Sarah Palin, Tax & Spend Conservative

September 9, 2008 — Ron Chusid

Sarah Palin is a strong social conservative, but as I have shown in numerous previous posts, she is no fiscal conservative. CBS News (via Marc Ambinder) has even obtained an email from Palin in which she justifies increasing taxes to fight social ills:

During Palin’s recent convention speech she sharply criticized Senator Barack Obama for wanting to end Bush’s tax cuts. She pointed to her sister and husband who are new small business owners in Alaska, “How are they going to be any better off if taxes go up?”

But in fact, the way the hockey rink was built was by raising taxes. Palin funded the project by pushing a special referendum that raised the sales tax by 25 percent. City hall records show the referendum was passed by twenty votes.

One Wasilla resident who voted for the complex is Mike Edwards. He says he spends about an hour a day at the facility watching his son play. He says he’s glad government stepped in to build the new ice because privately run rinks are much more expensive, costing teams as much as $300 an hour to practice compared to $185 at the public rink.

CBS News obtained 86 pages of city council documents that show Palin sought to justify the tax increase to fund the sports complex in part because the private sector had not stepped in to fill the gap. She noted the strong support in the community as a reason to move ahead.

But her most striking argument for raising taxes is one you might not expect from a fiscal conservative. She writes that the rink offers an opportunity for government to stop a social ill like drug abuse or juvenile delinquency before it starts.

Among the documents is this email written from Palin’s account to the “Dept Heads” of the council in January 2001. Although its left margin is sliced off, the message of the email is clear. Palin writes:

“…as I look at the money that government [spends] on projects, programs, personnel and facilities to ‘fix’ societies ills and I realize that it’s [be]come more politically correct and accepted for government to throw money towards ‘after-the-fact [services]’, instead of preventive measures that a community could take to support and promote…family oriented, positive, constructive activities and lifestyles. Even on the local level we [spend] hundreds of thousands of dollars on our Police Dept., Youth Court, DARE Program, etc… ‘after the fact’ fixes for juvenile problems. We are in a position to help prevent (Palin’s emphasis) the [problems] that we are now forced to pay to attempt to remedy.”

This approach sounds surprisingly similar to Senator Barack Obama’s philosophies about youth violence and health care spending. Obama’s “Blueprint for Change” bemoans the lack of money spent on preventive health measures, “The nation faces epidemics of obesity and chronic diseases as well as new threats of pandemic flu and bioterrorism. Yet despite all of this less than 4 cents of every health care dollar is spent on prevention and public health.”

Not only did Sarah Palin raise taxes for the sports complex, The Wall Street Journal recently described that poor planning by Palin in the development of the project led to years of litigation and over $1.3 million in extra costs for the people of Wasilla.

Posted in Barack Obama, Economy, Sarah Palin. Tags: , , , , . No Comments »

The McCain Campaign’s Solution To Increasing Number of Uninsured

August 28, 2008 — Ron Chusid

Evidence that the McCain campaign has absolutely no answer to the health care crisis can be seen in this report in The Dallas Morning News in which a McCain adviser attempts to dispute the significance of statistics showing a jump in the number of uninsured in Texas:

But the numbers are misleading, said John Goodman, president of the National Center for Policy Analysis, a right-leaning Dallas-based think tank. Mr. Goodman, who helped craft Sen. John McCain’s health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

“So I have a solution. And it will cost not one thin dime,” Mr. Goodman said. “The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

“So, there you have it. Voila! Problem solved.”

This is wrong on so many levels. It is true that an Emergency Room cannot turn anyone away. That does not mean that those utilizing an Emergency Room in this manner will not be charged. ER’s are far more expensive than other out-patient facilities, and those who are already forced to pay for their insurance out of their own pocket will have even larger bills.

Often such charges wind up going uncollected and ultimately result in the government paying more. The taxpayers wind up covering the uninsured, but in an inefficient and more costly manner. Rather than allowing such cost shifting to increase the costs of Medicare and Medicaid, it would be more efficient to apply the funds towards less costly out-patient care.

Even if there was no problem in paying for such use of the Emergency Room, this would be a poor substitute for health insurance. While ER’s do wind up providing more primary care than they should, they are not prepared to provide long term care of chronic disease or to provided preventative care. Receiving treatment from an Emergency Room is no substitute for having insurance coverage. You cannot make the problem of the uninsured go away by ordering the census bureau to stop counting them.

Update: Steve Benen points out similar problems with the McCain plan, but unfortunately makes the mistake made by many liberal bloggers with the counter-example he provides:

Of course, if we take McCain’s policy advisor at his word, and build a “socialized medicine” system around public hospitals, there’s a perfectly good model to follow: it’s called the VA system.

The McCain campaign looks very foolish for proposing ER’s as a solution for the uninsured. Unfortunately liberal bloggers who repeatedly link to this study risk looking almost as foolish. Studies of health care quality are very primitive at this point and mainly measure the ability of a health care system to input data into a computer system while revealing little of substance about actual care. The VA comes out looking good here due to its computer system, not due to the care they provide.

