The Cost of Meeting Unmet Medical Needs

Medical Claims

For fifteen years before Medicare, I practiced medicine in Philadelphia. At that time, the backlog of unmet medical care seemed infinite, impossible to satisfy. For one thing, we didn't have enough hospitals to fix all the hernias, gallstone, rotten teeth, festering bad leg veins, positive blood tests for syphilis, and a dozen other matters. But we set about it, doubling the number of medical students in each school's class, and doubling the number of schools. We built or renovated and re-equipped 124 hospitals in Philadelphia alone, as I remember.

Well, we were successful. It is no longer true that everybody's teeth are rotten, or that one Wasserman test in six is positive. Instead of throwing up our hands at an infinity of unmet elective surgical cases, we now hear suspicions that perhaps cataracts are being "harvested", cardiac pacemakers becoming universal apparel, tummies being tucked. But professional jealousies to one side, an undeniable statistic emerges. We only have thirty hospitals.

Backlogs are like waterfalls. The level seems limitless, until it suddenly disappears from sight. We spent far too much money on new hospital capital construction, and that spending spree has to account for a major portion of the cost of medical care that now doesn't seem to be producing anything worthwhile. These are the trailing costs of what can now be seen as temporary construction.

These thoughts came to me when a visitor to the Federal Reserve from Kazakhstan talked recently about medical care in that vast wasteland. At a time when petroleum supplies are short, Kazakhstan has discovered it has possession of the largest new oil field in the world. The social scene is like Texas in the Twenties, or perhaps the Yukon fifty years earlier. Whereas today it is questionable whether to spend the money to perform a Wasserman in America, positive tests are widely abundant in Kazakhstan. I daresay the hernias, varicose veins, bad teeth and whatnot are just as bad there as they were in America in 1960. And they are gunning up their engines to build lots of the biggest most expensive hospitals anywhere, because they can afford them.

Prediction: in 2050 nobody will be able to explain why medical costs are so high in Kazakhstan. After all, at that time there will be no positive Wassermans, no hernias, no gallstones.

http://www.philadelphia-reflections.com/blog/1248.htm

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Replacing Employer-Based Health Insurance

Employer-group health insurance will surely decline because so many are dissatisfied with it.

Dr. Fisher

Preamble

It might take a hundred pages to describe America's dissatisfactions with its health insurance system, but we mean to limit the grousing to features which could usefully be changed. The present system served us well enough for sixty years, and we tip our hat to those who struggled during depressions and war years to cobble together some kind of health financing system, never claiming it would be perfect. For reasons that were sufficient at the time, we ended up with a dominant system which is employer-based and reflects that fact. In this book we skip the quaint history, going right to the advantages of gradually migrating to better systems, which surely means migrating away from employer group purchasing. An important word is gradual, because we must fix this engine without turning the motor off.

Later on, we'll return to what's significantly awkward about employer group policies, but here let's summarize complaints in a paragraph. The predicament of employers, first, is that instead of pre-paying for health care which defines what it covers and how much the items will cost, employers now pay for "service benefits". That's merely a best-efforts description of the scope, while the associated prices no longer relate to either costs or the marketplace -- undefined scope and prices are blank-check health insurance indeed. Next, many employees feel they receive a poisoned pill. They get "job lock", where insurability is suddenly in doubt whenever they change employers. Even more, employees fear what might happen to their health care if the employer must suddenly reduce expenses. Third, being outside this system is no escape from it. Congressional tax preferences seem entirely unfair to anyone who doesn't get them. In fact, even those who do get tax breaks suspect hospital cost shifting merely taxes it back. Taken as a whole, employer group benefits are a third-party system twice removed: those paying the bills suspect their insurance vendor doesn't supervise enough. But employers are reluctant to pay insurance companies more money to supervise services because they know neither one of them can directly observe it. Economists mutter the insight that health benefits really aren't employer-stockholder money at all. The money belongs to employees in lieu of higher wages, so what right do employers have to constrain how it's spent? Both employers and employees view health benefits as a boomerang they can't even throw away without getting hurt. Fairness notwithstanding, the American Academy of Actuaries estimates the waste in the third-party arrangement is at least 30% more than people would pay with their own money; that's roughly what they get as a tax deduction. Finally, the uninsured don't complain about exclusion as bitterly as you might suppose; roughly half of them could afford to buy it. The country struggles to give health insurance to absolutely everyone, but a growing number of people absolutely don't want it. There's more to say, but this should get us started.

This book asks the reader to trace complaints back to causes, and unite around objectives. The employer-based system stands in the road of other approaches, some of them quite attractive. We could rather easily work for a system where each person selects and owns an individual policy. Right now, workers participate in a group policy owned and selected by an employer. As a matter of fairness, employees ought to own and select their own health insurance, and it wouldn't be terribly hard to do. Even if you regard fairness as a loser's argument, the switch might be made so that much better products --currently blocked -- can flourish. The main focus of this early chapter is on some potential opportunities within individual ownership of health insurance, gained by employers surrendering ownership of group policies, one by one, on request by each employee. The first of the advantageous opportunities, the Health Savings Account, already exists after a long struggle. Other alternatives which follow might be even better, but experience with this one teaches some important lessons. Primarily, almost all variants require legislation, because the existing system has resorted to government to enforce its bargains. Furthermore, sufficient public enthusiasm must emerge to persuade insurance executives that enough market exists to justify the development effort. Both Congress and the Insurance industry must be persuaded the public is behind them, and both are tough to convince. By far the best way to convince anyone of anything is to conduct demonstration projects, experiments if you will, capturing what works and discarding what doesn't.

Health Savings Accounts

Health Savings Accounts started in 1980 and by 2007 have slowly grown to insure 13 million persons. Because of impediments in various state laws, the distribution of HSAs is uneven geographically (see Figure 1). Since the pattern closely resembles the red and blue maps of the 2004 presidential election results, observers have perhaps unfairly attributed HSA resistance to devious politics. That may be true in part, but the pattern more likely follows the distribution of laws intended to foster employer group insurance, and thus reflects concentrated industries, especially the steel, coal and auto businesses. HSAs therefore tend to be legally hampered in areas of heavy union influence, although seemingly they should not injure unions or provoke their opposition, and unions may not be mainly at fault.

These HSA accounts have two components, the catastrophic health insurance policy, and the tax-sheltered savings fund. These two structures revolve around the familiar advantages of high-deductible insurance, which is considerably cheaper than fully inclusive insurance because it avoids the heavy processing costs of myriads of small claims which most people could afford to pay for in cash. That concentrates the coverage to high-cost claims which, although less common, present the dual catastrophe of often being unaffordable and almost always putting the beneficiary out of work. Almost everybody needs some kind of catastrophic protection, although the size of the deductible might vary among income levels. Secondly, to be attractive to young people and others without significant savings, the savings account feature was added, as a way of providing the funds to pay for small claims and deductibles, without losing the cost awareness of paying for services directly. This savings and insurance combination was made tax-exempt in an effort to enhance attractiveness in competition with the tax shelter now accorded to conventional health insurance provided by employers and covering the same range of services. The Health Savings Accounts therefore were a step in the direction of extending health cost tax exemption to everyone, and shifting cost control decisions into the hands of the patient by awarding the savings to him. Permission to save unspent funds in the accounts from year to year created portability between jobs, and thus lifetime coverage. A final incentive, the ability in theory to strive for paid-up lifetime insurance, was thwarted in Congress by prohibiting the money in the accounts being spent on the premiums of the catastrophic insurance. It would be of some interest to know who in Congress promoted this prohibition, and what the reasoning was.

Proponents of this reform measure proceeded in their advocacy with the charming innocence of those who believed they had a splendid idea for the benefit of everyone. Anyone who resisted, must not understand the issue very well, and needed only to have it explained in greater detail. This feeling was heightened by seeing groups oppose the HSA who would seemingly only stand to benefit from it. Since experience has shown that a third of those who enroll in HSAs have previously been uninsured, it would seem reasonable to expect the uninsured and those who work in their behalf, to support it. Sellers of individual health insurance were expected to recognize the enhanced commissions of selling lifetime portable insurance compared with the drudgery of flogging annual renewals. Insurance company risk was removed entirely except for the catastrophic coverage portion. Unions, who prize their ability to pressure health insurance companies on their members' behalf should welcome a role in advising members on best choices for their money. Those who negotiate for higher wages and benefits would seemingly welcome the diminution of vague "service benefits" as a tool and the substitution of visible actual dollars into the accounts as a collective bargaining achievement. Union members individually would seem likely to carry their objections to managed care plans to the logical conclusion of reaping the rewards of cost containment for themselves, without impairing freedom to spend extra for luxuries if they please. One would have supposed union members would actively welcome the sort of insurance that gave them free choice of their doctor or hospital. Ultimately, you would suppose that union members would wish to lighten the burden of health costs of their employers, if only to demand higher pay in return, or alternatively to preserve their jobs from the ravages of foreign competition. But alas, legislative experience has been quite different. Prohibiting the use of tax-sheltered accounts to pay health insurance premiums is an inexplicable clause inserted by opponents of the proposal. Prohibiting the use by employers of more than fifty employees was another. Limiting the number of people who could have these accounts to 750,000 was still another unaccountably restrictive Congressional feature. It is almost as though there were some strategy of inhibiting the spread of these policies, with the ultimate goal of calling for total elimination based on lack of interest. The original pioneers of this program, now twenty years older, trudge on in bafflement at resistance, but rather steadily enlisting new subscribers in the states where they are permitted by local law. One consequence would appear to be a resurgence of local state resistance to interstate sale of health insurance.

In a certain way, other obstacles in the road of HSA accounts do contain some understandable logic. For the most part, they are the residuals of old state laws which once enhanced other projects with at least comprehensible goals. For example, mandatory benefits. Chiropractors, optometrists, physiotherapists and a host of other limited licence practitioners fought long, hard, and expensively to lobby laws into existence mandating payment for their services as a condition for any health insurance in their state. These primarily outpatient groups see high deductible insurance as a way of raising the insurance threshold above the typical price of their services, thus excluding them from a federally subsidized system. Before ERISA was passed in 1973, special mandates were added in state legislatures by the hundreds each year. That led to interstate businesses going to Congress for relief from the need to satisfy varying requirements in fifty states. This difficulty was garrisoned by the McCarran Ferguson Act of 1945, which uniquely excludes the business of insurance from federal regulation. Just how we got here from the original antitrust dispute is hard to explain, but nevertheless anyone can see that toppling this complicated structure would require a fierce political campaign. Therefore, by far the easiest pathway is to amend federal law to make it clear that conflicting state laws are pre-empted. Essentially, that is what ERISA accomplished, and when amendments are proposed, why employers regard ERISA as so untouchable.

