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POLICY: One more time around on the VA issue, by Dave Moskowitz

This may be the last word for now on the idea of using the VA for the uninsured, raised by Dave Moskowitz last week. Let me try to put this in a little context. We’re not likely to have a universal health insurance scheme come out of the next Congress. As I write about elsewhere, the proponents of this year’s version of healthcare reform (California’s Prop 72) which I support because it’s better than nothing, come straight out and say that incremental change is all that we can expect. While I don’t approve, I don’t disagree. So Dave’s idea is an incremental change that’s worth considering and also not to far away from Bush’s idea of spending more money on community health clinics for the poor. I did though have a couple of concerns before I appointed Dave to run the much revamped VA. He replies here (and you may notice him getting into the somewhat cynical but jocular spirit of THCB):

You asked two more questions, which I’d now like to reply to:

Is Congress ready to come up with $100 B for healthcare? Perhaps Congress has grown amnesiac since the 1994 Contract On America. They are spending, after all, our taxpayer money. According to the Constitution, they’re supposed to be working for us, not the other way around. Congress has already spent $180bn for the War in Iraq, and have just been asked by the Administration for another $70bn, bringing the total to $250 B, a project which enjoys less than 50% popularity with their constituents. So it would be only reasonable, in a representational democracy, for them to spend $100 B of our money annually on a need near and dear to 70% of Americans. I understand that using the government to help the people has fallen out of favor as a political concept since Reagan took office in 1980, but perhaps the people will gently remind their elected representatives who’s paying their salary and why.

Why separate but unequal in healthcare when it no longer applies in education? Au contraire, gentle blog-meister. Separate but unequal is no longer supposed to apply in PUBLIC education, but Brown vs. Board of Education of Topeka, KS never struck down the inherent separateness (and demonstrated inequality) between public and private schooling. In the US, roughly 85% of education is public, open to all comers, and 15% is private. We’re all aware of public school districts where daily survival is the most one can pray for, let alone a college-prep education. And we’re all aware of the training ground set up by the power elite that includes prep schools like St. Paul’s, St. Alban’s, and Andover. After all, the Presidential candidates for the past four years have come only from those three high schools. Waterloo is still being fought on the rugby fields of Eton, so to speak. (Ed’s diversionary note: They don’t actually play rugby at Eton; they play this weird sport instead and the correct quote is “playing fields”. Anyway Rugby wasn’t invented till decades after Waterloo! End of history and English elitist culture lesson!) So separate and unequal is in no way un-American.

It’s actually as American and as much a pillar of capitalism as apple pie (not to intimate that the pillars of capitalism are grounded in less than cement). It’s seen, for example, in airplane travel (Business Class vs. Coach), ground transportation (luxury SUV vs. public transportation), housing (4-star hotels vs. economy motels; gated mansions vs. trailer-parks), food (fresh T-bone steaks vs. frozen bulk hamburger), medicines (branded vs. generic), etc., etc., etc. People get what they pay for. The goal of government is to ensure that the cheapest commodity is at least non-toxic. In government as in medicine: primum non nocere (first, do no harm). In the case of healthcare, I’ll let you in on a very well-kept secret: the cheaper public system is very likely to yield better patient outcomes than the more expensive, private alternative.

Here’s why: Modern health plans started with the Blue Cross/Blue Shield plans set up in the 1920’s by surgeons to make sure they got paid for the operations they did. Healthcare reimbursement has kept its close ties to the hospital ever since. For 70% of healthcare dollars to be spent in the last 12 month’s of a patient’s life means that it is spent on surgery and ICU care that is futile but expensive. An excellent example of how the system works is the recent decision by CMS to pay for lung volume-reduction surgery (essentially, popping emphysematous blebs) the week after a study in the New England Journal of Medicine showed that it was useless. Only in America!