The risk here is that those who are aware of the very serious flaws in the VA system will realize that this is a poor model for health care nationally. If liberal bloggers who have no first hand knowledge of health care promote the VA as a model they run the risk of increasing opposition to Democratic plans among those who are aware of the VA’s deficiencies.

Neither ER’s or the VA provide a good model of either of what is desirable for a national health care policy or what is advocated by Democrats such as Obama.

Posted in Health Care, John McCain. Tags: , , , , . 1 Comment »

Obama Remains Strongest Advocate of Medicinal Marijuana Among Major Candidates

May 12, 2008 — Ron Chusid

Earlier in the race, when there were multiple candidates, I’ve reviewed their positions on medicinal marijuana. Now that we are down to two (or three if you live in Hillary Fantasy Land) this remains an issue which differentiates the candidates. I’ve previously noted the differences between Obama’s views and Clinton’s views. The San Francisco Chronicle looks at the issue, showing that Obama has been the most consistent supporter of ending the federal drug raids in states where it is legal under state law but remains illegal under federal law:

As the candidates prepare for a May 20 primary in Oregon, one of 12 states with a California-style law, Sen. Barack Obama of Illinois has become an increasingly firm advocate of ending federal intervention and letting states make their own rules when it comes to medical marijuana.

His Democratic rival, Sen. Hillary Rodham Clinton of New York, is less explicit, recently softening a pledge she made early in the campaign to halt federal raids in states with medical marijuana laws. But she has expressed none of the hostility that marked the response of her husband’s administration to California’s initiative, Proposition 215.

Sen. John McCain of Arizona, the Republican nominee-in-waiting, has gone back and forth on the issue – promising a medical marijuana patient at one campaign stop that seriously ill patients would never face arrest under a McCain administration, but ultimately endorsing the Bush administration’s policy of federal raids and prosecutions.

After reviewing the opposition of Bill Clinton and George Bush to medicinal marijuana, and noting the positions of second tier candidates, they return to Obama’s views:

At a November appearance in Audubon, Iowa, Obama recalled that his mother had died of cancer and said he saw no difference between doctor-prescribed morphine and marijuana as pain relievers. He said he would be open to allowing medical use of marijuana, if scientists and doctors concluded it was effective, but only under “strict guidelines,” because he was “concerned about folks just kind of growing their own and saying it’s for medicinal purposes.”

Obama went a step further in an interview in March with the Mail Tribune newspaper in Medford, Ore. While still expressing qualms about patients growing their own supply or getting it from “mom-and-pop stores,” he said it is “entirely appropriate” for a state to legalize the medical use of marijuana, “with the same controls as other drugs prescribed by doctors.”

In response to recent questions from The Chronicle about medical marijuana, Obama’s campaign – the only one of the three contenders to reply – endorsed a hands-off federal policy.

“Voters and legislators in the states – from California to Nevada to Maine – have decided to provide their residents suffering from chronic diseases and serious illnesses like AIDS and cancer with medical marijuana to relieve their pain and suffering,” said campaign spokesman Ben LaBolt.

“Obama supports the rights of states and local governments to make this choice – though he believes medical marijuana should be subject to (U.S. Food and Drug Administration) regulation like other drugs,” LaBolt said. He said the FDA should consider how marijuana is regulated under federal law, while leaving states free to chart their own course.

Besides Obama, there have also been supporters of medicinal marijuana by minor candidates such as Bill Richardson and Ron Paul.

Posted in Barack Obama, Bill Clinton, Drug Policy, Health Care, Hillary Clinton, John McCain, Ron Paul, Social Issues. Tags: , , , , , , , . 1 Comment »

Krugman Wrong Again–This Time Both Obama and McCain Are Right

April 4, 2008 — Ron Chusid

The problem with being an economist, a newspaper columnist, or both, is that you might get a distorted view of the real world from looking at abstract data. Paul Krugman once again demonstrates this in today’s column. He has attacked Obama’s health plan with such regularity that we knew it was time for another attack. Daniel Drezner, writing at Megan McArdle’s blog, has predicting Krugman down to a science. His formula ends with Krugman’s columns arguing “Barack Obama is not a real progressive.”

If you are one of those people who believes that everything which is accepted as truth in the liberal blogosphere is true, and anything proposed by a Republican such as John McCain is not only wrong but evil, you might as well stop here because you are not going to agree with this post. Today John McCain is right and many liberal bloggers, along with Paul Krugman, are wrong.

While there is plenty to criticize in John McCain’s health care plan, Krugman chose to attack an aspect which is actually a good idea (and which is similar to a proposal made by Democrat Bill Richardson). Krugman quotes from McCain’s web site:

“America’s veterans have fought for our freedom,” says the McCain Web site. “We should give them freedom to choose to carry their V.A. dollars to a provider that gives them the timely care at high quality and in the best location.”