Ratio of Prices to Underlying Audited Costs

Beginning this book with a discussion of the struggles of the Health Savings Account brings us bang against what the reader will soon learn I consider the most intractable issue in American health care reform. It's an outward symptom of the issue which must be addressed if significant progress is to be made in health reform of any sort, and it won't be easy to address it. My plan is to defer analysis in depth until later, after first describing one by one how it blocks progress in every single promising proposal. Only when it seems likely the reader has become thoroughly fed up with it, will we attempt to lead through its very complicated analysis. Please be patient with a very brief introduction, first showing how destructive it is to Health Savings Accounts.

To be eligible for Medicare payment, every hospital must submit an audited Medicare Cost Report. That makes it public information, subject to the Freedom of Information Act (FOIA) of 1966, although rightly any competitive organization is uncomfortable about divulging business information. A significant item on the Medicare report is The Ratio of Posted Charges to Costs. That is, the audited costs are divided into posted charges of the same year. If a not-for-profit hospital just breaks even for the year, the ratio might be expected to be about 1.0. With the allowance of say 4% for bad debts, the ratio could be 1.04. Because Medicaid commonly underpays for its share, the ratio might have to be 1.20. But that reasoning gets you to the wrong conclusion; the ratio is commonly five or eight times greater than that. To make this idea more comprehensible, an electrocardiogram with costs of $25 carries a posted price of $380 in at least one hospital; that would create a Charge-to-Cost ratio of 15.02. Fifteen times its independently audited cost? There is considerable reluctance to defend or discuss this matter, so it unfortunately invites speculation, both fair and unfair.

The reason for introducing the charge to cost ratio at this point is to identify a vexing issue which makes health insurance seem so essential, while simultaneously interfering with making affordable insurance available. A person even a wealthy one, must have health insurance to protect himself against overcharging. Those who cannot easily afford health insurance look to high-deductible Health Savings Accounts because that makes insurance cheaper. Unfortunately, cash savings within the accounts can be quickly eaten up by even moderate exposure to huge price mark-ups. The attractiveness of these accounts is thus limited to those young healthy people who have no real health expenses, and to residents of those regions of the country where the practice of massive overcharging is uncommon. Without encumbering this narrative with too much detail, that is the explanation for the slow steady progress of HSAs, and their peculiar geographical distribution. If a representative charge for an electrocardiogram is $40, HSAs are a bargain. But if an electrocardiogram costs $380, purchase of HSAs is mainly restricted to those who have no great need for electrocardiograms. The outlook for HSAs is not completely bleak, however. At some time and in some areas the mass of subscribers will grow to a size where they can force the hospitals to confer a discount. Using collective purchasing power and the threat of publicity or even lawsuit, certain local brokers of HSAs have worked out arrangements for their members to receive market prices for their outpatient services. The most effective argument with hospitals has been that HSA holders do not create bad debts in their co-insurance. Unpaid deductibles and copayments are now the largest source of bad debts for most hospitals.

While focused on the hospital markup issue, let's engage in some unproven conjecture about it. Hospitals actually construct these inflated prices, but at first glance they would seem to have no great motive to antagonize cash paying clients this way, or to injure poor people, or to drive outpatient work toward free-standing clinics and doctor's offices. As a matter of fact, there is a small incentive in the rare wealthy foreigner who pays full freight, and the Medicare inpatient loophole of charge reimbursement for "outliers", cases with unusual costs. However, regulators are struggling to close such loopholes and cash payments are rare. I remember one oriental dignitary, reputed to own 8% of his country's Gross Domestic Product, who pulled out a wad of hundred dollar bills to pay a hospital, but totally befuddled the hospital clerk who didn't know what to do with real money. For every instance of this sort of thing, there are a hundred instances of hospital administrators genuinely distressed by their own mandate to collect seriously inflated bills from poor people.

Well, if hospital top management is conflicted by devising this practice, and mid level employees are distressed to implement it, well, who else has a motive to continue this markup? The obvious suspects are two: health insurance companies and Medicaid agencies. Obviously, sellers of health insurance rejoice in a situation where even people without important need for health cost protection must nevertheless buy it to protect against gouging. Think of an insurance executive before his home television, watching Presidents of the United States searching for ways to make their product mandatory for every citizen, and weeping because it is unattainable. Yes, health insurance companies have incentive to favor high hospital posted prices, but still it is difficult to see why hospitals would cooperate. State Medicaid agencies might also develop a motive to increase their own Federal reimbursement, and have occasionally engaged in some questionable maneuvers to do so through the arcane formulas of federal-state cost sharing. What's more, state governments are often in a position to help hospitals who play nice. In a naughty world, some of that may go on, but massive conspiracy seems implausible. So, if those with potential incentives are unable to force compliance, why do hospitals do this? Why would they persist in something they privately deplore, silently biting their lips at the criticism it provokes?

http://www.philadelphia-reflections.com/blog/1293.htm

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Exit, Pursued by a Bear

John Kastor

Everybody ends up getting fired in a recent book by John Kastor about recent events at the University of Pennsylvania just like everybody ending up dead in an Elizabethan play. The vital difference, of course, is that the dramatis personae at Penn can still relate to a bewildered audience their own versions of those grand events. To protect himself, the author peppers his book with more footnotes than a PhD. thesis. And thousands of stakeholders at the University can now realize that during those eventful times they were as clueless as Rosencranz and Guildenstern.

One basic fact about that institution is that the medical school spends three quarters of the entire university budget. That leads to grudges in the little law school, the little engineering school, and the little president's office, as they knuckle under to the Golden Rule. The department chairman with the gold, makes the rules. Since most of that gold comes from research grants, hence ultimately from the federal government, the medical students and the teaching faculty don't have the same power they had during the Vietnam War era, either. Although medical school tuition imposes a crushing burden on the students and their families, leading to debts close to a quarter of a million dollars apiece, the tuition money doesn't amount to much in the university scheme of things, either. In some schools, tuition amounts to two percent of the medical school budget. You could eliminate the students entirely and not see much difference in the "school".

Unfortunately, when you become dependent on government grants, you find they can suddenly be terminated, or awarded without funding, or held up for several months by Congressional bickering. Meanwhile, there are salaries to pay, contracts to fulfill. Even if you can furlough some of the staff, it's not easy to see what you do about a thirty-year mortgage on a research building when there is a lull in its research funding. If you try to save money, the granting agency will try to get it back; they aren't authorized to make grants to be squirreled away. If you shift money to unauthorized uses, you risk going to jail. And yet, if you don't do something along those lines, the whole enterprise can collapse.

Having said that much to be fair, it is still uncomfortable to see the financial transparency of our most valued nonprofit institutions vanish behind a Byzantine fog of secrecy, out of which arise the magnificent towers of new buildings, and in front of which an occasional limousine is to be observed. No wonder the research scientists feel the constant pressure to produce. A Nobel Prize every ten years, or so, would go a long way toward quieting envious remarks from the liberal arts faculty.

Housed in those ivy towers are three institutions, the teaching hospital, the medical school, and the university, with three boards of trustees, and at least three ruling potentates. At irregular intervals, congressional committees do things to the Budget Reconciliation Act which enrich one of the three components of the institution, or suddenly impoverish another, or both. Integration of the three under one governance sounds plausible until you notice how radically different is the mission of each one. You can take a big building away from one component and rent it back to them, and things like that; but you can't do it without starting whispers about Enron. You can gather up surplus funds from one of them during the decade of the eighties, but you have trouble giving it back twenty years later. Officials at Blue Cross come snooping to see if health insurance premiums are passing through this shell game, ultimately paying salaries in the department of English Literature. Everybody distrusts everybody else, somebody sasses somebody, and everybody gets fired.

Nothing unusual about that. It happens at every medical school.

http://www.philadelphia-reflections.com/blog/830.htm

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Perfect, the Enemy of Good

Health insurance to cover absolutely everyone is an admirable goal, but may also be an unachievable digression from reforms which really are achievable.

Dr. Fisher

One problem with health insurance reform debate is there's so little mention of health. After all, without illness the need for health insurance would vanish. So here, let's begin with the so-called statin drugs, the first really effective treatment for high blood cholesterol. Statin drugs do far more good than merely lowering cholesterol levels. Heart attacks, the commonest cause of death, declined so rapidly in the past ten years it's hard to say how low mortality rates will eventually go. Deaths from strokes, also caused by hardened arteries, declined almost as much and that's the whole purpose of treating cholesterol. Statins didn't do it all; it is about half due to prevention, where smoking cessation, aspirin and other drugs are effective, and half due to rescue treatments, like angioplasty, pacemakers and by-pass operations. But that's why the conquest of arteriosclerosis seems so assured; it doesn't all depend on a single drug which might later have unexpected disadvantages. Eventually, we can reasonably hope for prevention to displace rescue treatment, so maintaining the conquest of this disease should also get cheaper. This is already the most dramatic medical advance since the invention of antibiotics. No sooner do we say the mortality rate from heart attacks is down by 30% than we sense it may be down by 50%. Since it takes several decades to accumulate that rust in your arteries, the death rate from heart attacks may decline for thirty years, as we prevent rust accumulation from beginning in high school. Safety is still a question, but a small one. Right now, elated doctors whisper that perhaps arteriosclerosis has been conquered, don't say it too loud because that's bad luck.

Sixty years ago medical doctrine was, only two research challenges remain: arteriosclerosis and cancer. That's a little exaggerated, since HIV, schizophrenia, Alzheimers Disease and nuclear explosions would bother us badly even after cancer is cured. But it's certainly high time to redirect the healthcare reform debates to include the massive economic changes going on, independent of any insurance reform. Let's repeat, for emphasis, we won't need universal health insurance if people don't get sick. Or put the same idea in more measured tones: Americans will almost certainly become progressively more resistant to taxation for health insurance as this longevity extension sinks in. It may not matter that Canada, Britain, France and Zanzibar have universal health insurance plans. Americans younger than 35 are already past the political point where the need for health insurance is self-evident to them. The conquest of arteriosclerosis could easily push that resistance level to age 50, because people form their opinions from what they see happening to friends and relatives. Employers form their opinion about what they see happening to their employees.

If, then, it can be feared that employers might eventually rebel at sustaining major health insurance costs for employees whose lack of fatal disease is obvious from their personnel records, the present system of employer-based health insurance coverage could crumble. At the very least, it will draw employers to proposals for individual health insurance individually selected and owned, portable between jobs. At that point, another group will rise in rebellion. The employees themselves will resolutely oppose mandatory spending for health insurance they think they don't need. Insurance against the cost of obstetrics and baby shots, yes. After retirement, Medicare will take care of the ills of old age. Costs will progressively concentrate around the first year of life and the last year of life -- ninety years apart. Everything in the middle will depend on how much risk people are willing to take, and that depends in turn on how much the insurance costs. The fate of the whole health insurance industry depends on reducing claims costs, but their track record on that is quite poor. Consequently, their future attempts will likely be quite drastic, making insurance even more unpopular. For all these reasons, it is going to be very difficult to persuade the country to accept any reform that includes the word "mandatory". People may be restless with present forms of health insurance, but it's hard to imagine them switching to any alternative from which there is no retreat.

