more. (Clyburn is black).

And the GOP response? House minority leader John Boehner from Ohio tepidly stated that “ I know many Americans are angry over this health care bill and that Washington Democrats just aren’t listening”. Apparently, in the eyes of the GOP, this militant behavior is the Democrats’ fault. Not much of a condemnation of political violence, is it?

Or are the Republicans conniving to foment civil unrest through further manipulation of public opinion by distorting the size and impact of their fringe elements? Even the Republican National Committee have resorted to loaded imagery and veiled threats when, in a recent appeal to their supporters, they show Nancy Pelosi engulfed in flames as they urge voters to “fire” her. And of course, there’s the Republican Presidential darling Sarah Palin, who tips her hand in very revealing ways, when on her Facebook page, she singles out Democrats for defeat by showing their districts in the crosshairs of a weapon. Nice touch, Sara.

Add all this to the brain-dead obstructionism shown once again by the Republicans in Congress who could come up with nothing better than to attempt to derail the reconciliation process with a number of trivial amendments to the law-- such as banning erectile dysfunction drugs to convicted sex offenders. Now that’s creatively looking out after the vital health interests of the American people.

And finally, there is the Republican effort now underway in at least 13 states to challenge the constitutionality of the new health care legislation as an infringement of “states rights”. Clearly, the Republicans have no historical sensitivity or for that matter, sense of decency, because if they did, they would know that this phrase was the major rallying cry of the racist Jim Crow southern state governments as they doggedly enforced the systematic denial of civil rights to blacks--and then combated Federal efforts to enforce the US Constitution. It is no coincidence that this ugly phrase is once again trotted out by right wing human rights opponents--this time to try to obstruct health reform (even the compromised bill that was eventually passed). This is the sort of politically irresponsible behavior we have come to expect from the increasingly reactionary and irresponsible GOP. It is the kind of political behavior that can rip societies apart. And because of that, it is the kind of behavior that must be challenged in the courts, protested in the streets, shamed in the press and unequivocally punished at the polls.

From this distance, I’m not even sure I recognize the USA anymore. And I can confirm that to outsiders, the country looks increasingly erratic and disturbingly unbalanced. Maybe balance will be restored and maybe the vaunted American resilience will reassert itself, but it’s high time we all speak out for progress and civility and repudiate the tactics of division, fear, intolerance, and inhumanity.

Party Politics

By now it should be abundantly clear to anyone reading this blog that I’m deeply disillusioned with both the process and result of health-care legislation passed by Congress. For all the reasons I’ve enumerated I do not think this legislation will address the fundamentally unjust way we are attempting to provide coverage for sick people. As I’ve indicated before, the process itself has been tainted by problems ranging from overt corruption to a deplorable Faustian bargain made by the Obama administration with the pharmaceutical industry not to seek a negotiated national formulary, to cite just a few examples.

I need to be very clear, however, that at least I find the rhetoric behind the legislation to be laudable even if it is politically shortsighted and perhaps somewhat disingenuous. At least the Democrats still attempt to appeal to our more illustrious past, our better instincts and our hope for a brighter future (that hope thing again). This stands in stark contrast to the cynical self-serving demagoguery that characterizes the opposition Republican party. The consistent response of the GOP during the healthcare debate has been one of obstruction, disinformation, fear-mongering and in general, an appeal to its adherents basest instincts.

In past weeks, healthcare reform opponents have gone so far as to humiliate and harass a demonstrator in Ohio, who had severe Parkinsonism; they have indulged liberally in racial epithets; and they even spit on John Lewis and Barney Frank, esteemed members of Congress who happened to be black and gay respectively. This kind of rabid intolerance has been not only been tacitly accepted by political opponents of health care reform, it has been actively encouraged.

Bob Herbert writing in the New York Times on March 22 put it like this:

“At some point, we have to decide as a country that we just can’t have this: We can’t allow ourselves to remain silent as foaming-at-the-mouth protesters scream the vilest of epithets at members of Congress — epithets that The Times will not allow me to repeat here.

It is 2010, which means it is way past time for decent Americans to rise up against this kind of garbage, to fight it aggressively wherever it appears. And it is time for every American of good will to hold the Republican Party accountable for its role in tolerating, shielding and encouraging foul, mean-spirited and bigoted behavior in its ranks and among its strongest supporters.

For decades the G.O.P. has been the party of fear, ignorance and divisiveness. All you have to do is look around to see what it has done to the country. The greatest economic inequality since the Gilded Age was followed by a near-total collapse of the overall economy. As a country, we have a monumental mess on our hands and still the Republicans have nothing to offer in the way of a remedy except more tax cuts for the rich.