Genomics makes it possible (finally!) to prevent diseases from occurring, or at least not to be ambushed by them, as we all currently are. Genomics makes it possible to keep people healthier and out of the hospital. The current hospital-based system, which represents the medical establishment in every country, with its research institutes and medical schools, will not go quietly, as the TB sanitaria did in the 1950’s when streptomycin was discovered. But the dynamism of capitalism will save the private sector. In order to regain market share, the hospital-based system will be forced to adopt preventive molecular medicine. Patient outcomes will begin to improve in the private sector, too. There will be aggressive marketing, encouraging patients to stay with their fancy, branded private sector health plans. If the tobacco and ammunitions industries can survive despite their effect on the public health, then the private healthcare system will do fine, too. But we need both players, because the government by itself simply cannot pay for healthcare at the current level, let alone with double-digit inflation. Healthcare would have to be rationed, as in Canada and the UK.

This is politically unacceptable. Americans like the notion that anybody who can afford a liver transplant can get one, and Mickey Mantle can get two in a week. If the private sector folded, the $100 B annual price tag for 45 million currently uninsured Americans would balloon up to $600 B a year for all 270 million Americans. Getting this Congress to spend an extra $600 B a year on health for the nation will be infinitely harder than getting them to spend six times less. So by all means, let’s keep both systems. But if you happen to find yourself, for a time, in the public sector healthcare system, don’t be upset–you may actually be getting better care!

While I think he’s hit the nail on the head with his analysis of the wasted money spent on end of life care — and the Dartmouth crowd agree — I’m still not quite sure if I follow all Dave’s logic. Surely if Congress is going to spend a lot more on health care for all Americans, private sources (that is employers and individuals) will spend less. However, the idea that health plans have to compete on outcomes is something I like the idea of, even if its mostly fantasy for the near-future. I’ll see if this idea crops up elsewhere, but hopefully this has added something to the debate.

Meanwhile certain wags have pointed out that as a non-natural born citizen I can’t be Preznit and appoint Dave as head of the VA. Even if the Constitution was changed and I could be, I might find a tough opponent in a certain ex-steroid using body-builder. The Guvernator is raising my ire this week by both opposing Prop 72 (which given his business connections I’d expect) and much more so by toadying up to the most appalling union in America, the California Correctional Peace Officers Association, in opposing Prop 66 — the much needed amendment to the nutty three strikes law. You may recall that in the recall race Arnie said he was opposed to special interests. The prison guards have been the most egregious and aggressive special interest group in this state for over a decade. Good one, Guv.

POLITICS: My (almost) last word on Prop 72

I’m much more disgusted with both sides on the prop 72 debate than I was before this past week. I went to a “debate” on it at the Commonweatlh Club on Monday and then heard (and phoned into) an NPR show on it this morning. (The show wasn’t my finest hour, but then I matched the general level of debate and I’m on about 10 mins before the end of the show).

The opposition was the Allan Zaremberg from the American Chamber (at the debate) and a school board member Gabriella Holt (on the radio) representing public sector employers. The chamber of commerce’s major objection — and I am not making this up — was that the 20% of premium that Prop 72 would force the employee to pay (capped at 5% of income) would take away their choice to buy other things with that money! In other words the poor little poor minimum wage employee doesn’t want health insurance, otherwise he’d be buying it himself already! Obviously the Chamber hasn’t noticed how bitterly hotel and grocery workers in this state are fighting to maintain their health benefits, nor have they noticed how much employees in polls always favor health benefits over cash, nor have they noticed how shitty the individual insurance market is. This argument really reminded me of a southern lady I once sat next to on my first trip to the USA. I asked her about being in the south during the Civil Rights movement. The first thing she said to me was, “well I’ll tell ya one thing–the blacks didn’t want it!”.

