Vol. 40 March 1, 2011 Health Care Reform: Politics, Computers, and the Individual

March 1, 2011

There are always three solutions to any issue;
the perfect solution,
no solution,
and the one we get.

-Deval Patrick, Gov. of Massachusetts, referring to the Health Care Reform program in Massachusetts

For those of you who, like me, are having a hard time keeping track of the latest Senate and House bills and head counts, periodic promises of vetoes, contradictory federal court decisions, and a veritable blizzard of acronyms, here are some brief reflections to help maintain focus on the important issues.

“IT IS ALL POLITICS”.
Of course it is. Gov. Deval (Dem) just complimented past-Gov. Romney (Rep) on the excellent job he did crafting and getting passed the Massachusetts Health Care Reform Act of 2006.  It “guaranteed heath insurance to everyone and incentivized cost reduction and improved quality” AND included the individual mandate (see below). Romney is quietly aghast because he is trying to woo conservatives Republicans for his 2012 run for the presidency, and they want to scuttle the federal program which is modeled after his Massachusetts program. Romney’s response is to proclaim that not every state has to do the same thing, “What is good for Massachusetts is not necessarily good for Mississippi ( or Alabama, or North Dakota)”. That sounds great to proponents of  “States’ Rights” (wasn’t that one of the battle cries of the Civil War?), but the states have no money either. They want to be able to blame the federal government for the increasing cost of providing health care to everyone.

Meanwhile President Obama reminds us that his program allows states in 2017 “to do their own thing” if they think they can “insure everyone while reducing costs and improving quality”. He just announced his support of Senator Brown’s bill pushing that time period forward to 2014. (This clever “calling their bluff” might help deflate the distracting federal vs. states debate.) The “States Rights” guys are now aghast, because they would prefer  to stop Obama’s federal plan in the courts by attacking the individual mandate as unconstitutional rather than being held accountable to come up with viable state-based reforms.

Depending on your view the Massachusetts program is working or it is bankrupting the state. If you check out these references and look for others, you will see that there seems to be little data on the results of the Massachusetts bill after 2009. As a physician who believes that health care needs reforming, I can only hope that Don Berwick, MD and others who are busily supporting innovations and reform will be able to show us the data on what is working and what is not before politics completely obscure the original goals.

HIT, EHR, EMR, mHEALTH, and HITECH are all computerized medical information terms,
or are part of the sequel song to “Initials” in Hair.
While plans to build expensive proprietary systems proceed with all deliberate speed, physicians are rapidly buying iPhones, iPads, and Blackberrys to both enjoy and benefit from the easy connectivity to the rest of the world. The last time I pulled the Physician’s Desk Reference (PDR) off the shelf to check a prescription was last year, which was a year later than the last time my nurse did. There are over 500,000 apps for “smart” devices, but what do we all really value? CONNECTIVITY. Connectivity allows all sources of medical information and, by the way, maybe the patient, to communicate directly and easily. Neither the U.S. nor the U.K., which has been spending millions on its national program to computerize medial information for years, has developed standards for connectivity.”…[Without connectivity] this potentially transformational technology will simply create one more way for different health care providers to talk past each other”. (1)

THE INDIVIDUAL MANDATE
The individual mandate requires almost all legal residents of the United States to have at least a minimum level of health care coverage through their employer or purchased by themselves individually. Those lacking such coverage will be subject to a penalty to be paid as part of tax filing. (The wages and benefits for thousands of new IRS agents to enforce this regulation is a significant cost of the bill.) Eligible low-income people will be helped in complying with this mandate by government-run insurance exchanges and government-subsidized policies.

This mandate is supported by the health care insurance industry because it promises that the industry will gain 30 million new customers. In fact, this provision causes some to label the current health care reform act as the “preservation of the private health care insurance industry.” It was meant as a sweetener to offset the mandate to the insurance companies to NOT deny coverage to anybody for pre-existing conditions. The precedents for the individual mandate touted by its proponents go all the way from the Militia Act of 1792 to current state requirements for auto insurance. Ah hah! There is that “state” word again. Maybe that is why conservatives attack this federal provision even though it is supported by big corporations and was originally developed by fellow Republican Mitt Romney .

References:
1. Boston Globe editorial March 1, 2011

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Vol. 18 April 1, 2010 APRIL FOOL’S ISSUE

April 1, 2010

APRIL FOOLS DAY (according to one theory that ignores the 13th century literature references to “april fools”) was created around 1582 when the Gregorian calendar moved the first day of the New Year from April 1 to January 1. Those who persisted in calling April 1 “New Year’s Day” were often sent phony invitations to  New Year’s parties. Other pranks to fool people, usually performed in the morning, were soon added to the phony party invitations. Someone who pulled a prank after noontime on that day was also called a “fool”.