This is the party of trickle down and weapons of mass destruction, the party of birthers and death-panel lunatics. This is the party that genuflects at the altar of right-wing talk radio, with its insane, nauseating, nonstop commitment to hatred and bigotry.”

Perhaps it is this last phenomenon of right wing talk radio that best highlights how extreme both the rhetoric and the tactics have become. The ‘tea bagger movement’ is really an artificial and highly structured result of a conscious decision to attempt to foment disruption and discord in the run-up to the healthcare debate in Congress. There was nothing spontaneous or ‘grassroots’ about it. (Incidentally, I would like to retract whatever attempts I made in one of my previous posts to be understanding towards these people. Understanding and empathy are values that are completely lost on them.) It has been radio-- with its enormous potential to disseminate falsehoods and foment emotional unrest--that has played a pivotal role in all this. Radio can, of course, be a highly beneficial element of a free and well-informed society, but it also can be and has been horribly abused. Think of the chilling role of radio in unleashing the genocide in Rwanda. And most frightening of all is the way Nazi Germany so skillfully exploited the powerful propaganda potential of the then new medium.

In fact, I can’t help but draw parallels between the kind of rabid intolerance increasingly found in the United States and the slow terrible slide of Germany into its nightmare of genocidal insanity. If you think I’m exaggerating, read Richard Evans’ masterful and highly acclaimed historical analysis, The Coming of the Third Reich. Change the names, the dates and the places and he could be describing some of what is happening in the US right now. And as Bob Herbert points out, all it took was for good people to remain silent. It is indeed way past time that we,a s a nation, repudiate the politics of ignorance and intolerance.

I somehow needed to get that off my chest. But after rereading this, it’s clear and I need to change gears and leave US politics behind. I’m in New Zealand-- with a highly refreshing level of civility, incidentally--and I still haven’t reported on how things work here. (Hint: Kiwis occasionally grumble but they really don’t know how good they’ve got it). Next, the nuts and bolts of the New Zealand health system.

Half A Loaf

Looking back at yesterday's post written in reaction to my growing realization that meaningful health care reform simply is not going to happen this time around, I became aware that in the process of writing this entry, I violated one of the first maxims of blogging: keep it short and conversational.

All the necessary detail was contained in Jane Hamsher's comparison chart. Added commentary on my part may have been a bit redundant. A pithier summary of the overall state of affairs comes from my PNHPWW (Physicians for a National Health Program Western Washington) colleague and fellow primary care doc, Jim Squire of Seattle:

"I have always said that if you bake up some horse shit to look like

half a loaf of bread, then all you get is horse shit. It all depends on

what your definition of 'loaf' is."

And no matter how you slice it, this half-loaf just isn't made of the right stuff.

I Read the News Today, Oh Boy.....

I must confess that I’ve been out of the loop. Until just now I missed the latest flurry of legislative activity surrounding the most recent efforts of President Obama and the Democratic Party leadership to move forward with a House reconciliation bill that would allow the previously passed the Senate health care reform package to become law. Unfortunately, despite over three weeks of a virtual news blackout, clearly nothing has changed. The previously passed Senate bill and the last-minute legalistic tinkering being undertaken by the House will do nothing to provide the people of the United States with any meaningful protection from predatory insurance practices, employer health insurance abuses, exorbitantly priced pharmaceuticals, and the very real ongoing risk of adding bankruptcy to the stress and misfortune of serious illness.

Max Baucus's early and vigorous exclusion of meaningful reform proposals like single payer have stuck.

The Senate bill which was really written by Liz Fowler, the former VP for public policy and external affairs for Wellpoint, the nation’s largest for-profit insurance company, is in reality a windfall for the health insurers through direct Federal subsidies and lack of regulatory oversight. In addition to not being held accountable for flogging a fatally flawed product and shamelessly profiteering on the backs of the sick and unfortunate, now the power of the State through the IRS will be employed to compel more people than ever to participate in the insurance industry’s extortion. Rather than providing health insurance itself (or heavily regulating it a la Germany), the Government is compelling it's citizens to buy an intrinsically flawed, market-based product. Rather than building a safer ship or even installing better navigation equipment or improving watch procedures, the Senate bill packs even more passengers onto the Titanic. This ship of fools, too, will come to grief and seal the fate of even more potential victims of the US healthcare system than the estimated 45,000 excess annual deaths already caused by lack of health insurance. The only really good news is that this travesty of “reform” won’t even take effect until 2014. But it’s highly unlikely that this 4 year hiatus will allow for the replacement of this legislation with something like single-payer which could actually save the government $400 billion a year or improve the dismal health outcomes so often found in the US. No, even if the bill passes, I fear the Democratic “leadership” will declare “mission accomplished” (maybe they could stage it on a cruise ship instead of an aircraft carrier) and we’ll be saddled with yet another crazy quilt “system” that reinforces the rest of the developed world’s accurate impression that US healthcare is immoral, corrupt inhumane and just plain bizarre.

