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Tag: Policy/Politics

POLICY: NY Times opinion on Medicaid

Shorter NY Times opinion on Florida Medicaid: It’s so screwed up that screwing it over more can’t make it any worse, and really Florida Republicans are deserving of our trust, as they’ve proved their fairness to their poorer and darker-skinned citizens so often in their history (as in the 2000 election).

POLICY/POLITICS: Linking Katrina, Medicare Part D and bird Flu

Here’s my FierceHealthcare editorial today:

FierceHealthcare has been following two stories all year that both had big moments this week. One is the avian flu that’s been popping up in Asia and may end up being as deadly as the 1918 epidemic. The other is the new Medicare Part D roll-out. For Medicare Part D, the complex mix of plans being offered to seniors will test their ability to understand the options on hand — anyone who’s bought insurance in the individual market knows that’s not easy — and will also challenge the Federal government’s ability to run and police a complex program with many different private and public agencies taking part. Given the nation’s recent experience with a similar challenge on the Gulf Coast, we can be forgiven for looking at the Medicare roll-out as the next great test of government, and hope that it shows improvement. Especially if we have a real crisis in the near future if avian flu becomes the pandemic we all fear.

PHYSICIANS/POLICY: Malpractice explained

Susan Sheridan, whom I wrote about last month, is even more famous. She and her son Cal who has kernicterus syndrome are the hook for a piece in The New Republic by Robert Berenson. (You may only be able to get to the first page…) It largely tells the truth about malpractice, but just to reiterate, my reading of the data is that:

1) The tort system only picks up about half of malpractice2) The medical system barely ever apologizes (Susan never got an apology), but when it does law suits are much less likely3) Too much of the money goes to lawyers and expert witnesses, and lawyers and Democrats don’t want to change that, but as they don’t hold power–so what.4) Doctors, whose Republican allies now do hold power, are only interested in reducing caps on damages, which may reduce their rates a bit but does nothing to help severely injured victims of malpractice and more importantly nothing much to reduce medical costs for the rest of us. (I live in California where we have the MICRA caps and my insurance premiums ain’t going down — sufficient proof to me that the Republican talking points about this are bunk).5) Defensive medicine makes the system and the doctors more money and until they stop getting paid for it, the whole "8-10% savings" concept is a myth6) Special courts, non-binding arbitration, apologies, openness, and a near-miss reporting system are all good ideas and are the eventual solution, but the AMA won’t back them, and their Republican allies won’t either. Why not? For them tort reform has nothing to do with patients, and not much to do with doctors, but much, much more to do with stopping what are mostly legitimate lawsuits against malfeasant corporations — and it’s much better if that all gets mixed up with an evil lawyer suing Marcus Welby MD in their PR campaign.

So unless there is some real concession from organized medicine, we’ll keep what we’ve got and it doesn’t work.  The "good" news is that it’s only a minor issue compared to the complete morass of the rest of the health care system.

(Hat-tip to Brian Klepper for the article)

PHARMA/POLICY/POLITICS: Well at least he gets to put “former FDA Commissioner” on his resume!

So just like that after a contentious time getting confirmed, FDA Commissioner Lester Crawford resigns, after only formally being in the job for less than three months (although effectively having basically run the agency for three years). I wonder what further skeletons have crawled out of his closet?

Get ready for more confirmation fatigue as the Administration searches for someone else ready to screw their reputation by placing politics (and deeply unpleasant, mean spirited politics at that) before science.

POLICY/POLITICS: The ugly side of American character revealed by Katrina, by The Industry Veteran

The Industry Veteran has been a little quiet of late. But you wouldn’t expect him to keep too quiet about an event like Katrina. Given the way that the whole thing has been turned into an Iraq-style feeding frenzy by the Republicans eager to run a privatized New Deal Mk II, here’s his sage perspective.