My namesake from the public employer representative didn’t seem to realize that she was being a shill for the fast food companies and Walmart, which exposed its true colors by dumping $500,000 into the No on 72 campaign today. (I have a sneaking feeling that she’s a single payer advocate). She kept on claiming that the demands of 72 would increase labor costs for school districts, and therefore lead to lay-offs. I think she meant that there are some employees who do not get health benefits from school districts (my guess is that they are the lowest paid employees like the janitors), and that by covering them they’d run out of cash. However, even if that is right for a school district it certainly isn’t the case for other employers — especially the fast food chains and the Walmarts who cannot move their stores out of state, but would be forced to pay more in labor costs and TA-DA reduce their profits in consequence. That’s why they are opposing 72, and it doesn’t take a rocket scientist to figure out that they’d rather have the taxpayer take care of their employees than do it themselves. Worse, particularly in Walmart’s case, it’s forcing its competitors here (Albertsons, Safeway, etc) into the same behavior, which will force even more costs onto the taxpayer in the future in the absence of 72. This is a straight fight between allocation of revenue to labor versus corporate profit for immobile service businesses, whatever a certain Harvard PhD student might think.

The advocate of Prop 72 was the ex-head of the CMA and the AMA, Richard Corlin, and he wasn’t exactly a whole lot better. He delighted in consistently saying that he didn’t want government regulation, and that this was a tiny incremental solution that only worked for a few people (1 in 6 of the uninsured). He’s right but that’s not a good thing! As per usual you can expect organized medicine to protect its own arse first, and to only move very modestly in the direction of helping the people it serves.

So why am I for Prop 72?

1) It levels the playing field between big firms that can’t move (notably Walmart and the other grocery stores) preventing an ugly race to the bottom

2) The additional cost will start motivating large and medium sized business to finally get on the right side of this issue, pushing them to look for a universal solution that includes real cost containment and real universal coverage.

3) At the margin, as a value judgment, 1 million poor working people getting coverage is better than Walmart and McDonald’s shareholders getting slightly bigger dividends.

Meanwhile, polls have this Prop dominated by the undecideds.

Postscript: I have replied privately to the non-reply to my point by the Anna Sinaiko, the author of the Health Affairs article, and as she’s just a doctoral student I’ll give her a little while to respond to my attack on her dismal science. Of course if I don’t hear from her soon, there may just be one more little article on this topic before Tuesday. And it wont be pretty.

POLICY: Interesting book out on Soc Sec, Titles 18 & 19

Liberal historian Mark Santow has written a book about Social Security, Medicare and Medicaid with his fiscal conservative dad, Leonard. I haven’t got through much of it, and it’s a 100 pager, not a 3 pager, but well worth looking at for you wonks. Here’s the link to the explanation, and here’s the full PDF. The full title is Renewing the “Promise of American Life”: Social Security, Medicare, Medicaid And Beyond.

TECHNOLOGY: Stent Wars

The NY Times looks at the ongoing battle between J&J’s Cordis and Boston Scientific’s drug-eluting stents. Since Boston Sci has recovered from its recall problems over the summer it has been really cranking out the numbers. It’s Taxus stent sold over $600m last quarter, comfortably besting Cordis’ Cypher and putting it on course to become the best selling medical device of all time–recall that if it gets to a $1 billion quarter, only 3 drugs sell more than that in the US. Cardiologists like Taxus because it’s easier to put in and apparently the problems with early openings are behind it. However, there are some indications that Cypher might actually have better outcomes.The main issue in stents is the restenosis rate, or in English, when you put the stent in, how long does it take for the blood vessel to become blocked again? It’s been a progression as first balloon angioplasty was used, then a bare metal stent and now a drug-eluting stent. But it appears that the restenosis rate for Cypher is better than that of Taxus.

The results of some early studies comparing the two stents were reported last month at a major conference in Washington of cardiologists who perform stent procedures. The studies included one in Korea comparing Taxus and Cypher with a control group that received a bare metal stent that was not coated with any drug. The trial focused on patients with longer blockages, or lesions, in their vessels than the average patient who receives a stent, and had a high proportion of patients with diabetes or other diseases that can lead to complications. While both drug-coated stents achieved far better results than the bare metal control group, various measures showed that Cypher patients had a third to a half as much regrowth of lesions as Taxus patients. And while the number of patients who suffered such extensive reblockage that they needed a second procedure was too small to produce significant results, those data also clearly favored Cypher.