Perhaps saddest is the sense of resignation that has resulted in the capitulation of even some of the most passionate advocates of meaningful reform like single-payer. I’m referring specifically to the disappointing announcement by Dennis Kucinich that he would vote for this bill in an effort to get something, anything, passed. I really don’t fault him since he has had no support whatsoever from the Democratic Party. The complete failure of leadership on the part of Barack Obama, Harry Reid, and Nancy Pelosi is simply breathtaking -- and in my most cynical moments I think is simply indicative of the crying need for campaign finance reform and reclaiming our democracy from the power of corporate lobbyists and influence.

I have contemplated trying to enumerate all the problems with the latest legislative effort but it’s clear to me that I will never be able to write anything nearly as comprehensive and succinct as the comparison below that appeared in Jane Hamsher’s blog FireDogLake: http://fdlaction.firedoglake.com/ Ms. Hamsher is perhaps the one political writer I know of who best articulates the compelling case for rejecting the current “reform” legislation.

Here amidst all the propaganda, disinformation, misunderstanding, and willful lies is the naked truth about the woeful inadequacy of the proposed “reforms”. (Thanks again, Jane Hamsher!)

Myth	Truth
1. This is a universal health care bill.	The bill is neither universal health care nor universal health insurance. Per the CBO: Total uninsured in 2019 with no bill: 54 million Total uninsured in 2019 with Senate bill: 24 million (44%)
2. Insurance companies hate this bill	This bill is almost identical to the plan written by AHIP, the insurance company trade association, in 2009. The original Senate Finance Committee bill was authored by a former Wellpoint VP. Since Congress released the first of its health care bills on October 30, 2009, health care stocks have risen 28.35%.
3. The bill will significantly bring down insurance premiums for most Americans.	The bill will not bring down premiums significantly, and certainly not the $2,500/year that the President promised. Annual premiums in 2016, status quo / with bill: Small group market, single: $7,800 / $7,800 Small group market, family: $19,300 / $19,200 Large Group market, single: $7,400 / $7,300 Large group market, family: $21,100 / $21,300 Individual market, single: $5,500 / $5,800* Individual market, family: $13,100 / $15,200*
4. The bill will make health care affordable for middle class Americans.	The bill will impose a financial hardship on middle class Americans who will be forced to buy a product that they can’t afford to use. A family of four making $66,370 will be forced to pay $5,243 per year for insurance. After basic necessities, this leaves them with $8,307 in discretionary income — out of which they would have to cover clothing, credit card and other debt, child care and education costs, in addition to $5,882 in annual out-of-pocket medical expenses for which families will be responsible.
5. This plan is similar to the Massachusetts plan, which makes health care affordable.	Many Massachusetts residents forgo health care because they can’t afford it. A 2009 study by the state of Massachusetts found that: 21% of residents forgo medical treatment because they can’t afford it, including 12% of children 18% have health insurance but can’t afford to use it
6. This bill provide health care to 31 million people who are currently uninsured.	This bill will mandate that millions of people who are currently uninsured must purchase insurance from private companies, or the IRS will collect up to 2% of their annual income in penalties. Some will be assisted with government subsidies.
7. You can keep the insurance you have if you like it.	The excise tax will result in employers switching to plans with higher co-pays and fewer covered services. Older, less healthy employees with employer-based health care will be forced to pay much more in out-of-pocket expenses than they do now.
8. The “excise tax” will encourage employers to reduce the scope of health care benefits, and they will pass the savings on to employees in the form of higher wages.	There is insufficient evidence that employers pass savings from reduced benefits on to employees.
9. This bill employs nearly every cost control idea available to bring down costs.	This bill does not bring down costs and leaves out nearly every key cost control measure, including: Public Option ($25-$110 billion) Medicare buy-in Drug reimportation ($19 billion) Medicare drug price negotiation ($300 billion) Shorter pathway to generic biologics ($71 billion)
10. The bill will require big companies like WalMart to provide insurance for their employees	The bill was written so that most WalMart employees will qualify for subsidies, and taxpayers will pick up a large portion of the cost of their coverage