There's a great deal more to say, but let's veer to a new unwelcome consideration. For sixty years, since the administration of President Harry S. Truman, we have embroiled ourselves in a struggle to achieve health insurance for everybody. Many quite practical solutions to smaller problems have meanwhile been swept aside, as either irrelevant to the Main Thing, or hindrances which reduce the urgency of it. Somehow it has always seemed worth concentrating on the big reform of universal coverage while smaller conflicting improvements are forced to wait for the dust to settle. But the problem of 12 million or more illegal immigrant workers begins to demand solutions which have nothing to do with health insurance, and may make universal coverage impractical for decades to come. Illegal immigrants appearing in the accident rooms of border states were a manageable problem until their numbers grew so substantially. Since we obviously cannot extend free coverage to the whole undeveloped world, no proposal for universal health insurance is viable without a workable feature about non-citizens. Mix in the local politics of the border states and it is entirely possible that the exigencies of overall immigration will prove greater than the need to have a uniform health insurance system. The longer it takes to face this unpleasant reality, the longer we will delay small, non-universal, solutions to health care reform.

Although it is a digression from healthcare, it seems important to make a convincing case that immigration is a serious issue. The terrifying fact is, we have grown to need immigrant labor. The experience we gained in centuries of dealing with new waves of immigrants is not much help in coping with the new phenomenon of transient laborers in massive numbers. Historically, we struggled with bilingual education and crime ghettos, and mostly learned how to deal with that. Now, we need to fear the example of the rich Arab countries where transient foreigners greatly outnumber the citizens. The most extreme result is found in Kuwait, where hardly a single Kuwaiti citizen in gainfully employed; the rich citizens are helpless parasites on the labor of the illegals. Try proposing universal health care in Kuwait and see how much attention it gets. At the risk of being called an insensitive person, I'm afraid that being the richest country in the world may be exactly the reason why we can't do what Europe has done with health care. Meanwhile, this distraction keeps us from doing what we really might be doing.

* * *

In its thirty-year existence, cable television's C-span diligently filmed mountainous archives of mostly boring speeches, hearings and contemporary analyses of our government at work. The true genius of this expensive private philanthropy emerges with hindsight, as old fims which hardly anyone watched at the time can sometimes re-emerge to display what now everyone needs to know. The present case in point is to listen again to the soaring, convincing rhetoric of Bill Clinton's introduction of his Health Plan to Congress in 1993, bringing America to its feet with a realization that something was terribly broken about American health care. And then to be present in the next hour to the fumbling, circular and unconvincing solutions offered by Hillary Clinton before the sly, elaborately courteous, but pointedly probing questions of the Congress in hearings. She improved considerably with practice, but it is not lost on the viewer that she reverted to emphasizing the seriousness of the problem, rather than the aptness of the solution. The Plan was going to spend some money at first, save a lot of money later, but not harm the quality of care in the process. Just how it was going to do that was mainly supported by a passionate wish to do it, because it simply must be done. Total, universal, and hence mandatory, insurance coverage would, must, shall cut costs while it extended decent care to all. All other solutions had been exhaustively examined. Without total universal mandatory insurance coverage, nothing would work.

However, if one problem would make this solution unworkable, it is not necessary to describe twenty others. There are billions of people around the world who do not have American health insurance; obviously we do not expect to extend it to all of them. It would seem that we are talking about extending, giving, or mandating American health insurance to those who are within our borders. Assuming we ignore the handful of foreign tourists who pass through, that mainly means extending coverage to immigrants and those without coverage for brief periods, mainly new employment entrants and those temporarily between jobs. Switching from employer group policies to individually owned and selected policies would solve half the problem, but at the cost of extending income tax deductibility to everyone, hence eventually eliminating it for everyone. It would take a lot of persuading to convince everyone to give up that tax deduction, particularly when it is scarcely mentioned in the persuasion. But then let's look at the other half of the problem; we have 12 or more million illegal immigrants in the country, is someone proposing we mandate health insurance for them? What about next year, when several million immigrants go back home, and are replaced by several million different ones? When you dig into it, this sounds less and less like a health insurance problem, and more like an immigration problem. Would it not seem wise to delay the goal of universal coverage and solve other health problems while other people with other ideas solve the immigration issue?

And then, the issue of raising taxes by eliminating the tax deduction for health insurance. A considerable portion of this revenue source would be absorbed by subsidizing the people who don't currently get the deduction, which not only includes the uninsured but those who currently pay for their own health insurance, mainly the self-employed population. The residual federal reveue gain from the net effect of all this disruption would probably fall fall short of its promises, but even if it produced mountains of federal revenue, would it reduce the cost of medical care? It's pretty hard to see how shifting money from one set of pockets to another would have any effect whatever on the cost of running a hospital or doctor's office or pharmacy.

Whenever the Clintons or their spokesmen fumbled a little, it was possible to believe they did not fully understand the irrelevance of their solution to the problem they denounced. And whenever the Clintons appeared glib and polished, it was possible to believe this was all some sort of ruse. They couldn't win, and others seemed to grasp this before they did. Meanwhile, potentially important progress in the improvement of medical care was totally blocked by insisting that every proposal must meet the test of universal coverage. Tort reform, increasing the share of patient cost responsibility, permitting the interstate sale of health insurance, and -- stop right there, how will that insure the uninsured? By forcing every proposal, large and small, to be measured by whether it led necessarily to universal coverage, the debaters "framed the argument". Fifteen years later, we can see that the country did manage to get by without meeting that benchmark, and we can also see that a great many useful improvements were ridiculed and hamstrung by relentless suspicion that they lacked the sensitivity and conviction of the impossible goal made possible.

http://www.philadelphia-reflections.com/blog/1290.htm

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War Dance

History Footnote: Before the white man came, the Iroquois "nation"devised rules still characteristic of our modern political parties. At various times, there were five, six, or seven tribes in the Iroquois confederacy headquartered in upstate New York, allied to each other with fluctuating loyalty. Philadelphia's tribe were Delawares, or Leni Lanape; but the most warlike and dominant tribe were the Mohawks. Confederations work best when allied against a common foe. The rest of the time, member tribes mostly beat and cheat each other.

The Philadelphia Democratic Party appeals to a number of minority groups and recent immigrants, but it is more meaningful to think in terms of players. For example, university professors are mostly Democrats, but the teachers union is an active political player. Minorities generally vote Democratic, but the Black Ministers are players. Lawyers are rather evenly divided between Republicans and Democrats, but Plaintiff Trial Lawyers, the ones who sue people for a share of the award, are players.

Some people are players but keep it quiet. Certain rich donors are players but don't want to be known as such. The chiropractors and optometrists claim to be players but would rather not have the truth known. The news media and utility companies come close to denying they are players in spite of abundant evidence otherwise.

Well, the local players had a war dance just before the November, 2005 elections; the timing was no accident, and it was publicly described as a SEPTA contract negotiation. The issues had mostly been settled in advance, but the real deal-breaker was health benefits, Blue Cross health insurance paid by the employer to escape income tax and to make the pay packet appear smaller to the taxpayers. Step by step for twenty five years, employers in the form of the Republican politicians had been keeping up a steady drumbeat, trying to reduce the incentive to overspend health insurance because it seemed free, with resulting increase in employer costs. Slowly, business management convinced a majority of the public that "first-dollar coverage" was a villain, since the person covered by the insurance has no skin in the game. Even party loyalists had to admit that it looked as though the tax exemption of health insurance was injuring the image of labor. That concept carried the slogan of "sending jobs to China", or killing the goose that lays golden eggs in the Rust Belt. Five million Health Savings Accounts were sold in 2005 in spite of state laws hampering this form of health insurance, and from experience it seemed certain that five times that many would be sold if early-adopters reported satisfaction. The surrogate was deductibles and employee contribution to health insurance; just about everybody recognizes the need to make some token contribution to health insurance in order to have skin in the game and keep costs down. But not the SEPTA workers. In 2005, the brotherhood of Septa workers would go on strike for fifty days rather than pay one penny of "give-back" for health insurance. Their energy level was high, they were waving their arms, they were ready to overturn ashcans.

Bellevue

When union contract negotiations go on for days, all day, the public gets an idea the negotiating table is a shouting match the whole time, with "negotiators" carrying on with tom-toms and tomahawks in an even more physical and extreme model for their supporters on the street corners. For about ten minutes a day, that's true. But then the television people can turn off their lights and the war hawks fan out to talk with their supporters outside the room, which in this case happened to be in the Bellevue Stratford Hotel. Perhaps you didn't know the Pennsylvania Governor has quite a nice set of offices there. Perhaps you haven't noticed that all the parking spaces on the side alleys near the Bellevue "belong" to various politicians. Just try parking there yourself to learn a few facts of Philadelphia life.

In negotiating classes, they teach you never to make the first concession. By that reasoning, no negotiation would ever end. The more practical advice is to forget about any serious bargains until the last day of the contract, or even a couple days after that. The hard reality is that no one will make a concession while there is time for some invisible player to back out; no one wants to give his constituents time to realize he has sold out their trust, or violated their loud, insistent, wholly unrealistic demands. And so in 2005, after the shouting had gone on for some time, and even a real strike began, the Governor finally sauntered into his nice Philadelphia office. Time to get to work.

Ed Rendell

Those who didn't know him made the comment they could almost believe he was a victim of Attention Deficit Disorder. He talked all the time, moved all the time, and apparently showered all the time. That is, he was in and out of sight all night, but invariably reappeared with fresh shirts, clean shaves and sharp creases. His aides confided he wasn't very good at "detail work", which is to say he conducted the whole affair on a primeval level of dominance, bluster, charm and implied threat. Don't bother me with facts. Mayor Street, on the other hand, would come in and mumble something incoherent, and then had to leave for an important engagement. Word came in that the school teachers felt they really had to pay a small health insurance deductible, and it wasn't so bad. Foo, no guts.

Somewhere along the line, the newspapers started to echo that deductibles had their merits. Foo, bunch of Communists. The black ministers were reported to feel that if their people all had to pay deductibles, why couldn't the transit workers. Bah, bunch of muddleheads. In the hubbub, someone asked what Andy Stern thought. The trial lawyers didn't have as much to say as they once did; SEPTA had reduced liability costs by $87 million through adamantly refusing to settle any case without going to court. Paper tigers. What about chiropractic benefits, we demand the inclusion of chiropractic benefits. No, said SEPTA, we aren't going to agree to any of that sort of thing. Well, what about twenty visits a year to chiropractors?