It’s unclear what “far better results than the bare metal control group” means but I’d be very interested in the long term outcomes of this type of study. Recall that last year a Stanford group compared the long term results of those who had bare metal stents with those who had a CABG, and over a 10 year period the CABG group had much better outcomes at a much lower cost. So if the restenois rate for the DES doesn’t stay good in the longer term, they too might be a failure in health services research terms while being a huge market success. As with any technology assessment the attitude of the physicians on the ground is far more important than that of the academic wonks looking at longitudinal data sets. Meanwhile an earlier article in the NY Times questioned whether any of these surgeries–including CABGs–aimed at keeping arteries functioning were a good idea.

Researchers are also finding that plaque, and heart attack risk, can change very quickly — within a month, according to a recent study — by something as simple as intense cholesterol lowering. “The results are now snowballing,” said Dr. Peter Libby of Harvard Medical School. “The disease is more mutable than we had thought.”The changing picture of what works to prevent heart attacks, and why, emerged only after years of research that was initially met with disbelief. In 1999, Dr. Waters of the University of California got a similar reaction to his study of patients who had been referred for angioplasty, although they did not have severe symptoms like chest pain. The patients were randomly assigned to angioplasty followed by a doctor’s usual care, or to aggressive cholesterol-lowering drugs but no angioplasty. The patients whose cholesterol was aggressively lowered had fewer heart attacks and fewer hospitalizations for sudden onset of chest pain.

But really that’s what Dean Ornish has proved for years. With aggressive enough diet exercise and behavior changes, heart disease can be relatively quickly reversed. So does that spell the end for stents and CABGs and a trip to the breadline for cardiologists, cardio-thoracic surgeons and their suppliers? Well probably not. The level of change required to avoid surgery is pretty extreme. I gave a talk to Ornish’s group a while back and had the lunch they provided. I had to break out for a cookie run in the afternoon after the no-fat no-sugar experience was too much for my delicate constitution. In general Americans like this type of intervention over changing their lifestyle.

Their new stents, coated with drugs to prevent scar tissue from growing back in the immediate area, are increasingly popular among cardiologists, and sales are exploding. But there is not yet any evidence that they change the course of heart disease.”It’s really not about preventing heart attacks per se,” said Paul LaViolette, a senior vice president at Boston Scientific, a stent manufacturer. “The obvious purpose of the procedure is palliation and symptom relief. It’s a quality-of-life gain.”

TECHNOLOGY: Social networking meets health care

Those of you who’ve been paying attention may note that there’s a mini-boomlet going on again in Silicon Valley, and those of you clever enough to have bought Google stock at its IPO, or have been sleeping with the founders (and you know who you are!) are at the center of it. But there has also been a ton of venture capital pouring into social networking sites like Linked-in, Ryze, Tribe and Friendster.

These sites allow you to contact people you don’t know via a six degrees of Kevin Bacon approach. VC and rebel doc Chris Mayaud has become the most connected player in health care on Linked-in by matching his address book to the world. If he’s bugs you I apologize as I was the one who got him started on there! And even though I only have 1% of his “connections” I have had some work and interest come in from it.

There are also healthcare sites based on list-servs, or “groups” that act as bulletin boards, often for patient groups. But they tend to be long lists of email postings, and haven’t really changed much since the early 1990s, even though they are extensively used. And then again there are personalized medical record sites that funnel information to users based on their specific conditions. (That’s what my company i-Beacon’s health record used to do before the axeman came!)

Now there’s an interesting piece of software called Gencache that tries to do all three pieces — linking people, linking people to information of interest and providing messaging. If you’re interested in this sort of thing, ask Gencache Jay Limaye for a username and take a look around. He gave me a tour the other day, and although it’s early days for the software, it might be a proto-type for that all-in-one forum for that elusive medical community that we’re always hearing about.