Krugman fails to recognize that this is a good idea as he has been suckered into the belief, repeated by many liberal bloggers, that the V.A. health system is the Mecca of health care. This fallacy comes from computerized reports which evaluate health care plans. The problem, as most people who actually work in health care realize, is that the state of the art of evaluating medical outcomes is still quite primitive. Krugman raves about the integrated system and their use of information technology. While this probably has brought about significant improvements, the main benefit of such a system is the ability to generate data which improves their ratings.

In the private sector, there is very poor data available to evaluate care provided. Some H.M.O’s are trying, but their data at this point is pathetic. Private practices providing good care will not be recognized. The V.A. has an advantage as their system can provide just what data is needed to make themselves look good.

Those of us who actually see patients who also go to the V.A. system, as opposed to relying on computerized print outs, see plenty of evidence that the V.A. system has its faults. I see many patients who come to me because they do not receive adequate care from the V.A. They often go the the V.A. intermittently because they pay for their medications but do not receive meaningful care to manage their medical problems. The decisions made by the V.A. with regards to medications are frequently based upon short term cost.

Sometimes it is not only beneficial to the patient but also more cost effective in the long run to pay more to treat chronic diseases aggressively at an earlier stage. For example, while the consensus is that lowering the LDL to under 70 is beneficial in regressing heart disease in many patients, I’ve had the V.A. refuse to cover additional medications once the LDL is below 110. It wouldn’t take very many extra bypass surgeries to blow all the savings from refusing medications.

Hopefully some readers are thinking, “to hell with the cost benefits. If the medications mean I’m less likly to need bypass surgery, or less likely to die of a heart attack, I want to go with the current medical recommendations, not V.A. policy.” This comes down to that C-Word which Paul Krugman hates: Choice. Patients might want the choice to receive the medications recommended for their problems, not those which the V.A. finds most cost effective.

I fail to understand why some liberals defend choice when it comes to abortion rights, as they should, but some have absolutely no respect for an individual’s choice in matters such as health care and personal economic decisions. The V.A. system does vary in quality. There are also geographical issues. People often have to drive a long distance to receive care from the V.A. if going to the closest provider, and I also know of people who drive further to get to a V.A. facility they believe is of a higher quality than the closest.

John McCain is right. Let the veterans go where they choose. If the V.A. system is really the Mecca that many liberals believe it is, they will have no problem maintaining keeping patients coming. Paul Krugman believes that the V.A. system will collapse if patients have a choice to go elsewhere. Isn’t this a confession that the V.A. isn’t really providing the best care available?

John McCain is right on this one, but this is an easy issue. Changing health care for those who already have coverage is the easy part. The hard part is helping those who cannot afford health care coverage and who want to receive coverage. That’s where Barack Obama has an advantage over John McCain since McCain’s plans will do very little to help these people. Krugman once again objects because Obama’s plan includes choice. Those who both need and want his plan can take advantage of it, but everyone has a choice. Krugman writes:

Worse yet, Mr. Obama attacked his Democratic rivals’ health plans using conservative talking points about choice and the evil of having the government tell you what to do. That’s going to make it hard — if he is the nominee — to refute Mr. McCain when he makes similar arguments on behalf of such things as privatizing veterans’ care.

In other words, by supporting choice Obama gives cover to John McCain in a case where he is right. Partisan Democrats (many of whom probably should have stopped with my second paragraph) might see some logic to this if their primary goal is for Republicans to always be wrong. For those of us who want to solve problems regardless of partisanship, there’s no problem here. If it makes liberal blog readers feel better, remember that this isn’t only a Republican proposal. Bill Richardson proposed the same thing.

Paul Krugman gives conservatives quite a bit of help by spreading the fallacy that conservatives support choice and liberals support “having the government tell you what to do.” If these were the real differences between liberals and conservatives, I’d rather be a conservative, and so would the majority of Americans. Conservatives, who are hardly the supporters of choice and personal freedom which Krugman would portray them as, have benefited in many elections by portraying themselves in this manner, with the help of some such as Paul Krugman.

The reality is that Republicans talk about choice, but they seldom deliver on their rhetoric. They have no qualms about pushing the agenda of the religious right to pick up a few more votes(even though many Republicans don’t think much of their allies). Liberalism is at a cross roads after having been out of power. Some, such as Krugman and Clinton, are reactionary supporters of failed big government liberalism. Others of us stress civil liberties and favor individual choice as much as possible. We don’t know for certain what Barack Obama will do in office but, in contrast to Clinton, he has shown signs of understanding the limitations of a top-down government approach. His health care plan is just one example of this.