One by one, the other players deserted the SEPTA workers. The message from the other tribes in the confederation seemed to be, get what you can for SEPTA, but stop the strike by election day. The Governor produced the razzle-dazzle, a loan to the city to pre-pay the Blue Cross premium, in return for which Blue Cross would reduce the premium. The effect of that was to produce enough cash to appear to add ten cents an hour to the pay packet. We'll have to wait a year to see how this money gets restored to Blue Cross, but that's the general idea.

The strike was over, hurray. The next day, the Democrat party elected Democratic governors in New Jersey and Virginia, defeated some California amendments which would have hurt the trial lawyers and teachers unions. Surely, someone in the Democrat party nationally was telling himself that caving on the Philadelphia transit strike was a small price to pay for that.

http://www.philadelphia-reflections.com/blog/732.htm

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July 4, 1776

According to the records of the Pennsylvania Hospital, the following 48 persons were patients in the hospital on July 4, 1776:

The records indicate the following diseases were the reason for admission of those patients. Although in Colonial times there was no medical delicacy to avoid offending readers, present privacy standards require that we strip the diagnoses from the name of the patient and list them independently. There is some overlap, sometimes making it difficult to judge which disorder caused the admission.

• Sore, poisoned or ulcerated legs: 16 cases
• Lunacy, mind or head disorders: 10 cases
• Syphilis: 7 cases
• Fever and Rheumatic fever: 7 cases
• Dropsy: 5 cases
• Gunshot: 4 cases
• Diabetes: 1
• Blindness with clear pupil: 1
• Spitting blood: 1 case
• Dislocated arm: 1 case
• Inflammation of face: 1 case
• Scurvy: 1 case
• broken arm: 1 case

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The following physicians were elected at the Managers Meeting dated 5/13/1776:

• Dr. Thomas Bond
• Dr. Thomas Cadwalader
• Dr. John Redman
• Dr. William Shippen
• Dr. Adam Kuhn
• Dr. John Morgan

http://www.philadelphia-reflections.com/blog/1431.htm

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Nation's First Hospital, 1751-2008

As commonly stated in medical history circles, the history of the Pennsylvania Hospital is the history of American medicine. The beautiful old original building, with additions attached, still stands where it did in 1755, a great credit to Samuel Rhoads the builder and designer of it. The colonial building on Pine Street stopped housing 150 patients around 1980, supposedly at the demand of the Fire Marshall, although its perpetual fire insurance policy still owes the hospital several thousand dollars a year as unspent premium dividend. There may have been one small fire during two centuries of use, but its true fire hazard would be difficult to assert. It was just out of date. The original patient areas consisted of long open wards, with forty or so beds lined up behind fluted columns, in four sections on two floors. The pharmacy was on the first floor, the lunatics in the basement, and the operating rooms on the third floor under a domed skylight. It was entirely serviceable in 1948, when I arrived as an intern doctor. Individual privacy was limited to what a curtain between the beds would provide, but on the other hand it was possible for one nurse to stand at the end of a ward and recognize any distress among forty patients immediately. In this trade-off between delicacy and utility, utility was certain to be preferred by the Quaker founders. Visitors were essentially excluded, and if a patient recovered enough to be unnaturally curious about neighboring patients, well, he had probably recovered enough to go home.

Located between two large rivers, South Philadelphia up to ten blocks away was essentially a swamp until the Civil War. So, there were seasonal epidemics of malaria, yellow fever, typhoid and poliomyelitis at the hospital until the early twentieth century. Philadelphia was a port city, so sailors brought in cases of venereal disease, scurvy, even an occasional case of anthrax or leprosy. During the Industrial Revolution of the nineteenth century, tuberculosis, rheumatic fever and diphtheria were part of clinical practice. But underlying the ebb and flow of environmental effects, there was a steady population of illness which did not change a great deal from 1776 to 1948. These patients were all poor, because the rules in Benjamin Franklin's handwriting restricted service to the "sick poor, and only if there is room, for those who can pay." In 1948 there was a poor box for those who might feel grateful, but no credit manager or official payment office. The matter had been considered, but the cost of collection was considered greater than the likely revenue. When Mr. Daniel Gill was offered the position as the hospital's first credit manager, it was suggested that he be given a tenth of what he collected. To his lifelong regret, Dan Gill regretted that he refused an offer that he had felt he could not afford to accept.

So, the wards were filled with victims of the diseases of poverty, punctuated by occasional epidemics of whatever was prevalent. And a second constant feature of the patients was their medical condition forced them to be housed in bed. For centuries, physicians dreaded the news that a new patient was being admitted with "dead legs". Mental and neurological diseases presented a second major imperative for admission; such patients either couldn't walk or couldn't be trusted to walk alone. Coma or raging fever was another category of mandatory admission.

Therefore, the roster of patients who were in the Pennsylvania Hospital on July 4, 1776 was not substantially different from those who were present on July 1, 1948. The turnover was greater, because antibiotics made it easier to treat the disabling diseases of the poor, but the causes of admission were essentially unchanged. Instead of treating five dead legs a month, a modern physician might treat twenty, but after you have seen and smelled one dead leg, you have seen and smelled them all. Under the circumstances one Pennsylvania Hospital surgeon, Dr. C. Alexander Hatfield, became an internationally famous expert on the management of this class of conditions. But although scientific rigor was much elevated in the meantime, both Benjamin Rush and his distant descendant Alexander Rush undoubtedly experienced the same sights and smells when dead leg patients were wheeled into that same ward. The nurses curiously almost seemed to welcome such cases. They had been told exactly how to spring into action, and within an hour the odor and slime had disappeared; the nurses were very visibly proud of their accomplishment. It was a miracle only they knew how to conjure up; you could tell from their beaming faces that they had accomplished a triumph. We today can be fairly sure the patients in the hospital paid scarcely any attention to the commotion in Independence Hall on July 4, 1776 four blocks away. Just as the patients in the same beds were later unaware and unconcerned about the explosion of an atom bomb in Hiroshima, their focus was much more pointed. What was surely overpowering to both groups was the unbearable summer heat in Philadelphia before air conditioning. Modern physicians are astonished to learn what was then a commonplace: during a heat wave, almost every patient runs a fever. No one was taking their temperature, but it seems possible the doctors and nurses were running a fever as well.

Venereal disease is a constant among the poor. At present, the most prevalent condition is HIV/AIDS, but syphilis was a regularly fatal condition until it disappeared within a few years of the introduction of penicillin. About a sixth of the patients in the old Pennsylvania were suffering from syphilis on the day the Declaration of Independence was nailed to a post. Two hundred years later, a survey of the Philadelphia General Hospital revealed one Wasserman test in six was positive. Prostitution was supposed to be the underlying source. One thing was more or less unique. Other hospitals serving the poor reported a great deal of drug addiction, now delicately called substance abuse, but Philadelphia had remarkably little of it. In another essay, we have speculated on the likely cause of this anomaly, although in more recent days there is far less reason to remark about it. Gunshot wounds, then and now, provided evidence of the interactions between criminals and police; these fierce combatants seem universally meek and humbled when the medical establishment gets to see them.

For two centuries, the more things changed, the more they stayed the same. And then, in 1965, the heavens opened and Lyndon Johnson rained money in all directions. It took a few years for a mistrustful system to adjust to the idea that things had changed forever. A doctor could really do anything he knew to do, without concern about cost. The nursing school, the heart of the hospital, was not only unnecessary as a source of free labor, but actually an impediment to full Federal reimbursement of costs. Not long afterward, the resident physicians were actually paid a reasonable wage, after two centuries of being paid nothing at all. The large open wards were eliminated and replaced with semi private rooms, as insurance regulations insisted. The definition of poverty was changed to include people whose circumstances would have been considered luxurious before Medicare, so there are still thought to be poor people in the hospital. But the diseases of poverty are hard to find among all those people who would once have been expected to be treated in their homes. The floor space tells a story. Up until 1965, patients would have occupied 90% of the floor space of the institution, now they scarcely occupy 15%. The presence of patients, the reason for the institution after all, is far less dominant; doctors and nurses are a comparatively small proportion of the thousands of employees. That makes a big psychological difference. At one time, there was hardly anyone present except patients, doctors and nurses. Today, the other members of the medical industry predominate within these walls. There are many more computers than patients. But what is ultimately most puzzling is that so much more money is being spent on so much less disease. Life expectancy has increased by thirty years, several dozen diseases have disappeared, the disorders of 1776 which took months to treat are now cured in three days. It's all a very good thing, but it is puzzling.

http://www.philadelphia-reflections.com/blog/1432.htm

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Community Volunteers in Medicine

Comm Volu In Medicine

Mary Wirshup has a very different medical background from mine, but she's my kind of doctor. I couldn't help wishing, as she addressed our urban luncheon club, there could be thousands more like her, even while understanding more fully than she seems to, the reasons why doctors are driven from her behavior model. As we parted, it felt like saying a last goodbye to the Spartans marching to Thermopylae.

As 46,000 medically uninsured persons in Chester County get sickness and injuries, they know that a Federal Law prohibits a hospital accident room from refusing to see them, so ways are found to shunt patients to the CVIM free clinic, run by volunteers. This law is in turn a response to a government-created situation where a hospital which "accepts" patients must keep them. Any economics teacher can tell you that supply/demand issues are best addressed by price adjustment, so price controls in whatever guise lead to shortages. I must say I have little sympathy with the devious strategies which hospitals often employ to disguise their rejection of uninsured patients. At the same time, I know a lifeboat will sink if too many climb aboard. Nevertheless, the semantic switch from lack of insurance to lack of care implies that only more insurance can surmount the barriers to care, which is absurd. For one thing, I know too many hospital administrators who are paid a million dollars a year, and one who is paid two million. And at least two health insurance executives are in the newspapers with net worth over a billion -- yes, that's billion with a b. We have reached a point where reducing all physician income to zero would only reduce "healthcare" costs by 10%. As I look at Dr. Wirshup's modest clothing I can only surmise she plans to continue her modest living until she is 80 years old, after which her savings might see her out. Squeezing physician reimbursement is not intended to save significant money, nor intended to restore physician incomes to more equitable levels. It is intended to address the oversupply of physicians without confronting either the universities or the foreign trained lobby.

The elite tranche of medical schools do their part to relieve physician oversupply without reducing class size, through the encouragement of their students to go into research. I was well along at the National Institutes of Health before I finally decided I had not gone into medical school with that goal, and returned to teaching and patient care in a more satisfying model not too different from CVIM's obviously Pennsylvania Dutch spirit. The Amish at the far western end of Chester County reject the whole idea of insurance; their most characteristic statement is "Don't send me no bills." That attitude is rather a contrast with the shiny housing and automobiles in the Silicon Valley developments of Southern Chester County, or even with some rather bewildered Quaker farm families scattered over the rest of the county next to the horsey set. Chester County is America.