POLICY: Will infrastructure issues scuttle the VA idea?

Dave Moskowitz’s idea of using the VA as a public provision system to cover the uninsured has got a little bit of feedback. While some of you wonks might be thinking as I do that the VA would be overwhelmed as employers opted out of providing insurance if the VA (or would it now be the UA?) did a half decent job of providing care for free, Linkmeister Steve has a much more mundane objection. It surrounds of course the most important element of American life — parking. Steve writes:

It’s an interesting idea, using the VA to cover the uninsured. But I wonder if that $100B includes such prosaic things as parking. Here’s the VA 7/03 factsheet for Hawaii VA facilities. The Matsunaga clinic is located at Tripler Army Medical Center , which is a huge facility with about 500-750 parking stalls. I can speak from unpleasant experience that that ain’t enough. I doubt whether most VA facilities, particularly non-urban ones, are as large and as well-appointed or supplied with even that sort of infrastructure.

Additionally, Tripler has sentries (well, private rent-a-cops…why our military has to contract out that function is the subject of another article), and access is limited to the number of people who have military ID cards and a legitimate reason to go through. I have to flash my mother’s card AND her written prescription to pass muster.

I’m just sayin’ it would require a lot of mundane planning.

To which Dave replies:

Security should not be a problem for the public, given the added security the public is already used to in airports, museums, and government office buildings. It also represents a wonderful way to employ people getting off Welfare, i.e. expanding security is already a great jobs program for the government.

So there might be some additional expenses for security, but I would think they could legitimately come out of the Dept of Homeland Security (DHS) budget and not out of the US PHS’s budget. At Trippler, the base would just need to apply for extra funding from DHS, if the Pentagon’s budget was too constrained to help (a bit unlikely given the current climate). DHS and the military are already extremely well intertwined. And the US PHS, one needs to remember, is a uniformed service within the Coast Guard, if I’m not mistaken, making it already eligible for DHS funds.

As for parking, the VA has a terrific shuttle and bus system which is utilized well below capacity. In St. Louis, for example, there’s a daily bus to and from the outlying cities 200-300 miles away. The bus seats 60 but never has more than a dozen riders. So if people were worried about finding a parking space in the big city, they could just take the shuttle. For people living in the big city, they would just need to hop a bus to the nearest VA. The medical centers are all located in the center of the city, exactly where the uninsured people are.

So given that Dave thinks that parking isn’t a problem and that the VA Medical Centers are well located near to the uninsured, there are only two questions remaining before I put Dave in charge of the VA in my new adminstration (assuming I win the write-in vote a week from now!).

One: Is the Congress (or anyone else) prepared to front up the extra money required to cover the uninsured, even if it doesn’t require a new institution?

Two: In the year 2004, 50 years on from Brown versus Board of Education of Topeka is “separate but sort of equal” the best we can do in American health care — even if it is better than the current status quo?

INTERNATIONAL/PHYSICIANS: American doctors running off — to the UK!?

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So I spent most of last week at two different conferences. One in Vegas was sponsored by a subsidiary of SAS Institute, Better Management, and was mostly about the application of data analysis to health care process redesign. The other was the American College of Emergency Physicians meeting (ACEP), where I spent my time checking out the state of IT use among Emergency Room docs. More on both those meetings later this week.

Meanwhile, the most surprising conversation that I had the whole week was in a booth for the NHS at the ACEP meeting — yup that NHS, as in the UK’s National Health Service. As I’ve reported from time to time in THCB, having not basically spent much money on its health service from 1945 to 1997, the UK in the second Tony Blair government has decided that it should spend a bit more. Some of this is going on IT, (much more on that here), and some of it is going on improving the overall quality of care in the system. But most of it is going to decrease the waiting times for elective surgery, including paying for people to go have surgery done in France and even elsewhere in Europe.