THE TRADITION CONTINUES.

NIH REPORTS THAT ONLY 20% OF AMERICANS ARE ACTUALLY OBESE.
The NH discovered an error in its formula for calculating Body Mass Index  (BMI), a widely used standard of obesity which is posted on their website. The calculation error results in a grossly overstated BMI which negates decades of provocative research on obesity. The White House spokesperson for Michelle Obama declined comment by saying, “We have other more important health care issues on the front burner right now”. The NIH regrets any inconvenience that this may have caused, reassures researchers that study grant funds will not be reclaimed,  and states, “Hey, we can’t be right about everything.”

LAST SUPPER PORTIONS HAVE INCREASED 69.2% OVER THE LAST MILLENNIUM.
In a related study, and a timely one at that, two researchers studied 52 paintings of the Last Supper and concluded that the size of the main course in the paintings had increased by nearly 70% over the centuries. Plate size increased by 66% and bread size by 23%. The authors of this study published in the International Journal of Obesity just in time for Easter speculate that the increasing sizes reflect the increasing abundance and affordability of food over the years. (Apparently there is nothing new about “Super Size Me”.) (1)

H1N1 (SWINE) FLU PROGRAM A BIGGER STIMULUS THAN THE BANK BAILOUTS
The Government Accounting Office (GAO), the federal government’s premier watchdog agency, reports that the H1N1 (swine flu) epidemic efforts created more of an economic stimulus than the bank bailouts. The amount of money pumped into media outlets by the educational efforts was exceeded only by the amount paid to pharmaceutical companies for manufacturing and distribution of the vaccines, now readily available in excess supply due to underuse. More importantly, much of the trickle down economic benefits occurred in the offices of pediatricians, internists, and family physicians; our lowest income bracket health care providers. When asked by the GAO for comments, the CDC replied, “Hey, we can’t be right about everything.”

VIDEO GAME EXPERIENCE MORE BENEFICIAL THAN HONOR GRADES.
Army recruits with a history of prolonged play on video games have better success records as tank commanders and drone pilots than the valedictorians from the same schools. The study speculates that the better hand-eye coordination and enhanced perception of spatial relationships of the video game players accounts for the large discrepancy in skills between the two groups of students. The study authors speculate that these findings could be generalized to include endoscopic, laparoscopic, angioplastic, and other “minimally invasive”  procedures. “Perhaps it is time we altered our application standards for medical school and post-graduate clinical training.”

VEGETABLES CAN LOWER IQs.
Organic vegetables are suspected of  lowering the IQ in young children by at least 10 points. This result of a study of children in Western Massachusetts, Southern California, Oregon, and other tree-hugging communities surprised the authors who had received funds for the study from the National Association of Vegetable Investors (NAVI). A parallel study in rabbits revealed that carotene (the color in yellow and green vegetables) has a strong affinity for nerve synapse proteins in the brain. The carotene  binds tightly with the nerve protein, slowing the response time, EXCEPT in the occipital lobe which is responsible for vision. (Your grandmother was right after all. Eating carrots can help your eyesight.)

WEARING GALOSHES (OR RUBBERS) IN THE MOVIES DOES NOT HARM YOUR VISION.
This small study revealed no change in vision between children who removed their galoshes while in the movie theater and those who did not. The study authors concluded that “Mothers and grandmothers can’t be right all the time, either”, but admitted that the study result was weakened by its small size since they had trouble finding enough kids who still went to a movie theater to watch movies.

OLIVES IN A MARTINI ARE AS GOOD AS OLIVE OIL IN REDUCING CHOLESTEROL.
“You just have to drink enough of them” say the study’s authors.

PASSAGE OF HEALTH CARE REFORM BILL CAUSES MASSIVE SHIFT OF LOBBYISTS.
Lobbyists for bankers, business groups, hedge funds, insurance firms, Wall Street brokers, and others in the  financial sector are poised to reclaim their historical position as the number one group in expenditures to influence Washington policy now that the health care bill has been passed. The Committee for Truth in Politics, its membership and financing still a secret, has already spent $5 million in advertising opposing proposed financial reforms. The Center for Responsive Politics, which tracks spending by lobbyists, speculates that the financial sector lobbyists want to get back to its spending level of the past decade of $3.9 Billion. (2)

CELL PHONE USAGE MAY INCREASE FERTILITY.
In the midst of the scientific controversy about whether or not the low-level radio frequency (RF) coming from cell phones can cause brain tumors, one study has unexpectedly shown an increase in the birth rate in those women using the cell phone more than an hour a day. The mechanism of enhanced fertility is not known. “We compared the actual time spent on voice calls, texting, twittering, and Facebook and found no fertility differences among them, so we don’t think it is associated with just an increase in social intercourse. Likewise, we found no differences between heavy daytime users and heavy nighttime users.” Dr. Siegal Sadetski, a researcher at Israel’s Gertner Institute, stated, “Scientifically speaking, we don’t have proof yet, but as a public health concern, I’m saying we definitely should adopt precautions.” (3)

References:

1. Believe or not, this fun fact is actually true. Wansink and Wansink from Cornell and VWI are the authors. Look it up!
2. Actually some of these names and amounts are true. Check out Center for Responsive Politics website.
3. This quote is true too, but is wildly out of context. 