On Second Street in Society Hill, next to the park where William Penn's house stood and a few feet from Bookbinders, is the house of Dr. Thomas Bond. Bond conceived the idea of building the first hospital in America and with Franklin's publicity machine succeeded in getting it built, to care for the "sick poor". Dr. Bond started a second enduring tradition as well. When the Legislature expressed doubt that the institution was sustainable, he pledged to convince the local medical profession to serve the poor without charge. Some of the legislators who voted for the measure did so in the belief that charity care would never appear, so the gesture would be without cost. The physicians did indeed come forward, in sufficient numbers to run many institutions for two hundred years. In 1965 health insurance made its national appearance, and has regarded the benchmark low costs of charity care as a threat, ever since.

WWW.Philadelphia-Reflections.com/blog/1250.htm

http://www.philadelphia-reflections.com/blog/1250.htm

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Veterans Hospital

Philadelphia VA Medical Center Home

At a recent meeting of the Right Angle Club, Stephen C. Bennett an administrator, and Alix Esposito a social worker, kindly addressed the club about the Veterans Hospital where they work. The federal government pushes its mass produced products into every city, but gradually a local flavor starts to creep in; how this process works is illustrated by the fact that Steve's grandfather Claude was once the manager of the Bellevue Stratford Hotel. The VA hospital may be a piece of Washington D.C. planted on Philadelphia soil, but Philadelphia will surely absorb it with the passage of enough time. The VA was once a part of the Veterans Administration, but now it is a part of Department of Veterans Affairs, run by a cabinet Secretary, no less. It's the second largest department of the federal government, and since the only bigger department is the Department of Defense, the combination of the two shows you how far we have come from the nation's original opposition to "standing armies". The fact that these two components of our war machine are separate, on the other hand, surely symbolizes some hidden tensions between our regular armed forces and the American Legion, or the hidden frictions between two congressional committees, or else some other mystery of bureaucratic politics.

The Veterans Administration was founded in 1930, the Philadelphia VA Hospital was built in 1950. Originally, it was designated as a Deans Hospital, signifying the intention to confer prestige and lessen friction with the medical schools. Originally, Philadelphia's VA was affiliated with several medical schools, but in time its proximity to the University of Pennsylvania led to the elimination of ties with other schools. Although the bed capacity is growing in reaction to America's successive wars, its open wards converted after 1960 to more semi-private style, and its focus of medical activity shifting with changes in medical science, the VA remains isolated from the rest of the city and the rest of Philadelphia medicine. Part of this is physical; the hospital is confined by the University of Pennsylvania, the parking complex next to the Amtrak lines, and the Woodland Cemetery, so there is little room to grow. And comparatively little commonality with the neighbors. There are 2000 employees and a $30 million budget, marooned in a sea of automobile traffic going elsewhere in a big hurry, too big to ignore but too small to influence the local culture.

Vietnam War

The patients are distinctly different from those you find in other hospitals. There is a great deal of chronic mental disorder, a heavy influence of alcohol and substance abuse and rehabilitation, and even some residential apartments for patients. On a national level, between a third and a half of homeless people are veterans, but for some reason in Philadelphia, only a tenth of the homeless are veterans. During the Vietnam War, the system of draft avoidance through educational exemptions resulted in that generation of veterans coming from an unusual concentration of low income and low educational subgroups. The system of government pensions and promotions tend to retain employees in the system for a lifetime. It's true that informal transfer arrangements allow a certain amount of migration to Florida (in the winter), or Maine (in the summer), or California (to see what LaLa land is all about), but those who do this stay within the VA system. Consequently, the interchange of ideas and techniques that professionals carry with them between hospitals is curtailed, confined somewhat to variations within the VA system, conforming to its social norms. An archipelago, although not exactly a gulag archipelago.

Veteran

But by far the greatest source of distinctiveness in the VA hospitals comes from the byzantine eligibility standards for the patients. The reimbursement systems of Medicare, private insurance -- which more or less copy each other -- changed around 1988 in a way that more or less eliminated psychiatric inpatient care in the community, especially if it lasts more than a month. The VA, on the other hand, was forced by circumstances to increase its attention to this area. Consequently, all social workers everywhere inquire immediately whether an addict or a schizophrenic might be a veteran. A differential sorting process quickly gets under way, with the VA as the preferred place to send such patients if at all possible. Non-veteran victims of the same conditions tend to have a worsened time of it, because the pressure on state and local governments to make some provision, has been relieved.

Walter Reed Hospital

At the other extreme, the social elite of the armed forces are not admitted, either. President Eisenhower was unquestionably a veteran, but he had his famous hospitalizations at Walter Reed Hospital. There's an income limit for VA admission, which automatically cuts off 20-year veterans above a certain rank, possibly major. And there are overlapping disability classifications for military hospitals and veterans facilities, with considerable latitude available to uniformed boards of three serving officers, only one of whom is a physician. The result is a general perception that if you have any influence at all, you can generally avoid the VA and be treated in a military hospital, probably in a VIP unit. Good for them; I'd take advantage of it if I had a chance, too. But by siphoning off the top brass, a lot of pressure to improve quality is removed as well. If a VA hospital had eight or ten Admirals and Generals as patients, with academy classmates coming to visit, it's safe to assume that courtesy, orderliness and cleanliness would instantly improve. And take it from me, the quality of care would improve, as well.

http://www.philadelphia-reflections.com/blog/1598.htm

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Rejecting Preventive Health Care for Good Reason

WHILE we debated whether to disregard what could be afforded, and provide sickness care to all, the idea subtly changed to providing health care for all. That is, the proposal was not merely to expand sickness care to everyone, it included an expansion of what anyone would get, and who would provide it. Medical care is provided by physicians, sickness care is provided by doctors, nurses and hospitals, and healthcare is provided by an undefined larger group of providers. No wonder it costs more, and therefore a surprising number of people are unsure they want it. The issue centers on "healthcare" versus sickness care". How's that, again?

Preventive Health Care poses unique issues for seniors.

For example, the notion that preventing disease is superior to treating disease, goes back at least to Benjamin Franklin. Arguing that the Pennsylvania Legislature ought to help build the nation's first hospital, Franklin offered the truism that it saves money in the long run to treat people early and get them back to work. Franklin could hardly have foreseen that it isn't always true. Preventive medicine implies it is cheaper to spend small amounts, possibly every year, for many people, than to spend large amounts for a few. It's a matter of arithmetic, of course, and doesn't always have the same answer. When the math works against a preventive approach, it's usually argued the gain in health is worth it; but that's not invariably the case, either. Once a person ceases to be an , the equation rebalanced. And as an individual approaches end of life, his renunciation of what it takes to prolong life gathers more respect. It's a conflicted opinion, of course. Older people are outraged by any suggestion their lives do not deserve to be prolonged, but still outspokenly prefer to die rather than wear a colostomy bag, or a respirator, or be fed with a spoon. If they are Jehovah's Witnesses and refuse transfusions, that too, commands more respect when they are elderly. This is a familiar problem, not a new one. What's new is more subtle and pervasive.

The public probably does not fully appreciate the disappearance of what might be called capricious diseases, caused by the operation of chance, or God's will. These are fatal illnesses like heart attacks, strokes, epidemics, and other things not anyone's fault. Except for cancer and Alzheimer's Disease, most really common serious illnesses which remain, are to some extent self-inflicted. Smoking causes lung cancer, alcoholism causes accidents and homicides as well as cirrhosis of the liver, taking recreational drugs damages lives, unprotected sex causes HIV. Obesity causes hypertension and diabetes, neglecting your medicine undermines treatment. If this keeps up, we are going to see the day when every obituary will seem too shameful to print. Poor Jud is dead; it's his own fault.

It's maybe even worse than that. The 2000-page Obama care plan was too complicated for even the Congressional committees to understand. But the public was not hostile for technical reasons, the public was irked at the idea. All the President's celebration of saving money through mandatory preventive care provoked the public to tell him, Get off my back. Almost every smoker has tried at least once to quit, absolutely every obese person has repeatedly tried to lose weight unsuccessfully. It's hard, let's see you try it. And now it goes beyond nagging, we are going to take the position that every person with a self-inflicted disease is costing the nation money we can't afford. The country has a right to punish people who drive us to bankruptcy. Let's have some Wellness police, and fair but firm punishments. Is that really what Obama has in mind? Well,sir, you just get off my back.

Even so compliant and dutiful a person as my late wife declared that when she got to be seventy, she was going to try marijuana. The fact that she actually lived thirteen years longer without doing it, did not change her basic attitude. When you get to a certain age, many of the old rules don't apply to you, doggone it.

http://www.philadelphia-reflections.com/blog/1705.htm

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Reforming Health Reform (2009), New Jersey Style

Congressman Robert Andrews

A single e-mail to constituents, and no other communication visible to the general public, announced a town hall meeting with our Congressman, Bob Andrews, on the campus of Rowan University, from 6 to 8 PM, August 24, 2009. The subject was to be Health Care Reform Legislation. On arrival, it was hard to find the auditorium in the square mile of new college campus, and only a small sign entitled "Event" indicated the place to park. Lots of cars.

By counting seats in a row and multiplying by the number of rows, the University Auditorium held 3000 people, but at 6PM it was difficult to find a vacant seat. The doors were almost blocked by two lines of people standing to speak at microphones in the center of the hall, snaking all the way out past the television cameras and then out the door. These people were strangely silent, preoccupied but not rude, apparently rehearsing their speeches. In the lobby outside the doors, several workers were distributing posters showing "Thank You!", checking people off on lists of some sort. Many of those who got posters were wearing red T-shirts emblazoned with something or other.

Rowan University

When I finally got a seat inside, it was behind a whole row of such T-shirted poster-holders, mostly but not entirely of the black race. The Congressman was giving a little speech to the effect that he was one of the committee members who wrote the bill, so of course he had to support it. Strange, that as a member of Commerce and Labor he was working on a bill which traditionally is the province of the subcommittee on Health, of the Ways and Means Committee. In any event, that gave him the ability to explain some of the language which was a little too hard to understand. Several in the audience shouted out something unintelligible at that point, but mostly the audience sat in silence, waiting for the questions. He soon opened it up for questions, because he wanted to know what his constituents were thinking.

Although a few inevitably wandered off the point, questioners were confident, moderately deferential, remarkably effective. No matter how it was stated, and no matter how it began ("I have always voted for you, Congressman"), they were at the microphone to run a sword into him. To some extent, posting the entire bill on the Internet has changed politics. One old man, reading from his papers, said that page 343 says, etc; to which the harassed Congressmen blurted out, "That isn't true!" And the old man held his ground, "Oh, yes, and what else isn't true, that's written in the bill?"

