'According to the logic of those now shedding crocodile tears, we ought, in order to remain truly American and truly free, retain the precious liberties of our people to be illiterate, to suffer accidents without indemnification, as well as to be sick without indemnification.' -- Irving Fisher, The Progressive, January, 1917By Dr. Stephen R. Keister / The Rag Blog / July 21, 2009
In recent weeks we have been treated to wails of pain and indignation regarding the cost of government subsidized health care from our elected representatives. Most frequently the most plaintive cries are from those senators and representatives who show no compunction about large appropriations for foreign military adventures and who show total disregard for the taxpayers’ subsidies of executive salaries and bonuses.
Though I have previously addressed the matter of health care costs in brief, I feel it prudent to further explore the matter, something that is much overdue as Irving Fisher noted in the Progressive in January, 1917
"At present the United States has the unenviable distinction of being the only great industrial nation without universal health insurance. Health insurance is like elementary education. To function properly it must be universal and to be universal it must be obligatory. Certain interests which think they would be adversely affected by health insurance have made a specious plea that it is an un-American interference with liberty.We have previously noted that, in the interest of maintaining a financial base for a public health option, we must eliminate waste, and that the place to start is for Congress to eliminate the Bush era giveaway of Medicare trust funds to the insurance industry as so-called Medicare Advantage Plans. Second, we must get rid of the absurd Medicare Part D "prescription insurance,” which is basically a giveaway of Medicare money to the insurance cartels and pharmaceutical industry, and supplant it with a true prescription plan written to the taxpayers’ advantage, with a regulated choice of medications, at negotiated cost as is done by the Veterans Administration.
“According to the logic of those now shedding crocodile tears, we ought, in order to remain truly American and truly free, retain the precious liberties of our people to be illiterate, to suffer accidents without indemnification, as well as to be sick without indemnification. It is by the compelling hand of the law that society secures liberation from the evils of crime, vice, ignorance, accidents, unemployment, invalidity, and disease."
The costs of pharmaceuticals in the United States exceeds that of other nations, in the vast majority of instances, by a minimum of 50%. I have cancer of the prostate, as well as spinal stenosis, a matter which gives me an objective outlook on another matter that we will deal with presently. I can get medication from Canada for my cancer for $400 per 100 tablets, as opposed to $400 for 30 tablets in the United States.
The pharmaceutical industry in the United States spends more for advertising than it does for research, a fact which is well documented. Look at television, for instance, and note that almost every other ad is for a prescription or non-prescription drug. The United States is one of two industrialized nations that permit prescription drugs to be advertised on television. Congress must put a stop to this practice, which in turn increases the cost to the little old lady who cannot afford her blood pressure medication. Do we need to see ads for male impotence 5-6 times during a televised baseball game?
We next face the costs of medical care per se. A very though provoking, well written letter by Dr. Geoff Berg of Warren, Rhode Island, appears in the June 20, 2009 Economist, and I quote:
"Sir. Regarding your article on the future for health care reform in America, it is providers, not insurers, that are the problem… The heart of the matter is the perverse fee-for-service system that pays providers merely for delivering services but for creating services as well. The only way to curtail health-care spending is a meaningful way to scrap this fee-based system in favor of salaries with modest incentives for improved outcomes. The health care system is killing America. It would appear that those who are trying to affect a cure have neither an appropriate diagnosis nor an effective treatment."There is merit to Dr. Berg's logic. although I totally disagree with his whitewashing of the insurance cartels, PHarma, and the manufacturers of medical equipment. There is much to be said for salaries (like at the Mayo Clinic for instance), for the physician population as a whole. Too many practitioners are overly busy, and cannot give a patient decent time to be heard. Perhaps this is due to avarice, but more likely it is caused by the HMO culture that demands that a physician (i.e., provider) see more and more patients, to increase the income of the HMO management.
This leads to over-testing, excessive use of X-ray and CT scanning, laboratory procedures, and consultations, rather than taking time for communication with and examination of the patient. The more tests the higher the cost of overall medical care. For instance, I have a friend who three days ago called her urologist to ask a simple question, and has not received a call back, in spite of being told twice by a nurse that “your chart is on his desk.” Now, if this was, indeed, something urgent, we could be discussing the matter of increasing malpractice insurance costs which frequently are a matter of miscommunication, or lack of communication, rather than bad practice per se.
Of course, this once again returns us to the inadequate supply of physicians in the United States in comparison to the European nations. Part of this problem goes back 50 or more years when certain institutions in the United States connived to prevent “training too many doctors.” This matter must be faced immediately by the Congress by passing legislation, as has been proposed by the American College of Physicians, for government subsidization of medical education for qualified candidates (internists and family practitioners) provided they will practice in an under-served area at fees commensurate with their training and professional needs. I might add, once again, that the idea of a Medical Academy similar to Annapolis or West Point should be considered. If the tax-payer can be asked to underwrite healing.
Finally, we come to a subject that is frequently avoided in the culture of the United States, the matter of end-of-life care. Let us start with a simple question. Has the reader and his family discussed the matter of terminal care; is he/she familiar with the matter of advance directives (i.e.living wills), or of providing a member of the family with power of attorney for end of life care? Is everyone well versed in hospice care to handle suffering from a terminal illness?
These subjects must be widely discussed in the development of a national health care program. I for one, desire a dignified death, free of machines such as artificial ventilation or kidney dialysis, and do not wish to be inflicted with tubes coming from every orifice. I want to be kept comfortable, free of pain, and to have the ability to face death without worrying about certain conservative politicians, who, in offering homage to the religious fundamentalist movement, would wish otherwise for me.
On July 18, Public Agenda noted that Medicare spending in the last two years of life ranges from, on an average, $93,842 for patients at the UCLA Medical Center to $53,432 at the Mayo Clinic. This is well documented in a July 18 article in USA Today. These are matters that the framers of any health care legislation should be considering. Thus, perhaps the President’s thinking in rushing through legislation prior to the recess must be reconsidered to allow further thoughtful consideration of important adjunct issues.
Once we begin to discuss “end of life” we may open a Pandora's Box for the politicians who thrive on mythology and prejudice rather than reason and logic. I can see the entire matter of health care being converted to an opportunity for the purveyors of nay-saying to appear for long hours on C-span. I would suggest a White House conference consisting of two experts in bioethics, two physicians from the field of geriatrics, two leading members of the hospice movement, a Jesuit theologian, and a reform rabbi to meet and consider the matter at length. Professor Peter Singer, a professor of bioethics at Princeton University, recently published a very thought-provoking article in The New York Times Magazine entitled "Why We Must Ration Health Care."
As Paul Krugman noted on June 24 in the New York Times,
"Really bad news on the health care front. After making the case for a public option, and doing it well, Obama said this: ‘We have not drawn lines in the sand other than reform has to control costs and to provide relief to people who do not have health insurance or are uninsured. These are the broad parameters that we've discussed.’ There he goes again, gratuitously making a gift to the other side. My big fear about Obama has always been not that he doesn't understand the issues, but his urge to compromise -- his vision of himself as a politician that transcends the old partisan divisions -- will lead him to negotiate with himself and give away too much.”We need to learn more about this very complicated area of legislation. There is an abundance of information at Physicians for a National Health Program for those interested.
[Dr. Stephen R. Keister, a regular contributor to The Rag Blog, lives in Erie, PA. He is a retired physician who is active in health care reform. His previous articles on The Rag Blog can be found here.]
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