Posted in Barack Obama, Health Care, Hillary Clinton, John McCain, Op-eds. Tags: , , , , , , , , , , , , , . 4 Comments »

Financial Incentives in Health Care

September 19, 2007 — Ron Chusid

I think that, for the most part, liberal democrats really mean well when they make recommendations regarding medical care. Unfortunately sometimes those with little first hand knowledge of health care come up with some quite erroneous assumptions. This is seen in a post from Ezra Klein today where he writes:

Indeed, the reason people get medical care — in particular expensive medical care — is because their doctors tell them to. I have never in my life sat up in bed and thought, “huh, I should really get some laparoscopic surgery.” If I get a surgery, it’s because my doctor told me to. And if I can’t afford it, I have to ignore his diagnosis.

For that reason, if you want to safely cut back on care patients buy, you need to get doctors to stop recommending so much wasted care. You can do that in a few ways: Put them on salary rather than on fee-for-service deals, so they don’t make more money when they recommend treatment. Create new research institutions that test the cost effectiveness of care so they have a better idea of which treatments are worth recommending. Offer bonuses for using proven therapies. Etc, etc. But this idea that the way to better run medical care is to rejigger the financial incentives so patients have to ignore their doctor’s advice is really quite bizarre.

People do not receive care simply because a doctors tells them to. A doctor is not going to tell a patient out of the blue to have laparoscopic surgery. If such a recommendation is made the patient most likely presented with a complaint for which this is the best way of diagnosing and possibly repairing the problem. Another possibility is that a test showed that the procedure is necessary.

Ezra is concerned with doctors who recommend “so much wasted care” but the actual evidence is that Americans receive far too little care as opposed to too much. There are far too many people with cardiac risk factors who are not being treated with Statins. There are far too many patients in Atrial Fibrillation who are not being anticoagulated. There are far too many diabetics and hypertensives who are not being treated to goal. There are far too many people who do not receive recommended screening tests for cancer such as colonoscopies (another procedure mentioned by Ezra).

There is certainly the possibility that an unscrupulous surgeon might recommend unnecessary procedures for the income but this is not as serious a problem as Ezra might suggest. This is also where it is beneficial to start with a good primary care physician who can be involved in the management of the case, as opposed to relying solely on the surgeon’s recommendation.

It is an erroneous assumption to assume that doctors on salary will order less than those in fee for service practices. Often the opposite is true. While I am in private practice, a large number of local physicians are employees of the local hospitals. I receive no financial benefit from Ezra receiving laproscopic surgery, whether or not it is necessary. I will also avoid referring to individuals or institutions which I feel are overly quick to do surgery or other tests. On the other hand, a salaried physician is placed under pressure to refer within their system and to increase overall revenue for the system. A salaried physician is far more likely to refer within their system, even if this mean unnecessary procedures being done, than a good primary care physician in primary care who will make decisions purely based upon what is good for the patient as opposed to what is good for his employer.

Salaried physicians are also often under pressures to refrain from using treatments which are beneficial due to cost. Some liberal bloggers have become overly enamored with the VA system based upon statistical analyzes, forgetting that statistics is the science which demonstrates that the average human has one testicle and one breast. Those who actually deal with the VA see a totally different situation than is described in some liberal blogs. For example, the literature shows quite convincingly that it is necessary to lower the LDL in a high risk cardiac patient to under 70 to achieve regression of blocked coronary arteries. To save money the VA is not willing to spend more on medications to lower the LDL much below 100. Actos will decrease mortality in many diabetic patients (provided it is avoided in those prone to congestive heart failure) but the VA will only pay for less expensive diabetic medications. For those who do have congestive heart failure, another expensive drug, Coreg, will improve mortality. The VA requires more severe cases than is recommended by most cardiologists before they will approve the medication, denying many patients the benefit of a drug which can prolong their lives. (Fortunately Coreg is going generic, and undoubtedly the VA will reassess their cost-driven analysis of when it can be used.)

Ezra recommends that we “Create new research institutions that test the cost effectiveness of care.” There has been increased emphasis on evidence-based medicine for several years, which includes consideration of cost effectiveness. This is done in our current research institutions, making it unnecessary to build who new institutions. This also helps to reduce unnecessary surgery if such studies show that more conservative treatment is more effective.

Ezra recommends that we “Offer bonuses for using proven therapies.” This is already being done. Medicare has begun a program to actually provide such bonuses, and incentive programs are becoming more common in other plans. Often these incentive programs provide bonuses for providing more care under the realization that the real problem we face is not excessive medical care but too many patients not receiving care which they would benefit from (and which could reduce costs long term).

At least I’m relieved that Ezra does not recommend increased oversight of physicians. Managed care organizations have attempted to create huge bureaucracies to oversee the decisions of physicians and require approval before many procedures. Over time most found that the vast majority of what physicians recommended was worthwhile and it cost much more to require such authorizations than the money which was saved from denying an occasional procedure.