Our congressman represents a working-class district, as clearly illustrated by his previously running for Congress without opposition. In searching for the reason this solidly Democrat audience was so antagonized, one gathers they generally have Unionized health benefits, and feel threatened that insuring the "illegals" will be paid for by impairing their own insurance. Somehow they feel that anyone who denies it is lying to them. ("It isn't what's in the bill, it's what will be in the bill ten years from now.") Except for college professors, they have the most luxurious health insurance coverage in America, and are accustomed to boasting of it. Somehow, this privileged position drowns out their envy of rich people. When told that only the top x% of the country would have its taxes raised, one man bore right in on the Congressman. "You never heard anyone asking a poor man to give him a job". (Yeah, right, right on, Yeah.)

Although the people in red shirts holding posters put up a fight for fifteen minutes or so, they soon subsided out of recognition of who owned the room, and the remaining three hours of "questions" were almost uniformly negative. After an hour, the television cameras left the room, and at that signal the people in front of me wearing red shirts, also left. After a succession of speakers praised physicians somewhat excessively, a couple of physicians got up and made a poor showing at the microphone. One of them, a fat woman, had the poor judgment to tell these folks that many diseases like diabetes were self-inflicted, but later heard that it would help if our President would himself stop smoking and leave the rest of us to mind our own business. Two women who proclaimed themselves single mothers were no better treated..

At 9:30, a meeting scheduled to end at 8PM still had a thousand people in the audience, and fifty at the microphones. But I had had enough. They made their point. All that remains is to see how fairly the television editors extract significant clips, and to find out how the rest of the nation feels.

LATER FOOTNOTE: As matters turned out a few months later, this national legislation had more of a local New Jersey effect than the audience could have guessed. Mandating health insurance for 30 million uninsured, Obamacare accomplished it for 15 million of them by forcing them into the state Medicaid program, which is widely acknowledged to be the worst program in American medicine, because it is the most under-funded. New Jersey residents are firmly opposed to anything which would raise their already high local taxes, and will focus intently on the attempt in the coming lame-duck session of Congress (November 2010) which intends to transfer federal money to states to pay for Medicaid, and which is given only the narrowest chance of success.

http://www.philadelphia-reflections.com/blog/1714.htm

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Time To Care

Dr. Norman Makous

It sometimes seems as though Medicare has been a standard part of the scene for so long it now needs major reform, but when a doctor has practiced Medicine for sixty years he has seen a lot of contrasts between the old way and the new way, not all of them favorable to the new -- which we are now tired of, and trying to repair. That's particularly true if the doctor practiced at America's first and oldest hospital, because it sustained many traditions from two centuries before, and was among the last to yield to the imperatives of newcomers for the last forty years, their hands grasping for the purse strings. Dr. Norman Makous must either have a remarkable memory or a thick, detailed diary. He tells three hundred pages of fast-reading anecdotes about sixty years of his own medical practice, before summing up in fifty pages of reflection. One by one, he describes the innovations in his field of cardiology and how they affected him and his patients. Thiomerin, one of the first of many easy ways to pump out excess body fluid accumulation, transformed the treatment of congestive heart failure. Synthetic digitalis claimed to but probably did not much improve things over dried digitalis leaves; it certainly raised the cost. Cardiac catheterization, electro-shock resuscitation, ultra sound diagnostics, MRI and CAT scans, cardiac surgery using the heart-lung machine, and finally cardiac transplants -- all started out as headline-news spectaculars, evolved into cutting-edge advances, and then settled down into the Standard of Care that you obtained a plaintiff lawyer to sue about. All in one medical lifetime, supposedly prepared for by one Medical School course, followed by one residency apprenticeship, the specialty of Cardiology was completely transformed at least six times.

Time to Care

Meanwhile, the leadership of the medical profession was tenaciously resisted by those who supposedly followed its direction. Hospital administrators, either trying to reduce costs or to maximize institutional reimbursement, and sometimes just trying to glamorize their corporate vehicle; million-dollar-a-year salaries for administrators probably held out some perverse inducements, as well. Nurses, cut loose from hospital training programs to invent a new profession of nursing administration within university campuses remote from the scene of sickness. Health insurance executives, trained in the art of income maximization by Business Schools, driven by the need to lobby and the need to accommodate quirky laws lobbied by others, pressured by corporate human resources departments who were in turn pressured by unions and corporate managements -- and constantly bothered by expensive new technologies invented by doctors "who needed new toys". University administrations, placed in charge of numerous recalcitrant medical staff physicians, applying the principles of the German research systems upon an intransigent profession that persisted in preferring the care of sick people to the chase for research grants. And politicians, elected for two-year terms in which they felt pressure to accommodate a hundred conflicting interest groups.

Against all this and more, Dr. Makous describes how the practicing physicians especially those trained in the traditional way, found only one sympathetic, kindred interest group -- the patients. During a period when everybody else seemed determined to snitch a piece of the health insurance money pie, the patient wanted one major thing from the doctor. He wanted to be helped through his illness. The patients loved their doctor, in what was known as the patient doctor relationship. But a strange thing was also true. The doctors loved their patients, the only group in society who seemed to care what the doctor was trying to do.

http://www.philadelphia-reflections.com/blog/1725.htm

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Glutes, Abs and Pects

Union League of Philadelphia

Robert Matsey, the director of Executive Fitness at the Union League, recently entertained the Right Angle Club with a discussion of new trends in muscle building. Which is to say the old theory of Dynamic Tension, as featured in adolescent magazines by Charles Atlas, is being superseded by platform stabilization, a much more popular approach among senior citizens. Since a few members of the club are already in the Medicare age range, and more are approaching it with concern, the talk was greeted with great interest.

Personal Trainer

Bob Matsey has a degree in marketing, so it all comes down to this: the more powder you use in a cannon, the bigger bang it makes. But if said cannon is sitting in a canoe, the extra gunpowder doesn't add much firepower. The new approach stabilizes the platform to magnify the cannon power, without paying so much attention to adding directly to the gunpowder. No one said that weight lifting and pushups don't bulk up your muscles; but if you want to climb stairs and lift things, it will get you farther to stabilize the pelvis and shoulder girdle than to split your seams with muscles that can't do much. Or, worse still, that will lead you to throw out a lumbar disc -- or a cervical one -- struggling to perform a simple task. All of which leads to a complicated discussion of the function of the hamstring muscles of the back of the thigh, which is mainly to overcome the inappropriate architecture we inherited when we became two-legged animals. And, as well, to overcome the tendency of a young straight back to curl up with age and inactivity, and press your nose toward the ground. One of the main causes of back pain can be traced to shortened tight hamstrings, a condition which destabilizes the platform of the pelvis.

Sitting down is the great enemy of posture and bearing; fifty years of it leads straight toward turning a former soldier into a skinny old geezer. Sitting down to a dinner table turns people into fat old geezers, deep inside which is a skinny geezer hidden by the fat.

Muscles

Every medical student is puzzled to learn that most energy expended by muscles is used to lengthen, not shorten, muscles. Without getting into the biochemistry of this issue, it can be taken to explain the tendency of muscles to shorten up when under-used. And, in turn, explains why stretching works a lot better than "body building" against a resistance. It thus may help to understand why it is sometimes easier for skinny old retirees to re-build their muscles into proper balance and coordination, essentially training infantile muscles to work together the right way. Those who have struggled to "work through the pain" may actually reinforce bad coordination, and will require still more sweat on the brow to force things to work the right way all over again. For example, there are two kinds of hamstring muscles, short ones and long ones. The short ones stabilize the pelvis, but if you whip things into obedience, you may be improperly recruiting the long hamstrings to act as stabilizers, making you in effect "uncoordinated" and awkward. RNT stands for reactive neuromuscular training, a process which amounts to improving a muscular coordination flaw by forcibly exaggerating it. The scientific basis for this jargon is a little hard to follow, but it does soon become very clear that RNT is quite uncomfortable. It makes a sort of argument for a compulsory draft into the armed forces at an early age, to beat bad muscle coordination out of the whole public at an early age, before they start sitting themselves to death in front of a computer.

A great deal of emphasis nowadays is placed on gluteal strengthening, a sort of unnatural posture training which can unfortunately be easily dismissed as worthless. In the spirit of defending this particular fitness training, a lady at a nearby table in a fancy restaurant was heard to exclaim to her luncheon partners, "What I mind most about growing old is that I have lost my ass!" Since obviously this disability is greatly to be avoided, get some gluteal training, ladies.

Along the same lines, the economics of fitness centers was recently explained with considerable seriousness, but not by Robert Matsey, who disassociates himself firmly. The trick, explained the outside expert, is to get people to sign up for a whole year of training when they first come in, full of enthusiasm. Since most of them will drop out of attendance after a couple of weeks, it is possible to run quite a profit running a fitness center with hardly anyone showing up.

And finally, Tom Hawes, former president of the Right Angle, rose to link this discussion with the current debate about health care reform Relating how an elderly couple in Florida went to a physician specializing in sex counseling, asked him to obseve their technique and comment on it. He later told them their technique was surprisingly good, and he had no recommendations. The charge for this service was $50, readily agreed to. Nevertheless, they returned with the same request three more weeks in a row, until the doctor asked them what they expected to learn from all this. "Oh, that's not the idea. She's married, and I'm married, so we can't go home. The motel charges $100 and you only charge $50. "

"But the beauty part is that Medicare reimburses us $43."

http://www.philadelphia-reflections.com/blog/1744.htm

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Finding the Nerve to Cut Health Costs

WASHINGTON

Over the next several weeks, members of Congress will be confronted with one scary story after another about what will happen if they try to cut health care costs.

Tax the costliest health insurance plans? Workers will be denied medical care. Reduce the growth of spending on home health care agencies? Elderly patients living alone will be left to fend for themselves. Set up a commission to reduce Medicare waste? Again, the elderly will suffer. Impose a tax on plastic surgery? That’s unfair to unemployed women looking to enhance their appearance. (Seriously, the plastic surgeons are making that case.)

But here’s the thing: It is abundantly clear that our medical system wastes enormous amounts of money on health care that doesn’t make people healthier. Hospitals that practice more intensive medicine, to take one example, get no better results than more conservative hospitals, research shows. And while the insured receive better care and are healthier than the uninsured, the lavishly insured — those households with so-called Cadillac plans — are not better off than households with merely good insurance.

Yet every time Congress comes up with an idea for cutting spending, the cry goes out: Patients will suffer! You’re cutting bone, not fat!

How can this be? How can there be billions of dollars of general waste and no specific waste? There can’t, of course.