It’s interesting that even displays of shock and regret about Katrina, together with the belated recognition of larger problems concerning class and race uncovered by the hurricane, show an ugly side of the American character.  Read this op-ed piece from Harold Meyerson of the Washington Post and the LA Weekly.  He makes the point that American culture at its core is indifferent to the well being of the larger community.  With some minor qualifications, Meyerson is certainly correct.  This country was founded on the dark side of John Locke’s Whig philosophy, the idea that property constitutes the basis of liberty.  While “possessive individualism,” as it came to be called, can possibly be pushed in directions to show strong fellow feeling, its more typical implementation over the course of American history has been, “I’m looking out for me and mine, screw everyone else.”Reagan-Bush hucksters have self-righteously propagated the current incarnation of possessive individualism over the past 25 years by adding a fillip regarding the sanctity of markets.  According to their dogma, if any goods, services or social action appears desirable or necessary, a market will emerge to fill that need.  It is a manifest evil, according to these cowboy capitalists, for government to act in lieu of such a market or, even worse, to somehow alter the operations of an existing market to account for such an unmet need.  Of course if a market consisting of the poor and minorities makes it difficult to derive profits and, as a result, such a market is slow to emerge or never emerges, well, life’s unfair.  The free market fascists contend that government planning in the face of a market system’s well documented failures is, by definition, elitist.  Now here we have a natural disaster marked by the worst job of US government planning and response since the end of World War II and what do the Republicans propose to remedy the situation?  Well more of the same “free” market thinking that produced the problem should do the trick.  Doesn’t it make sense that generations of socially structured inequality can be remedied by granting liability exemptions to hospitals and physicians while businesses can be encouraged to hire the dispossessed by temporary exemptions from environmental safeguards?  Temporary exemptions from the estate tax will really help rebuild New Orleans as a city that provides greater opportunity, won’t it? See Wall Street Journal, 9/15/05.

The darker side of American character also helps explain the Democrats’ largely spineless failures to attack either the tactical failures or the pernicious social philosophy of Republicans.  The Democrats’ timidity comes from the fact that Republicans won the last two presidential elections, and all the off-year Congressional elections since 1994, by appealing to the dark side of the political center: prosperous suburbanites who aren’t terribly concerned about the general welfare.  As John Dickerson wrote in Slate, “For [suburbanites in SUVs], hurricane Katrina isn’t so much about race or poverty, it’s about homeland security—about what would happen if someone bombs their mall.”  The Democrats remain desperate to curry favor with this voting segment and only gauche party crashers such as Howard Dean will acknowledge that an understanding of hurricane Katrina requires us “to come to terms with the ugly truth that skin color, age, and economics played a significant role in who survived and who did not."  While the Democrats continually try to out-center the Republicans, the latter take the center for granted, favoring instead their fundamentalist and plutocratic bases.If studying social disasters is useful because they reveal a country’s underlying values and the way things really work, then I am even less sanguine about the prospects of significant health care reform than I was three weeks ago.

POLCY: HDHPs, employer insurance and regulation the Cato Way | SignalHealth

Over at Signal Health Tom Hilliard has been having an entertaining time with Mark Pauly and the boys from Cato. Go over there and take a look at the latest round of back and forth. Suffice it to say that if Mark Pauly had to buy his insurance in the individual market rather than receiving from the Ivy League Ivory Tower he sits in, I suspect that he would be rather more concerned about the way the individual market works, particularly the 20% he acknowledges doesn’t work well.

Meanwhile, Eric Novack and I are both reading Cato’s Michaels Cannon and Tanner’s latest work which is out today. (I had planned on a pre-publication review but then again…) We’ll be discussing it in another podcast sooner or later, but you’ll get the basic idea from the SignalHealth discussion.

Meanwhile, Health Affairs has some numbers out about the rise of the HDHP and the HSA.  You can see the full article here. But here’s the abstract pull:

Almost 4 percent of employers that offer health benefits offer one of these arrangements in 2005, covering about 2.4 million workers. Deductibles, as expected, are relatively high, averaging $1,870 for single coverage and $3,686 for family coverage in high-deductible health plans with an HRA and $1,901 for single coverage and $4,070 for family coverage in HSA-qualified high-deductible health plans. One in three employers offering a high-deductible health plan that is HSA-qualified do not contribute to HSAs established by their workers.