Contrary to what Ezra believes, the best course is to alter incentives in order to get patients to follow their doctor’s advice. While I don’t agree with making this mandatory, John Edwards appears to realize the value of this in stressing the need for preventative care and routine care of chronic diseases. It is more cost effective to find tumors earlier than later. It is also more cost effective to treat diabetes, hypertension, and hyperlipidemia aggressively, starting at an early age, than to pay for coronary artery bypass surgery, renal dialysis, and treatment following strokes. Besides, as I’ve previously discussed, such care is also desirable for the manner in which it improves the quality of life for patients regardless of the potential monetary savings.

Posted in Blogs & Social Media, Health Care, John Edwards. Tags: , , , , . No Comments »

John Stossel’s Vision of Health Care for Few

August 22, 2007 — Ron Chusid

John Stossel suffers from a couple of common fallacies on the right about economics and health care. He believes that if the free market is superior to government in most activities it must be superior in all. Secondly he assumes that the only plausible alternatives are either government run health care or a totally free market system. This fallacies have been seen in reviews of his previous writings on health care and are again evident in his discussion of the World Health Organization’s ranking of nations on the health care delivered.

Stossel admits there are problems with our health care system but attributes them to the United States now having a pure free market system:

First let’s acknowledge that the U.S. medical system has serious problems. But the problems stem from departures from free-market principles. The system is riddled with tax manipulation, costly insurance mandates and bureaucratic interference. Most important, six out of seven health-care dollars are spent by third parties, which means that most consumers exercise no cost-consciousness. As Milton Friedman always pointed out, no one spends other people’s money as carefully as he spends his own.

The problem with a pure free market system where everyone is responsible for their health care costs has already been discussed in multiple posts. This includes this response to a previous column by Stossel, the previous posts which I linked to in that post responding to similar proposals from Rudy Giuliani, as well as other health care posts on this site.

The other problem with this argument is that the countries leading in the survey have greater government involvement in health care than the United States. If our degree of government involvement makes our system inefficient, it is hard to imagine how the health care systems in other industrialized nations would be able to function at all if we accept Stossel’s logic. If the problem here is having health care covered by insurance as opposed to spending our own money, our system which includes growing deductibles and copays should be far better than those systems where people only pay a nominal amount or nothing at all.

Stossel also tries the usual misdirection we see from conservatives when he argues, “Even with all that, it strains credulity to hear that the U.S. ranks far from the top. Sick people come to the United States for treatment.”

The problem here is that Stossel is trying to substitute a single measure of health care for that used in the survey and concentrate solely on the strong points of our system. It is widely agreed, including by most critics of our health care system, that the United States leads the world in tertiary and subspecialty care. Our system does an excellent job of treating the sickest and most complex patients provided that they have access to the system. Rather than moving to a totally free market system as Stossel recommends, or to a government controlled system as few actually advocate, we need reforms which will preserve the strengths of our system while improving access to care for all Americans. (more…)

Posted in Health Care, Op-eds. Tags: , , , . 11 Comments »

Paying For Health Care Reform Without a Free Lunch

August 8, 2007 — Ron Chusid

One reason I’ve been disappointed in Hillary Clinton’s campaign is that, when talking about health care, she has discussed the easy arguments such as promoting preventative health care while avoiding the difficult decisions. David Leonhardt questions the cost savings from preventative care in a column in The New York Times:

The theory goes like this: By practicing preventive medicine, doctors can keep many people from getting sick in the first place. Those who do end up with a chronic illness will be closely tracked so that fewer of them develop complications. These steps will result in less illness, which in turn will require less health care. With the savings, the country can then lower its medical bills or provide health insurance for the 40-odd million people who lack it — or maybe even both.

As Hillary Clinton recently told The Atlantic, it’s possible to “save money and improve quality and cover everybody.”

The would-be reformers have hit on something important here. The current health care system doesn’t pay hospitals, doctors and nurses to keep people healthy; it pays for tests, surgeries and drugs. So Americans often get expensive invasive care of dubious medical benefit while missing out on sensible basic care. Millions of other people go without any care for chronic illnesses like heart disease and diabetes. If Medicare and private insurers paid for more preventive care, Americans would be healthier than they are today and live longer.

But the current presidential candidates go one step further. They don’t merely argue that preventive care delivers good bang for the buck. They argue that it delivers good bang for no bucks whatsoever. And this is where the candidates are overreaching.

No one really knows whether preventive medicine will save money in the long run, let alone free up the billions of dollars a year needed to help pay for universal health insurance. In fact, studies have shown that preventive care — be it cancer screening, smoking cessation or plain old checkups — usually ends up costing money. It makes people healthier, but it’s not free.

“It’s a nice thing to think, and it seems like it should be true, but I don’t know of any evidence that preventive care actually saves money,” said Jonathan Gruber, an M.I.T. economist who helped design the universal-coverage plan in Massachusetts.

This is a tough idea to swallow because better health really does seem as if it should lead to lower medical bills. Indeed, if it were somehow possible to wave a wand and turn people into thin nonsmokers who remembered to take their statins, this country’s health care expenses would fall.