One major stumbling block is a lack of staff, as you can’t just turn on the pipe and get more British doctors. There are significant shortages in several specialties, hence the NHS has been recruiting abroad, paying relocation and housing for doctors prepared to take 2 year contract. So far they have recruited about 300 doctors, mostly Indian psychiatrists (as apparently that’s a very easy transition). However there are about another 1,200 doctors who have agreed to move to the UK, but haven’t got there yet. What blew me away was the fact that 300 of these are Americans. Note that these are American doctors moving to the UK to work at UK salaries, which are about less than half the average US level.

Now I know not having to pay for housing bumps up the pay level somewhat, but that’s still pretty flabbergasting. Apparently the type of doctor signing up is either one who’s hit a glass ceiling or one at the end of their career looking for a new adventure. American docs just out of residency struggling to pay off those loans will not find this too attractive.

Meanwhile the only special thing the immigrant doctors have to do to qualify for the program is to pass an English language test. Apparently male American doctors have been having trouble with the listening and comprehension part of the test, which (I was told) was something that didn’t surprise the female American doctors (who all passed that part of the test just fine, thankyou) at all!

Given the back and forth last year between me and Sydney at Medpundit about Canadian docs moving to America, I wonder what she’ll make of all this?

PHARMA/POLICY: A research and policy institute for the “third way”

I’ve been working behind the scenes with a very talented group led by Dave Gershon, an over-qualified MD/JD who’s spent time on Wall Street. Dave has putting together an organization called The National Institute for Pharmaco-Economics & Healthcare Policy. The goal of the Institute is to start asking and answering the really hard questions that have been hitherto mostly avoided.

  • What pharmaceutical and medical technologies and processes work best in the real world?
  • What costly new technologies are justified in terms of savings elsewhere in the system and improvements in health and the economy?
  • How can the right therapies at the right time be made available to those who need them?

To answer these questions is to provide a guide to some of the most important questions that will be facing us as we create the health care system for the next ten to thirty years. In my view, saying that we can do everything is not realistic, but saying that we can’t do anything is equally untrue. Anyone reading THCB (or the newspaper) has seen far too many articles about unnecessary care variation, marketing-driven prescribing, and unevenly applied medical technologies.

We can do better and we can do it with integrity. And we can advise decision makers in the public and private sectors how to cooperate on doing the right thing, while maintaining innovation.

That’s the underlying concept of this new Institute, and I encourage you to go take a look at the web site, at http://www.healthcare-economics.org and give me your feedback.

POLICY: The VA as a solution for the uninsured, by Dave Moskowitz

Today there’s a new contributor to THCB. Dave Moskowitz runs a genome company that claims that judicious use of ACE inhibitors can reduce the prevalence of heart disease and cancers. But those of you interested in that must navigate over to his GenoMed web site. Here I’m more interested in his ideas for changing the health care system. Dave has an interesting idea: expand the VA and use it as a basis for public-sector health care service provision to cover the uninsured. He writes:

We both agree that a single-payer system would be a disaster (Editor’s note: I don’t — I think some version of single payer would be better than the current system, but Dave has confused single payer with “government as the only provider”). I don’t think it’s the best answer, with long waiting times and rationed care. There is a need, in my mind, for both a private sector healthcare system, and a state-supported healthcare system. The incentives in both are perverse enough that they need each other to stay honest.

For example, if the private system remains primarily a fee-for-service system, then the incentive is to do unnecessary medicine and run up the bill (the current U.S. system). On the other hand, a capitated or salaried government-run system encourages physicians to do as little as possible for their patients. I’ve seen this at close hand when I worked at the VA for 11 years. The only way to keep the two systems honest is to make them compete on patient outcomes.

Now, we need to discuss the mix of private vs. public healthcare. In the UK, it’s 95+% public, and in the US it’s 95+% private. What would be ideal is an 80% private, 20% public mix, essentially the ratio of public vs. private schooling in the US, inverted.