The last line is by far the most significant (hence my bolding it).  Even though the HSA is supposed to be the employees benefit, in fact in a third of the cases setting up a HDHP is straight cost-shifting to the employee. You were getting something and now you’re getting nothing to deal with the first chunk of medical expenses. So at least those employers have figured out how not to screw over their own risk pools (assuming that they keep some of that money that would have ended up in the HSAs in reserve to cover the expensive cases). You know that the rest of them will go down that path too — in fact a survey that was covered in this THCB article confirmed it a while back. Oh, the joys of a "jobless recovery".

And of course employers are getting out of the game of providing insurance anyway.  Another Kaiser Foundation survey this morning confirms that the percentage of employers offering insurance has gone from 69% in 2000 to 60% in 2005. In effect the HDHP over time offers the employer a way to get out of the game without having to bear the shame of leaving the field completely.

This of course continues to boil the frog….

Finally, it does make me chuckle that in the comments to this post about Medicare Part D, Eric Novack is apparently appalled that a combination of lobbying from drug companies, PBMs, health plans and providers mixed in with the endemic scratch my back corruption of the current Administration and its leaders in Congress ended up with a welfare plan for them all called Medicare Drug Coverage. But it’s a little weird that he thinks that the water-carriers for the Administration over at Heritage are actually surprised. The guys from Cato might be forgiven for being true believers, but Heritage, AEI and the rest sold their souls long ago, and know exactly how they’re dealing with.

CODA: I hate to link to Tech Central Station given how dishonest it is in its lack of transparency, but if the funny Cato boys will insist on writing there, then this one from Randy Balko is worth a chuckle.

POLICY/POLITICS: Blame for Katrina–enough to go around but it’s FEMA in the lead, with UPDATE

With all the BSing that’s gone on from the Administration about what went wrong and finger pointing, there is clearly much blame to go around. I’m impressed that New Orleans mayor Ray Nagin went ballistic when nothing was happening last Thursday night, but there are reasonable questions being asked of him by the right wing bloggers about why he didn’t or couldn’t use the city’s municipal and school buses to evacuate people in advance of the Hurricane or after it (I assume that after it he didn’t have anyone to drive the buses). Not that of course those questions are being asked in a particularly nice way, but I won’t discuss my last post or Nagin’s ethnicity.

However, even if there is local and state blame, that doesn’t absolve the Bush Administration for two reasons.  The first one is that there is a clear line of command in these situations, and this comes straight from Bush’s mouth on August 28, the Thursday before the storm.

Bushdisaster9kr THE PRESIDENT: This morning I spoke with FEMA Undersecretary Mike Brown and emergency management teams not only at the federal level but at the state level about the — Hurricane Katrina. I’ve also spoken to Governor Blanco of Louisiana, Governor Barbour of Mississippi, Governor Bush of Florida, and Governor Riley of Alabama. I want to thank all the folks at the federal level and the state level and the local level who have taken this storm seriously. I appreciate the efforts of the governors to prepare their citizenry for this upcoming storm. 

Yesterday, I signed a disaster declaration for the state of Louisiana, and this morning I signed a disaster declaration for the state of Mississippi. These declarations will allow federal agencies to coordinate all disaster relief efforts with state and local officials. We will do everything in our power to help the people in the communities affected by this storm.

In addition here’s an article which basically shows that even within all the bureaucratic BS going on, the Federal government is in charge in a disaster situation, and FEMA has the ability to do basically what it likes–which those of you hooked on The X-Files know has always been the case (although alien takeovers weren’t the issue last week)

But the main point is that, whatever the bureaucratic BS, a real leader would have got those buses into New Orleans and got the people out by Wednesday at least. That would have to be a Federal effort rounding up a few hundred buses in neighboring cities and getting them into New Orleans, while setting up tent cities to deal with the volunteers. It was this lack of action after the flood between Tuesday night and Friday morning that is the really criminal part, and even if the locals had screwed up, that does not mean that the Federal government is absolved of blame. We needed Presidential leadership, and we got little boy lost — again.