But any effort to promote health has its own costs. Doctors and nurses need to spend time with patients to persuade them to change their behavior. (Ever tried to get someone to stop smoking or drinking?) For a new program to work, it has to reach people who are not being helped by whatever exists now — and who thus will be among the most difficult and expensive patients to treat. The program would also have to treat a whole lot of people who never would have gotten sick.

Jay Bhattacharya, a doctor and economist at Stanford’s School of Medicine, estimates that to prevent one new case of diabetes, an antiobesity program must treat five people — “not cheaply,” he says. Along the same lines, Mr. Gruber found that when retirees in California began visiting their doctor less often and filling fewer prescriptions, overall medical spending fell. People did get sick more often, but treating their illnesses was still less costly than widespread basic care — in the form of doctors visits and drugs. Louise Russell, an economist at Rutgers, points out that programs that focus on at-risk patients cost the least, but even they are rarely free.

As Dr. Mark R. Chassin, a former New York state health commissioner, says, preventive care “reduces costs, yes, for the individual who didn’t get sick.”

“But that savings is overwhelmed by the cost of continuously treating everybody else.”

The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.

Certainly, there are examples of preventive care that can save money. As Mrs. Clinton has noted, Safeway and a handful of other companies have held down health costs by emphasizing prevention. (This, of course, is only over the short term.) Perhaps the best examples fall under the category of what Dr. Brent C. James calls “do it right the first time.”

Not only won’t preventative care save money in the short run, it will also cost more to provide such care to people who are not currently receiving care. I believe that in the long run preventative care, as well as more intensive care of chronic diseases, will save money. It is far less expensive to treat problems such as diabetes early, than to pay for renal dialysis, coronary artery bypass surgery, and treatment of stroke patients after years of inadequately controlled diabetes. Not everyone develops these problems, but the number of diabetics has been growing and these costs will increase.

Nobody can say for certain that the overall savings from preventative care will outweigh the additional costs. While I believe they will, ultimately I support preventative care and better routine care of chronic diseases as they are what is better for the patient, not merely because this might save money. Leonhardt is right that such discussion of preventative care does not provide a satisfactory answer as to how a health care package will be financed in the early years.

Posted in Health Care, Hillary Clinton, Op-eds. Tags: , , , , , . 3 Comments »

Better Red Than Dead?

August 5, 2007 — Ron Chusid

In 2003 one reason I decided to support John Kerry’s health care plan, besides the inherent benefits of his plan, was that I feared this might be our last chance to solve health care problems without returning to much more intrusive ideas such as HillaryCare or government run health care programs. One election cycle later, we see many in the liberal blogosphere calling for a single payer plans. While the candidates, other than Dennis Kucinich, still do not support a single payer plan, some of the plans proposed this year do contain more mandatory government involvement than Kerry’s more voluntary plan.

Kenneth Rogoff, writing at The Economist, sees a similar trend, fearing that as health care costs become more expensive, more people will think “better red than dead” and back a greater role for government:

In addition to reducing mortality, new medical techniques can also have a huge effect on the quality of life. Roughly 250,000 hip replacements are performed in the US each year. Under-60 patients are becoming more important as newer artificial joints prove their capacity to withstand more active lifestyles.

At $6,000, the average cost of a hip replacement is only a thousandth the cost of what it supposedly took to implant a bionic arm, eye, and two legs on the fictional The Six Million Dollar Man in the popular mid-1970’s TV show. Of course, hip replacement patients don’t get superhuman speed, strength, and vision – at least not yet. If Tour de France officials think they have big problems now with steroids, just wait 10 years.

In principle, greater use of market mechanisms to allocate health care can slow or even temporarily reverse the rise in healthcare costs. But improved efficiency has its limits. Ultimately, the evidence suggests that societies spend ever-larger fractions of their income on health over time, in contrast to food expenditures, for example, which fall as countries become wealthier.

Spending pressures, in turn, lead to acceleration of innovation. This raises long-term wellbeing all around, but exacerbates short-term inequalities and frictions.

Arnold Kling responds by claiming to be exposing a health care fallacy, but actually repeats a common fallacy on the right that people can afford health care if we were only to eliminate unnecessary services. While there is some money spent unnecessarily, this represents a small proportion of health care dollars. Kling writes, “Getting a colonoscopy every five years after you turn age 50 may be a helpful precaution against colon cancer.” For most people screening colonoscopies are actually recommended every ten years, with screening at five year intervals being reserved for those with a history of potentially precancerous polyps and a higher risk of developing cancer. Terminating such screenings could increase health care costs if we wind up treating more people for colon cancer.

It is not only the expensive procedures which cause financial problems. Even the intensive routine care of diabetics which studies prove will reduce morbidity and mortality are expensive when the costs are totaled. Turning health care costs over to individuals as conservatives advocate will result is less preventative care and less routine care of chronic diseases, increasing costs in the long run. It is far more cost effective to assist individuals in receiving aggressive care of diabetes and hypertension at an early age than to pay for renal dialysis, coronary artery bypass grafts, and post-stroke rehabilitation or nursing home care.