11. The bill “bends the cost curve” on health care.	The bill ignored proven ways to cut health care costs and still leaves 24 million people uninsured, all while slightly raising total annual costs by $234 million in 2019. “Bends the cost curve” is a misleading and trivial claim, as the US would still spend far more for care than other advanced countries. In 2009, health care costs were 17.3% of GDP. Annual cost of health care in 2019, status quo: $4,670.6 billion (20.8% of GDP) Annual cost of health care in 2019, Senate bill: $4,693.5 billion (20.9% of GDP)
12. The bill will provide immediate access to insurance for Americans who are uninsured because of a pre-existing condition.	Access to the “high risk pool” is limited and the pool is underfunded. It will cover few people, and will run out of money in 2011 or 2012 Only those who have been uninsured for more than six months will qualify for the high risk pool. Only 0.7% of those without insurance now will get coverage, and the CMS report estimates it will run out of funding by 2011 or 2012.
13. The bill prohibits dropping people in individual plans from coverage when they get sick.	The bill does not empower a regulatory body to keep people from being dropped when they’re sick. There are already many states that have laws on the books prohibiting people from being dropped when they’re sick, but without an enforcement mechanism, there is little to hold the insurance companies in check.
14. The bill ensures consumers have access to an effective internal and external appeals process to challenge new insurance plan decisions.	The “internal appeals process” is in the hands of the insurance companies themselves, and the “external” one is up to each state. Ensuring that consumers have access to “internal appeals” simply means the insurance companies have to review their own decisions. And it is the responsibility of each state to provide an “external appeals process,” as there is neither funding nor a regulatory mechanism for enforcement at the federal level.
15. This bill will stop insurance companies from hiking rates 30%-40% per year.	This bill does not limit insurance company rate hikes. Private insurers continue to be exempt from anti-trust laws, and are free to raise rates without fear of competition in many areas of the country.
16. When the bill passes, people will begin receiving benefits under this bill immediately	Most provisions in this bill, such as an end to the ban on pre-existing conditions for adults, do not take effect until 2014. Six months from the date of passage, children could not be excluded from coverage due to pre-existing conditions, though insurance companies could charge more to cover them. Children would also be allowed to stay on their parents’ plans until age 26. There will be an elimination of lifetime coverage limits, a high risk pool for those who have been uninsured for more than 6 months, and community health centers will start receiving money.
17. The bill creates a pathway for single payer.	Bernie Sanders’ provision in the Senate bill does not start until 2017, and does not cover the Department of Labor, so no, it doesn’t create a pathway for single payer. Obama told Dennis Kucinich that the Ohio Representative’s amendment is similar to Bernie Sanders’ provision in the Senate bill, and creates a pathway to single payer. Since the waiver does not start until 2017, and does not cover the Department of Labor, it is nearly impossible to see how it gets around the ERISA laws that stand in the way of any practical state single payer system.
18 The bill will end medical bankruptcy and provide all Americans with peace of mind.	Most people with medical bankruptcies already have insurance, and out-of-pocket expenses will continue to be a burden on the middle class. In 2009, 1.5 million Americans declared bankruptcy Of those, 62% were medically related Three-quarters of those had health insurance The Obama bill leaves 24 million without insurance The maximum yearly out-of-pocket limit for a family will be $11,900 (PDF) on top of premiums A family with serious medical problems that last for a few years could easily be financially crushed by medical costs

*Cost of premiums goes up somewhat due to subsidies and mandates of better coverage. CBO assumes that cost of individual policies goes down 7-10%, and that people will buy more generous policies.

Documentation:

1. March 11, Letter from Doug Elmendorf to Harry Reid (PDF)

1. The AHIP Plan in Context, Igor Volsky; The Max Baucus WellPoint/Liz Fowler Plan, Marcy Wheeler
2. CBO Score, 11-30-2009
3. “Affordable” Health Care, Marcy Wheeler
4. Gruber Doesn’t Reveal That 21% of Massachusetts Residents Can’t Afford Health Care, Marcy Wheeler; Massachusetts Survey (PDF)
5. Health Care on the Road to Neo-Feudalism, Marcy Wheeler
6. CMS: Excise Tax on Insurance Will Make Your Insurane Coverage Worse and Cause Almost No Reduction in NHE, Jon Walker
7. Employer Health Costs Do Not Drive Wage Trends, Lawrence Mishel
8. CBO Estimates Show Public Plan With Higher Savings Rate, Congress Daily; Drug Importation Amendment Likely This Week, Politico; Medicare Part D IAF; A Monopoloy on Biologics Will Drain Health Care Resources, Lancet Student
9. MaxTax Is a Plan to Use Our Taxes to Reward Wal-Mart for Keeping Its Workers in Poverty, Marcy Wheeler