Vol. 10 December 1, 2009 Health Care Reform Bills

December 1, 2009


“If you like laws and sausages, you should never watch either one being made.”
– Otto von Bismarck

The Senate now begins a two month debate on the Health Care Reform bill, and the outcome will go to a Senate-House conference committee for MORE discussion. During this log-rolling turmoil, which I have no ability to follow nor any influence upon, here are a few facts to keep in mind as guide posts during the legislative meandering (also presented as a table at end of this volume).(1)

Single payor provisions contained in either the Senate or House HCR bill: 0

Per cent coverage of legal residents under 65 yo. in Senate and House bills: S 94%, H 96%
Per cent covered now: 83%

Benefits covered by Senate and House bills respectively: Basic + 4 levels/ Basic

  • There is no consensus on the definition of “Basic benefits”.

Year that insurance coverage denial for “preexisting conditions” is first prohibited:S2014/H2013

Coverage for elective abortions in either bill: 0

  • The Senate bill will allow plans to offer a premium for an elective rider to cover abortion.
  • Estimated actuarial premium for an insurance rider to cover elective abortions: $1/mo(2)
    “How can you tell a gregarious actuarial accountant from all the others?
    …He’s the one looking at other people’s shoes.”

Changes in current rules and regulations that prohibit ILLEGAL immigrants from accessing federally funded health insurance: 0

Chances that final HCR bill will establish a new mechanism for the federal government to help provide affordable access to health insurance for the presently uninsured: 100%

  • Senate bill will establish a “Federal Insurance Exchange” that will “compete” with private health insurance plans in offering subsidized plans. House bill will authorize the Dept. of Health and Human Services to “negotiate rates with providers” via a “public plan”. “The devil in these details” remain obscure at this time.

Employers will be required to offer health insurance: S-No, H- only if company payroll is>$500,000 per year

Costs over 10 yrs.predicted for each bill: Senate $849 Billion, House $1,200 Billion

Costs over 10 yrs. of wars in Iraq and Afghanistan to date: $937 Billion (3)

Allowable annual income for family of four to be eligible for tax credit for health insurance costs in 2013:  less than $82,800

What health insurance companies will call the 47 million uninsured gaining coverage under any of these bills: NEW CUSTOMERS!

How much more in 2006 did health insurance cost in the U.S. than was calculated for a comparably wealthy country:  $91 Billion (of a total cost of $145 Billion) (4)

Number of people in 2005 who had health insurance through Medicaid : 60 million
Per cent of total Medicaid costs paid for by federal contribution to states : 57%
Per cent of poor adults covered by Medicaid in that same period:  28% (5)

Estimated cost to all of U.S. healthcare for overweight and obesity alone: $79 billion
Per cent of that cost borne by Medicare or Medicaid: 50

REFERENCES

1. adapted from Assoc. Press, Boston Globe, Nov, 20,2009, A12
2. thehealthcareblog.com, Nov.12,2009, A Lewis
3. http://www.costofwar.com
4.  McKinsey Global Institute, Harpers Magazine, Dec 2009, p.8
5. NEJM361:21, Nov.19.09,2009-15, SRosenbaum

COMPARISON OF HEALTH CARE REFORM BILLS

.                              Senate Bill                                       House Bill                               Now

Single payor mechanism NONE NONE None
% coverage under 65yo legal residents 94% 96% 83%
Benefits Basic + 4 levels Basic multiple levels
prohibits preexisting condition denials starts 2014 starts 2013 denials common
cover abortions elective premiums no coverage available no federal/state coverage
illegal immigrants no coverage non-federal coverage states vary
government plan “Federal Exchange” federal plan to compete with private plans via insurance Exchange a new public plan negotiates providers rates via Exchange state Medicaid plans can vary by 100%
employers offer coverage not required required if >$500,00 payroll states vary
COST $849 B over 10 yrs $1.2 T over 10 yrs most expensive in the Western world
Government subsidy tax credit for family of 4 making <$82,800 same; starts 2013 Health Savings Acct.
adapted from Boston Globe, Assoc. Press, A12, Nov. 20,2009

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