Posted in Blogs & Social Media, Health Care. Tags: , , , , . No Comments »

Giuliani Continues Usual Scare Tactics About Democratic Health Care Plans

July 31, 2007 — Ron Chusid

Rudy Giuliani offered a health care plan lacking in substance, instead falling back on his usual tactic of name calling. Giuliani equated the proposals of the Democratic candidates with the views of Michael Moore, claiming the Democrats support socialized medicine.

This is the same tactic used by George Bush in 2004 when he claimed that John Kerry’s plan was a government take over of health care when it actually centered voluntary measures to assist businesses and individuals who were having difficulties with the cost of health coverage. Republicans typically scream socialized medicine when they are the ones who back increased government intrusion in health care decisions, including on abortion rights, end of life decisions, and medical use of marijuana. Giuliani has opposed allowing cancer patients to use marijuana for relief of symptoms.

Giuliani is especially dishonest when he compares the plans of the Democratic candidates to Michael Moore. While most Democrats probably agree with Moore’s description of the health care crisis, none of the candidates agree with Moore’s solutions. Of all the candidates, only Dennis Kucinich has backed a single payer plan, and Moore has said that even Kucinich’s plan does not go far enough for him.

Giuliani also promises to solve all our problems–quickly:

He said he can solve global warming in five to 15 years and would end illegal immigration in a year and a half to three years. “I give ourselves 18 month to three years to accomplish it,” he said.

Update: The New York Times has more on Giuliani’s proposals. Giuliani claims that under the current system “there is no incentive to wellness.” In general people would prefer to be well as opposed to being sick. However if promoting incentives for wellness is the criteria we judge plans by, Giuliani’s plan fails.

Giuliani is very vague on his plan, but he did discuss the use of Health Savings Accounts.  A major problem with HSA’s is that they are used along with high deductible insurance plans leading people to avoid routine care of chronic diseases and preventative care to avoid taking money out of their own plan.

Posted in Democrats, Health Care, Rudy Giuliani. Tags: , , , , , , , , , , . No Comments »

A Review of Michael Moore’s Sicko

June 20, 2007 — Ron Chusid

[youtube=http://www.youtube.com/watch?v=joaAfBr9tAE]

Last night I took Michael Moore up on his offer and watched Sicko prior to its official release, with the trailer appearing above. The documentary made many excellent points on health care, but after seeing its overall philosophy, I am surprised that it received favorable reviews from Fox News and The Wall Street Journal. Perhaps their reviewers also have had unpleasant experiences with the health insurance industry.

Moore briefly mentions the problems of the uninsured, but concentrates on the millions who do have health insurance yet still run into problems. He shows people having financial difficulties after paying their deductibles and co-pays, or paying the bill when an insurance company refuses to cover a necessary service. He shows how insurance companies cherry pick the healthiest applicants and deny those it expects to have to pay out on.

Moore might give a false impression that people with chronic diseases cannot obtain coverage at all. In many states they can receive coverage in theory–if they can afford the rates. The chances are better if covered by an employer as opposed to needing to obtain individual coverage, but a catastrophic case might also cause an employer to drop or reduce coverage. Michael Moore has a valid point that insurance companies are in the business to make money, and that often means finding ways to avoid paying claims as opposed to covering medical care for the sick. Similarly, viewers might get the impression that insurance companies find ways out of paying every claim. They actually do pay out on a sizable number, but that doesn’t help the many people, such as those shown in Sicko, who do not have their bills paid.

Moore shows not only victims of the health care system, but those who worked for insurance companies and are now confessing about the tactics used. This includes medical directors for insurance companies who were well paid for finding justifications to deny claims. The health insurance companies attempted to rationalize this to their medical directors by claiming they were working only to deny payment, not medical care.

The more controversial aspects of the movie are sure to involve the visits to Canada, Great Britain, France, and, most of all Cuba. I prefer to stick with aspects of the movie I’m personally familiar with, health care in the United States, as opposed to debating health care plans in foreign countries I have only read about. Moore also goes beyond health care to support considerable more government services than many who are pushing for health care reform in this country are advocating. I’m sure that Michael Moore does white wash many of the problems in other countries, but the fact remains that all these countries are able to provide health care for all its citizens. That does not mean that we should necessarily follow any of these particular models, but universal health care is something an affluent society such as ours should be able to find a way to provide.

Detractors of Michael Moore are bound to attack his more leftist economic positions and attempt to claim that the Democrats are as far left as him. As noted in a previous post, Michael Moore believes that none of the Democratic candidates, including Dennis Kucinich go far enough. Only Kucinich backs a single payer plan, with the rest of the Democratic candidates advocating plans which preserve private insurance plans as well as private medical practices. The plans advocated are actually very similar to those enacted by Republican governors in California and Massachusetts. I’ve seen claims that Sicko is virtually a Hillary Clinton campaign ad. It is true that the movie takes a highly favorable view of Hillary Care while ignoring the problems, but Moore ultimately attacks Clinton for selling out to the insurance companies.