1. Estimated Financial Effects of the “Patient Protection and Affordable Care Act of 2009,” as Proposed by the Senate Majority Leader on November 18, 2009, CMS (PDF)
2. ibid
3. ibid
4. ibid
5. Health insurance companies hang onto their antitrust exemption, Protect Consumer Justice.org

1. What passage of health care reform would mean for the average American, DC Examiner
2. How to get a State Single Payer Opt-Out as Part of Reconciliation, Jon Walker

1. Medical bills prompt more than 60 percent of U.S. bankruptcies, CNN.com; The Patient Protection and Affordable Care Act Section‐by‐Section Analysis (PDF)

So, if you still think the proposed legislation is better than nothing, you’ll still have four years to wait to see how bad it really will be. In the interim, an additional 180,000 people will die for lack of health insurance; the insurance industry will continue to raise premiums unchecked; big Pharma will continue to gouge consumers and systematically lobby to deprive them of any meaningful collective bargaining arrangements to reduce costs; personal bankruptcies -- often among the insured -- will continue to accelerate; and globally, US healthcare will become even more synonymous with institutionalized human rights abuse through market-based denial of health care. In fact, it will probably be far more than just four more years of this wretched status quo. Through this colossal failure of leadership we may have squandered our very best chance to implement reform for a long time to come. That is, of course, unless we manage to elect a new generation of political vertebrates who will do the right thing. Got hope?

I really regret that I am so comprehensively pessimistic, but I see nothing in this health reform process to convince me that our politicians have anyone’s best interests at heart other than their own. If this were not the case we would see something more meaningful. As hard as it is to say this, I think I understand the anger, frustration and mistrust of the rank and file Tea Baggers.(But far less so their leaders.) Unfortunately, they simply don’t realize the depth of their ignorance and the degree to which they been manipulated by and played into the hands of the very political forces they profess to reject. As I said in a previous post, the solution is ethical, responsive government -- of the We-The-People sort-- that reflects the values and compassion of our communities that really do care for one another. That is really the only way we can join the ranks of all the other developed countries who employ democratic processes to carry out this most vital of democratic functions.

Next, we’ll see how things are set up in New Zealand, with a dose of reality based on a busy week in the trenches in Darfield on the South Island. Not surprisingly, it’s not perfect and there have been a few surprises, but ultimately everyone gets cared for without bankrupting individuals or the government.We'll see how they do it.

What Chief Inspector Wallander Knew

Although I read a lot, I’ve never been particularly enamored of the police/detective genre. Other than an odd Tony Hillerman or Sarah Paretsky when I’ve been sick or have been looking for diversion on a long flight, I’ve usually put my reading energies elsewhere. Recently though, I stumbled upon the Swedish author Henning Mankell and his acclaimed Kurt Wallander series. I just finished his book entitled The Man Who Smiled. In addition to a riveting plot and well-crafted atmospherics, it unexpectedly contained some moral philosophy from the lips of Inspector Wallander himself.

The story revolves around an extremely wealthy international business tycoon, Dr. Alfred Harderberg (the non-MD type, incidentally) with all the trappings of international Uberwealth: the biz jet, the beautiful-people staff, the architectural splendor, the sartorial perfection, the radiant smile and the intimidating aura and implicit threat of seemingly untouchable power. The problem was that behind the façade of all this wealth and power lay the frozen heart of an inhumane criminal who, as it turns out, was trafficking in human organs. And as he learned about this horrific underworld from a journalist he was interviewing, Wallander felt that he had taken

“a journey into an unimagined world where human beings

and body parts have been reduced to market commodities,

with no sign of any moral consideration.”