There would clearly be a dynamic equilibrium between the two systems. If the private system priced itself too high, or continued to spend too much on administrative costs, then it would lose clients to the public system. The lines would get longer at the public clinics, and people would complain. In fact, the distaste people have for long lines would keep most folks in the private system. But people who currently have no medical care at all, the 45 million Americans, would at least get some care, smelly waiting rooms and long lines notwithstanding.

How much would it cost to deliver healthcare for 45 million through the VA? About 6 times what the current VA healthcare budget is. A few years ago, it was $15 billion. It’s probably closer to $20 billion now. Here’s how I figure the ramp-up. Currently, the entire VA infrastructure takes care of 3 million people. It consists of 150 medical centers and some 300 satellite clinics and nursing homes. Not a single new building would need to be built. Instead, staff would need to be expanded.

45 million patients is 15 times more than the VA currently serves. But VA physicians currently have an average of 300 patients in their panel (many subspecialists have only 150). If every VA physician were to take care of 1,000 patients, which would require half-time clinical work, then the number of patients seen could be increased immediately to 9 million. Hire 5 times the number of physicians, and you’re up to 45 million patients.. Throw in an extra 1X of spending for ancillary help, and you’ve multiplied the current budget by a factor of 6, and you’re taking care of the VA’s current 3 million patients plus the 45 million uninsured.

Here’s an unexpected consequence: half of the medical schools won’t have to close. Without this change, the VA will close most of its hospitals, and the 125 medical schools with a VA hospital on campus will have to lay off at least a third of their research and clinical faculty.

Interestingly enough the $100 billion that Dave suggests we should spend on beefing up the VA to cover the uninsured is roughly what many experts think the cost of covering them with a decent insurance coverage would be and double the current $50 billion that gets spent on the uninsured in various places now. This idea has some similarities to Bush’s concept of spending more on community health centers (albeit on a much, much larger scale), and has the advantage that it wouldn’t require a system change, just more money. The current Congress seems happy to spend more money, but unhappy to implement new social programs.

On the other hand, if there was a decent service that was available for free, why would those providing marginal benefits to their employees keep them up? They’re dropping off in droves anyway, and if the employer can point to the VA system and say “go use that”, it’s not much of a stretch to say that many would. So this might accelerate the collapse of employment-based insurance, especially for those on low or middle-income, leading to more demand and more money needed by the repositioned VA.

Still, an interesting idea, and no less likely to pass than the Kerry plan or the Bush plan, given the current deadlock in the Congress!

Meanwhile, veteran health economist Joe Newhouse has a piece in the NEJM on Financing Medicare in the Next Administration. The shorter version? The gap in the increase between Medicare spending and GDP means that we have an upcoming crisis. But neither candidate will admit to it, so we’re screwed.

POLITICS: Dateline Nevada

So I’m in Vegas, which is in Nevada, and I’m getting a flavor of what a “swing state” means and where all the billion dollars (mostly raised from California & New York) has gone. Every single commercial is about the election. In California it wasn’t a quarter this bad when Arnie was running 2 per commercial break during the recall election. Not only does Kerry flip-flop on the war and Bush suck on the deficit, but lawyers and doctors are fighting on 3 separate malpractice propositions. And all this for the votes of 2 million people? About time something was done about the electoral college for the health of the populations of the swing states and the relative financial state of TV stations in Vegas and Los Angeles. Los Angeles is basically 9 times the size of Nevada, but tell that to the Founding Fathers.Meanwhile, congrats to health care wonks Ross at the PublicHealthPress and Jonathan Cohn on the Red Sox victory. Jonathan told me that it was the greatest day of his life, and given that mine was this day in 1997, I understand. Of course, these things come in threes, the Patriots, the Red Sox and maybe another late finisher from Boston?

Meanwhile, it does look like the docs might win one of those malpractice suit propositions in Nevada.

Note: due to a problem when Blogger had a malfunction this post dissapeared yesterday, so I’ve put it back in. I hope that Google (which owns Blogger) spends some more of their massive amounts of cash upgrading the whole thing soon!

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