There is no way that Michael Moore will receive anything but opposition from the insurance industry, but he does try to appeal to doctors. In both England and France he makes a point of showing that, despite “socialized medicine,” the doctors continue to have an excellent standard of living. On top of that, they don’t have all the paper work hassles we receive from the insurance companies, as well as denial of payment. Michael Moore is receiving support from groups of doctors and nurses who have joined together in Scrubs for Sicko to give information to movie goers.

Moore looks at previous health care legislation, including portions of the Nixon White House tapes showing Nixon’s true motives for pushing HMO’s as a means to deny care. He also shows how George Bush’s Medicare Part D plan was really a scheme to provide greater payments to the pharmaceutical and insurance industries, but he does leave out many of the details. Moore could have said more about how many patients who were eligible for both Medicaid and Medicare had their prescription coverage changed from plans which negotiated lower prices to new plans which paid the pharmaceutical companies significantly more. He also said nothing about the Medicare Advantage Plans included in the legislation. Under these plans, insurance companies are paid more than it costs to treat regular Medicare patients, even though they cherry pick the healthier patients and engage in dishonest sales techniques.

Moore makes a variation of an argument which I have often made to libertarian-leaning friends who question why I would support changes in health care, even if far less than those advocated by Moore. As Michael Moore points out, we already have “socialized” police, fire fighters, soldiers, and teachers. In the rest of the developed world universal health care is also seen as the norm, although Moore does brush over the fact that many countries do provide universal care through utilizing private insurance. In the case of health care, the insurance industry has simply failed, substituting a business model based upon avoiding payments as opposed to providing a service.

There’s bound to be denial from the right as to the accuracy of the movie. While it certainly doesn’t excuse the other problems in their system of government, I’ve previously provided information on the validity of Moore’s comments on health care in Cuba. The National Coalition on Heallth Care has reviewed health care costs, as well as the number of people, including those with insurance, who declare bankruptcy due to health care costs. The American Society of Registered Nurses has also reviewed Moore’s facts and found those on the US insurance system to be accurate. Among their findings:

When we surveyed select counties across the world for life expectancy, which was defined as the life expectancy at birth for both sexes, the U.S. fared very poorly.

The U.S. came in 17th, tied with Cyprus, with a life expectancy of 78.0. Here are the countries in the top 17: Japan (81.4); Switzerland (80.6); Sweden (80.6); Australia (80.6); Canada (80.3); Italy (79.9); France (79.9); Spain (79.8); Norway (79.7); Israel (79.6); Greece (79.4); Austria (79.2); New Zealand (79.0); Germany (79.0); U.K. (78.7); Finland (78.7); Cyprus (78.0); and the U.S. (78.0).

In our survey of select countries across the world for infant mortality, which was defined as the number of deaths per 1,000 live births, the U.S. again did poorly.

The U.S. came in 16th, below South Korea, with an infant mortality rate of 6.4. Here are the countries in the top 16: Sweden (2.8); Japan (3.2); Finland (3.5); Norway (3.6); Czech Republic (3.9); France (4.2); Spain (4.3); Denmark (4.5); Austria (4.5); Canada (4.6); Australia (4.6); Portugal (4.9); UK (5.0); New Zealand (5.7); South Korea (6.1); U.S. (6.4).

The next question is whether the U.S. truly spends more than any other country in the world on health care. This would indeed indicate a mismanagement of funds budgeted for the health care system…

Again, Moore’s facts checked out. The U.S. spends $5,711 per person. That’s a whopping 33% more than the next highest spending country, Norway. Norway spends only $3,809 per person.

Here are the top 27 highest per capita spending countries in the world: U.S. ($5,711); Norway ($3,809); Switzerland ($3,776); Luxembourg ($3,776); Iceland ($3,110); Germany ($3,001); Canada ($2,989); Netherlands ($2,987); France ($2,902); Australia ($2,874); Denmark ($2,762); Sweden ($2,704); Ireland ($2,496); U.K. ($2,389); Austria ($2,306); Italy ($2,266); Japan ($2,244); Finland ($2,108); Greece ($1,997); Israel ($1,911); New Zealand ($1,893); Spain ($1,853); Portugal ($1,791); Slovenia ($1,669); Malta ($1,436); Czech Republic ($1,302).

It is not necessary to agree with all of Michael Moore’s personal beliefs to see the movie and acknowledge that we do have a problem. Nor must we necesarily agree with Michael Moore’s solutions. The problem is only worsening as the number of uninsured , as well as under-insured, continues to grow.

Posted in Entertainment & Leisure, Health Care, Hillary Clinton. Tags: , , , , , , , , , , , , , , , . No Comments »
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