The parallels with the United States health care system are inescapable. And it is not an “unimagined world”. Beautiful, perfectly turned out business elites of for-profit insurance health insurance companies are paid tens of millions of dollars annually to issue ever more claims denials, rescisions, exclusions and otherwise come up with mechanisms to exclude the very people who need health care the most. And it is all while carrying out their “fudiciary responsibilites” to shareholders and the non-human legal entity otherwise known as the corporation. As individuals these elites are so insulated from the suffering their corporate power unleashes that they truly appear to have no moral compass whatsoever. Like Harderberg, they too have reduced human beings and human illness to a mere market commodity. This to me is the greatest injustice in an exclusively market-driven healthcare system that knowingly applies a false economic analogy, somehow equating human health with a refrigerator or an iPod. Most remarkable of all, in a political system populated by politicians who are so tainted with corrupt corporate money, it is all perfectly legal--- with little threat to the corporate benefactors of seeing any political effort by their representatives in Congress to regulate or change this fundamentally immoral system.

By 1834 the British Empire had banned the slave trade as morally unacceptable. They finally reached the conclusion that human life could never be bought or sold. In the United States the abolition of slavery was a more difficult process, only to finally be settled through devastating civil war. Why is it that moving in the direction of respecting fundamental human rights is always so contentious in the USA?

It is my fervent hope that my country will finally come to the same conclusion that chief inspector Wallander arrived at in the pages of a detective novel: that human beings ,their bodies and their health can never be reduced to mere commodities to be subjected to the whims of the markets and the elites who control them.

US Health Care: The Problem.

So just what is the problem with US healthcare? Let me give you an example that is very close to home. It occurred right in my community, a place of education and affluence and also a place where people silently suffer.

The woman who cuts my daughter’s hair immigrated to the US from South Africa a number of years ago. She has always worked as a hairstylist. Her current work situation is structured such that she is a “contractor” who leases her workspace from the salon she ostensibly works for. She is technically not an employee of the salon and as a result, she receives no benefits and no health insurance. She is one of the 45 million Americans whose only health plan, as Alan Grayson, US Congressman from Ocala, Florida, so boldly stated on the floor of the US House of Representatives last summer, is, quite simply: “don’t get sick”.

Unfortunately, she did get sick. It turned out to be nothing serious from a medical standpoint, but she did have an episode of acute asthma triggered by an unanticipated exposure to a neighbor’s cat. Her bronchodilator inhaler was empty and because she had no doctor and no health insurance,she had no choice but to seek assessment and treatment in the emergency room of a major regional hospital. The assessment and treatment of this relatively straightforward clinical situation took a total of seven hours, and resulted in being subjected to numerous blood tests, EKGs, chest x-rays, and other unnecessary tests before finally receiving the simple nebulizer treatment that made her better. Afterward, she was billed nearly $2000 for her medical “treatment”. In a primary care setting, this would have been a relatively routine office visit and would have cost a fraction of the bill she was sent. Worse yet, since she was unable to pay this bill, she was turned over to a collection agency who harassed her and significantly damaged her credit rating. The bill was eventually negotiated down and settled but not without significant stress, aggravation and financial hardship. This scenario plays itself out thousands of times each day in the USA and is the leading cause of personal bankruptcy in the USA. And the majority of those who go bankrupt, DO have health insurance, albeit woefully inadequate.

But this person was lucky. She did not have a life-threatening, chronic illness. For a truly heartbreaking account of what’s in store for people who don’t have health insurance and are unfortunate enough to have a life-threatening chronic illness, I would refer you to the prologue of T.R.Reid’s book,The Healing of America. There he tells the story of a 32-year-old woman who had severe systemic lupus erythematosis (SLE) who died because she was unable to get the treatment she needed due to lack of health insurance.

As Mr. Reid states in his book:

“those Americans who die or go broke because they happened to get sick represents

a fundamental moral decision our country has made. Despite all the rights and privileges

and entitlements thatAmericans enjoy today, we have never decided to provide

medical care for everybody who needs it. In the world’s richest nation, we tolerate a

healthcare system that leads to large numbers of avoidable deaths and bankruptcies

among our fellow citizens. Efforts to change the system tend to be derailed by arguments

about big government or free enterprise or socialism--and the essential moral question

gets lost in the shouting.... All the other developed countries on earth have made a

different moral decision”

It’s time we stop shouting and start caring about our fellow citizens. It is ironic indeed, and not just a little hypocritical, that in a country that still has political arguments about whether it is a “Christian nation”, caring and compassion are so absent from the discussion. T.R. Reid is right: It is, in the final analysis, a moral issue.We have the wealth, the know-how and the technology, but do we have the will to change what is so obviously unjust?

Next, I’ll share a few thoughts on human rights and health care from author Henning Mankell’s fictitious Swedish police detective, Kurt Wallander.