The only way to cut health care costs is to cut health care costs and, in the process, invite politically potent scare stories.

I’m as skeptical as anyone of the ability of the United States Congress to formulate good policy, but the last few days have offered reason to hope that its members may be summoning the political courage to endure the scare stories.

That would be a big deal. Health costs, through Medicare, are the main source of the huge long-term budget deficit. In recent years, they have also caused insurance premiums to rise so quickly that employers haven’t had the money to give workers a decent raise. David Cutler, a Harvard health economist, estimates that the measures already in the health bills will increase the typical family’s income $2,500 a year by the end of the decade.

Real health reform also has the potential to save lives. Because we now pay doctors to provide more care rather than better care, we have not given them an incentive to reduce hospital-acquired infections and other avoidable errors. A new amendment from three senators — Susan Collins, a Maine Republican; Joe Lieberman, the Connecticut independent; and Arlen Specter, the Pennsylvania Republican turned Democrat — would increase the financial penalty for giving patients such infections.

Even this idea, however, has its own scare story. The Washington Post reported on Sunday that hospital groups were “quietly steaming” over it and suggested their support for health reform could be in danger.

•

One piece of encouraging news came on Saturday, when the Senate finally began listening to its own health care advisers.

To help it oversee Medicare, Congress set up an outside board of doctors, economists and other experts in 1997, called the Medicare Payment Advisory Commission. Medpac, as it’s known, tries to figure out which services Medicare may be paying too little for, thus creating shortages, and which ones it may be overpaying for.

Perhaps the single clearest example of overpayment is home health care. Home health agencies, which care for Medicare patients with specific health needs (as opposed to those receiving general long-term care), have been proliferating in recent years. Yet, according to the most recent data, they still had fat profit margins on Medicare, 16.6 percent. One reason, the Government Accountability Office found, was that fraud was rife.

So Medpac has recommended cutting home health payments, and the Senate bill would do so, by 13 percent over 10 years. On Saturday, the Senate rejected a Republican amendment, supported by a few Democrats, too, that would have blocked that cut.

The home health provision is actually typical of the cost-cutting measures that have made it into the Senate bill: it’s pretty good. It won’t be perfect, obviously. Some people somewhere may indeed have to stop working with a home health agency they like and find a new one. But that’s not a reason to waste billions of dollars a year subsidizing an industry’s profits.

The real problem with the Senate bill is that it doesn’t go far enough to cut costs and improve care. Here too, however, there are positive signs. For months, centrist Democrats have been saying that cost containment was one of their biggest priorities, but they had not done much to help the cause. That has now started to change.

“Senators are now really focused on cost containment,” says Mr. Cutler, who has been advising some of them.

The day before the Senate defeated the home health care amendment, Senators Collins, Lieberman and Specter introduced an amendment with some measures to push medicine away from the insidious fee-for-service payment system. The cost-cutting momentum continued on Tuesday, when 11 of the 13 freshman Democratic senators announced their own package of measures. Neither proposal is earth-shattering, but both would make a difference.

Among other things, the freshmen’s proposal would do more than the current Senate bill to push insurers to use a standardized payment process. Right now, doctors and hospitals often have to fill out different forms for different insurers. “There’s a lot of money there,” Len Nichols, head of health policy at the New America Foundation, says.

Intriguingly, officials from a rainbow of special interest groups showed up at the freshman senators’ news conference to praise the proposal. To me, their presence highlighted both the biggest strength and the biggest weakness of the proposal. On the one hand, it has a real chance to make it into the final bill. On the other hand, it, like the Collins-Lieberman-Specter amendment, also fails to fix the single biggest flaw in the Senate bill.

Last month, Senator Harry Reid, the Democratic leader, gutted an independent commission — a more powerful version of Medpac, meant to shield Medicare payment decisions from political interference — that many economists consider necessary. Mr. Reid’s bill would allow the commission to take action only if Medicare spending was rising even faster than total health spending. If total spending rose 8 percent one year and Medicare spending rose 7.9 percent — a miserable situation — the commission would have to sit on its hands. AARP, unfortunately, has emerged as an opponent of a strong commission.

But without one, health reform will be hobbled. And the Senate may be the only hope for changing it.

The House has shown little interest in cost control. President Obama and his administration have pushed aggressively for it, but they have limited leverage. Mr. Obama can’t credibly threaten to veto any of the health reform bills that now seem likely to emerge from Congress.

So after the 11 freshmen announced their plan on Tuesday, I caught up with Mark Warner, the Virginia Democrat who is the group’s leader, underneath the Capitol building and asked him how he and his colleagues would deal with the inevitable scare stories still to come: How do you respond to a lobbyist who effectively accuses you of killing patients?

“I don’t know any other way than you take incremental steps,” Mr. Warner said, “and you hope you get to the tipping point where fear and misinformation don’t have an effect, because people see these things don’t do what they are accused of doing.”

That, obviously, is the long-term strategy. In coming weeks, we’ll see how well Mr. Warner and his colleagues deal with the immediate pressure. The Grim Reaper is a tough opponent.

http://www.philadelphia-reflections.com/blog/1747.htm

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Only Three Things Wrong With American Healthcare

Although Congress is offering several thousand pages of proposals for healthcare "reform", none of them even mentions the three main difficulties, to say nothing of fixing them. Let's be terse about this:

1. Health insurance is fine, but if you make it universal, there is no impartial way to determine fair prices. Somebody must haggle with the vendor in order to introduce the issue of what is the service worth? The customer doesn't care what it costs to make, or whether the vendors are being paid fairly. If everyone is insured, no one cares what it costs. Not only do all costs rise, but they rise without coordination, without a sense of what each component is worth, relative to alternatives.

2. Employer-based insurance is fine, but it ends when employment ends. You just can't stretch employment-based insurance because you can't stretch employment.

3. State Medicaid programs are fine, but just about all fifty states are going broke trying to pay for it. Extending it to more people by raising the income limits just makes things worse. Items 2. and 3. are related. Trying to do both -- expand Medicaid as employment shrinks -- during a recession is incomprehensible. Item 1. (price confusion) gets drawn into this because the States try to pay less than it costs, hoping to shift the deficiency through hospital cost-shifting, utterly confounding the information which prices provide. The doctors have no way to tell which is the cheapest approach to a problem, so they don't try. Without control over prices, we can only control volume.

That's really all there is to this mess. Not one word of the current legislation even mentions these problems, so of course the legislation blunders. Even a child can see that compulsory expansion of benefits to universal coverage will fail if you can't pay for what you already have. No one will make sacrifices for a new system if the sacrifices seem futile. They are futile, so leave me alone.

The current administration has been compared with bank robbers who see they are trapped, and decide to shoot their way out. Let's see them try to shoot their way past the first Tuesday after the first Monday in November.

http://www.philadelphia-reflections.com/blog/1754.htm

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How Does New Jersey State Aid Affect School Districts?

The Sunday, April 11, 2010 Philadelphia Inquirer contained an eighteen-page statistical summary of the schools within the eight-county area around Philadelphia. The New Jersey school districts, but not the Pennsylvania ones, report per-pupil spending right next to the proportion contributed by state government. If you know something about the sociology of New Jersey, you form some conclusions about state school aid which probably apply to all states, while confessing they only provably apply to New Jersey. Let's therefore say, it only provably applies to New Jersey that you spend more for schools if you are spending someone else's money.

In the welter of numbers supplied by this statistical report, it seems useful to focus on the strip of school districts along Haddon Avenue, starting from the place where the retreating British soldiers once ferried from Philadelphia to Camden (in 1778, of course.) Haddon Avenue extends directly East until it strikes King's Highway, where the British then turned North to scuttle toward the safety of their navy at New Brunswick. We are thus talking about the school districts of Camden, Collingswood, Haddon Township, Haddonfield and Cherry Hill, with Haddon Heights and Pemberton thrown in because of special features they illustrate.

Pemberton Township in Burlington County spends the largest amount of per-pupil school money in South Jersey, $18,970. It jumps right out at you that 82% of that money is contributed to the school district by the state government. Starting back at the Delaware River, 99% nonwhite Camden gets 88% of its school money from the state, and has the second-highest spending of $16,131 per pupil. Moving along the path of the British soldiers, the next town after Camden on Haddon Avenue is Collingswood, spending $14,262. Next comes Haddon Township, spending $13,243. It thus seems to prove that the further you get from the Delaware River, the less you spend on education, because next in order comes Haddonfield, with spending of $12,273. But not quite, because Cherry Hill increases a little to $12, 914. The percentage of state funds follows a parallel sequence from Collingswood to Haddonfield (36%, 31%, 6%) and then rises slightly to 11% in Cherry Hill. For comparison, nearby Haddon Heights spends $13,449, of which 10% derives from state government. And just in case you think there is a racial implication, nearby Gloucester City is 84% white, and gets 82% of the $16,046 it spends on schools, from the rest of the state by way of state contributions. However, these numbers also allow you to calculate how much the local districts spent of their own money. It turns out it is just the reverse. The more state aid a district gets, the less it spends, itself. The more state aid it gets, the more it spends, period.

The conclusion seems to emerge that an education assistance program designed to achieve equality, actually stimulates appreciably more spending in poor districts than in prosperous ones; at least so far, poor educational quality in poor districts is acknowledged to remain poor. There are some people who might say these statistics suggest a racial correlation, but some others could say the correlation is with distance from Philadelphia, while others would associate factors undisplayed in the statistics. Because there are more non-teachers than teachers employed by the schools, it is not certain that extra money going to schools will improve the teaching. Nevertheless, what is not demonstrated at all is a tendency for better education to be found where school money is most liberally applied. At least, it is safe to say that anyone who claims the quality of education parallels these spending patterns in New Jersey, would be laughed at.

Robin Hood

Of course it is true that prevailing opinions about the local quality of education are as biased as the opinions about the local football teams, or the differing quality of tomato pies. That's partly because prevailing opinion of the school system has a strong effect on local real estate values, one of the main concerns of real estate agents. My neighborhood in Haddonfield is very close and sociable, so it's been confided that three empty-nest neighbors have sold their Haddonfield houses and moved to Haddon Heights to save money on taxes. When people make decisions like that, they generally know what they are doing. Available data, however, can be misleading to others because total school spending including subsidies does not reflect local property taxes, while local spending does. Empty-nesters are also very likely downsizing to less expensive homes, where of course the taxes seem lower, and are also moving to districts which have fewer children per house. Where that isn't the case in the school districts from which they flee, subsidies are extracted from state income and sales taxes, which move from district to district, right along with empty-nesters who move. For those with children attending public schools, emphasis in these considerations is somewhat different.