And as for health care, that goes for the evacuation of the hospitals too. It’s clear that that ended up being largely a private effort (and well down to HCA’s management which really stepped up in the crisis when it realized that the Feds weren’t helping.  Perhaps we should have completely for-profit private health care organizations so that all rescue efforts can be run out of Nashville! But if that’s not going to happen, and if every victim isn’t going to be in a hospital — as is clearly the case — then we have to depend on the Federal government.  After all this is the same Federal government that’ll move heaven and earth to make sure the sick people don’t smoke pot.

UPDATE: Brown was basically fired this afternoon–one week after Bush said "Brownie, you’re doing a hell of a job".  Odd.  Usually these incompetents get awarded the Presidential Medal of Freedom.

POLICY/POLITICS: A harrowing story from Katrina

SignalHealth pointed the way to this story, which I’ve since found at another source by a couple of hotel guests who were basically imprisoned in New Orleans and not allowed to leave by the law enforcement and FEMA people who were supposed to be there to help them. Now before you take this entirely at face value, I’ve Googled a little bit, and found that the two authors of this account are San Francisco Paramedics who are very active in their SEIU chapter and were extremely anti-Bush, the military and police to start off with, and are posting this on an extreme left-wing (by my standards not by Fox News standards) web site.

But the problem with thinking that they’ve just made all this up is that it correlates with so much else that we know about what happened. Late on Thursday night on FOX NEWS (really!) Geraldo was in the Convention Center saying "just let these people walk out of there". They weren’t allowed to go. They were just left there. Even worse was reported by another Fox correspondent, Shepard Smith, about people just abandoned on the freeway. It seems very likely that the two SF Paramedics were among those out there. See this for the link to that piece of video.

I saw someone on CNN or MSNBC — a white man – telling his story about how the buses that they’d paid for had been commandeered (UPDATE: I’ve found the link the story about the buses for the hotel guests)– that matches the Paramedics story. This guy was taken out by a black man standing next to him, who’s name he didn’t know but whom he credited with saving his life. (UPDATE: And here’s another story from a St Louis lawyer that confirms the bus story AND the trapped on the freeway story)

Over at HIStalk, there’s a link to this incredible story about how three college kids took a whole SUV load of water and supplies into the Convention center TWICE before any real help got in there. And they had to smuggle their way in as "press".

When you start putting these pieces together, it’s clear that something went badly, badly wrong in our emergency preparedness, and how we responded to desperate people in our own country. The only people who emerge with any real credit seem to be the health care workers in the hospitals who kept their patients alive against the odds, and the people who went around the official channels to do what they could.

I would not have said anything other than on Saturday night at a dinner party, in so-called liberal San Francisco no less, one woman started explaining to us all that these were stupid people who should have a) left before the hurricane, and b) should have taken adequate supplies with them to the convention center and SuperDome, and c) were dumb and not like us because….well you can get the gist if I tell you that she was white, and in fact Irish. I lost it and pointed out that the English said exactly the same thing about the dumb starving ungrateful Irish in the potato famine. If you have time, read the whole history of that very sorry episode and weep.

I can think of no better riposte than to link to the greatest essay ever written on the topic. Go read it and marvel at how little distance we’ve come.

HOSPITALS/POLICY/INDUSTRY: Katrina and the response

We have all been shaken by the devastation in New Orleans and the Gulf Coast. After a couple of days to reflect, three thoughts come to my mind. First has been the absolute heroism of health care workers in New Orleans, and those helping from neighboring areas. The tales of nurses, doctors and other workers keeping patients alive by hand-pumping ventilators, and performing near-miracles in conditions that none of them could have believed they’d ever have to work in reminds us that medicine and health care is a calling far more than just a job. Second, the time for investigations and blame if any will come later, but it’s beyond belief that it’s taken this long to get either food, water and medicine into New Orleans, or those stranded people out. Finally, it can’t have escaped anyone’s attention that the vast majority of those "left behind" are poor and African-American. And that’s a microcosm of what’s going on in our society and in our health care system. Hopefully this disaster may give us a chance to reflect on that and to make some changes.

I linked to the Red Cross earlier this week, but Instapundit has a long list of other charities who need help.

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