The voters have no idea how "equal" became "more" money for education. A fair conjecture would be that the poorer districts kept pressing the legislature for more as a matter of "fairness", leaving the more prosperous districts to shout "outrage", but less effectively. By voting down a majority of local school budgets both groups are shouting, all right, although it would be more effective to shout at their representatives in Trenton. Especially in a census year, when gerrymandering is on every agenda.

http://www.philadelphia-reflections.com/blog/1800.htm

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Cataracts and Deference to Seniors

Last week I had a cataract extraction; it went well. I now see like an eagle, there was no pain at any time, and it only interrupted my life for about six hours, total. While I suppose there is a chance of complications during the next month after surgery, I'm an optimist and statistics are on my side. As they say in South Philadelphia, fageddabout it.

Cataract Extraction

Those were of course not the serene thoughts I had in advance of the surgery, which carries certain risks. Persons with myopia like me often have a mismatch in the size of their eyeball and the size of the retina inside, so the retina can tear or detach during the first few days after the eyeball's integrity has been pierced. The lens can get stuck and break apart as it is being removed, hemorrhage can occur. The surgeon's hand can slip; he can sneeze at the wrong moment. So, bad things could have happened to me, making my twinge of anxiety entirely justified. But that's all behind me now; I even forgot to ask the surgeon what type of lens he intended to implant, so I could argue with him. Let the Captain run the ship. I was surrendering my fate to the largest eye hospital in the country. They perform between fifty and a hundred of these procedures every day, and my surgeon is the chief of the cataract department.

And yet, and yet, I have a few grumbles, leading to some generalizations about health care for the elderly. In the first place, I was told by an administrator who sounded terribly fierce that I had to be there at 8:15 AM, in the company of the person who would drive me home, or they wouldn't do my surgery. I told her I doubted that very much, so we got off to a poor start. The procedure ought to take less than ten minutes to perform, perhaps twenty if you count the formalities. Furthermore, I was a consultant to that hospital once, and still had a certain amount of standing in the Philadelphia medical community, having once been a trustee of almost everything you can be a trustee of. Sure enough, when my driver and I arrived at 8:15, there were more than fifty others waiting. They finally called my name at 1:30 in the afternoon, and by roughly 2 o'clock I was out of there. I was by no means the last one waiting to be called, and it sort of felt as though we were all treated like logs of wood. While I was inside the operating room, a couple of nurses were chattering, and one said she much preferred to work on weekends, because there were no administrators around. I could see what she meant.

To keep this essay from sounding like constant whining, let me tell a little of the history of this operation. Until perhaps twenty years ago, a cataract extraction involved keeping the patient in the hospital after the operation with the head in sandbags, for two full weeks. Now, it takes ten or twenty minutes, and you are free to have lunch with a friend in an hour, unless you give in to your driver who has been waiting five hours and wants to go home.The results are far superior, and you don't have to wear glasses that look like the bottom of Coke bottles afterwards; in fact, I already see pretty well without any glasses before a week is up. In the past, the great fear was a complication known as sympathetic ophthalmitis, in which disturbing the lens of one eye would set up a sort of allergy which could also make you blind in the other, good, eye.

Spitfire

In the famous Battle of Britain in the Second World War, the British pilots to whom so many owe so much were covered with a plexiglass canopy in a fighter plane called the Spitfire. Enemy machine gun fire would often shatter this canopy, and among a lot of other damages, shards of plexiglass got lodged in the eyeballs of the pilots. For the most part it was left in place because other injuries needed tending more urgently. Long after the Battle, it finally dawned on a British ophthalmologist that this wasn't supposed to happen, it was supposed to cause sympathetic ophthalmitis and the pilots were supposed to go blind. From this it was finally deduced that plexiglass was safe to use as a lens implant, a so-called "hard implant". You can still see people walking about with these lenses, recognizable because their eyes seem to glow when the light shines into them, like crocodiles along the Amazon at night.

The second step in the migration to modern cataract surgery was the insight that soft pliable forms of plastic retain a memory of the shape they were moulded into. So, the old lens can be scooped, lasered or sucked out of place, and a squeezed-down soft lens can be shoved into the vacated space. Retaining its shape-memory, it springs back into the correct shape for a lens, and you are all set.

And finally, there was the stitch. If you cut into the side of the cornea, you have to stitch it up after you are through. And then later you have to remove the stitch. An eye surgeon who should be more famous if he were more popular then invented a form of curved incision which did not requite a stitch because the pressure within the eye held it closed. It was a simple and brilliant idea, which took scarcely a few extra seconds but eliminated one of those sources of complications which dogged the statistics. There was only one problem. This surgeon decided to apply for a patent for his invention, and the medical world had a fit; not only did he patent the curved incision, he sent bills for royalties to every eye surgeon he could prove was using it. I happened to be seated the the House of Delegates of the American Medical Association when this matter came up, and the uproar was considerable, including some ribald limericks which were read the House "as a matter of personal privilege". Shortly afterwards the courts did the right thing and disallowed the patent.

So that pretty well summarizes how cataract surgery became a modern miracle, with a great many elderly people now playing demon bridge when they would otherwise be fed with a spoon. Somehow, the national gratitude is not quite equal to its obligations, and we hear people grumble that eye surgeons make too much money. When the achievements of politicians match those of the average eye surgeon, perhaps they will have a point. But not sooner.

But I'm allowed to complain, and perhaps obliged to issue a warning to my fellow elders about the true source of our discontent. It seems to start with eye drops, but it's more than that. There's a simple technique for instilling eye drops, which involves pulling down the lower lid, creating a pocket, and putting the drop in the pocket, after which the subject blinks his eye and spreads the drop around. Works slick, takes no extra time, and little trouble. And while a half-dozen nurses put drops in my eye, and must put fifty drops in fifty eyes every day, not one of them did it right. The drops were spattered on the eyelids and eyelashes, much of them running down my cheek. One extra-large nurse with an attitude put her thumb on my upper eyelid and spread the lids so painfully apart that I cried out in protest. It's supposed to hurt, was the unwelcome answer. I resolved then, and soon carried out the threat to scold the surgeon and the Physician-in-Chief about the responsibilities of supervision, but there are two other more serious issues behind this indignity.

In the first place, the reimbursement mechanisms were modified so that hospitals were no longer paid for maintaining a school of nursing. Within a few years, all hospitals had trimmed this expense, and nurses went to college to be trained in nursing, miles away from the nearest hospital, and eventually trained by other nurses who had themselves had scant experience with patients. Although it is boasted that they now have batchelors's degrees instead of mere diplomas, their skill with patient care is far inferior to that of the generations which went before them. Instead of being well trained, they are rule ridden.

The other underlying issue lies with us, the patients. In France people retire at fifty I hear, and in this country we retire at sixty-five. But we sit around, essentially quite healthy, until eighty-five or later. Everybody knows we have nothing important to do, so they waste our time. Or rather, whenever there is a choice of wasting a minute of working-person's time, or an hour of a retired person's, it is the retired person who is dumped on, and it's only going to get much worse with time. Hey, folks, it's degrading to be so useless. Go to work and accomplish something. Don't let the younger generation treat you like logs of wood.

http://www.philadelphia-reflections.com/blog/1967.htm

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Ethics of Obamacare

Arthur L. Caplan

The Right Angle Club was recently addressed by Arthur L. Caplan, Director of the Center for Bioethics of the University of Pennsylvania. His topic was Healthcare Rationing. It was interesting to hear the viewpoint of someone who views the 2010 mandatory health insurance system primarily through the lens of its ethics; just like the Tea Party objectors, he sees the new system as merely a rationing system to be viewed with concern. However, his initial salvo is similar to that of the bill's proponents before it was enacted: "Every system always rations in some way or another." If you expected the outcome to be rationing from the beginning, your focus is naturally fixed on just what sort of rationing results, perhaps measured by whatever kind of rationing you had formerly hoped for, yourself.

Ethics is, after all, a system of constraining native, unconstrained, outcomes into something deemed more suitable. That's a definition which could be equally well applied to reform of all sorts, and repeatedly tends to cast reformers as underdogs fighting the establishment. Since the American healthcare system in 1950 could fairly be described as rationing healthcare with money, and its history from then to now has been one of jumbled similarity to 1950, most discussion accepts a financial rationing description for what Obamacare changed. There is much uneasiness about totally supplanting the marketplace with insurance, since universal insurance leaves no room for setting prices -- except by government proclamation, filtered through some sort of insurance bureaucracy. There was a time when many people thought that was better than paying for it yourself, but now that it's here, there are growing doubts.

UPENN

There's surely going to be a last-ditch effort to overturn Obamacare, whether through Congress or the Courts, and failing that, through stalling it until the President can be replaced in 2012. Let's assume for the moment that such efforts fail, and are not followed by armed rebellion. If the central issue is how do we find more acceptable methods of rationing, two proposed methods have begun to seem attractive. The first is proposed by Congressman Ryan of Wisconsin, to the general effect of taking what we now spend, chopping it up, and issuing vouchers for the same amount less net middle-man costs. This approach stops the rise of costs right where they are, and thus pleases Congress. But the thing to be rationed is redefined as well. It rations future cost rises, net of any savings wrung out of the system by competition for voucher money. It's fair to claim this system should not deny the present level of care to almost anyone. It has a price, however. If you want future miracles, you have to pay for them.

Obama Care

A second proposal depends on the observation that most healthcare costs are concentrated in the first year of life, and the last year of life. Strip those costs out, and what is left would almost surely be manageable, particularly in view of how the concentration of costs in those two areas steadily increases. Essentially, this system promises to take generous care of the helpless when they are born and when they die. Healthcare costs during the years of school and employment, however, could more confidently be left to people who are sentient and reasonably healthy, so that's where the inevitable rationing would be concentrated. Once more, the payment system has been modified to avoid such third-rail issues as euthanasia for Grandma or for self-inflicted diseases, or even for abortion. Those would be left to the public to manage during stages of life where there is reasonable likelihood that the patient's own wishes can be paramount. For now, we pass over the technicalities of last-year-of-life insurance, but it could fairly begin with reliance on reimbursing Medicare after the fact, while traditional first-dollar insurance for pregnancy and newborns, or even mandatory government reimbursement, might seem acceptable even to strong conservatives.

So, what's proposed here is a substitute for both the traditional system, and the bewildering command and control system of Obamacare. It shifts the subject matter for rationing away from those areas that frighten the public the most, toward either: rationing future unknown scientific advances, or, rationing healthcare during the years when it is comparatively predictable, and involves patient cooperation during the years of reason. That's the summary; other proposals are welcome.

Regrettably, after the November 2 election, we first must endure a lame-duck Congress, followed by two years of White House-Congress gridlock. There will unfortunately be scant tolerance for ethicists, during that grievous national experience.

http://www.philadelphia-reflections.com/blog/1993.htm

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