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Monday, September 7th 2009

Obamacare: Health Care In America

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President Obama is set to address a joint session on September 9th specifically on health care

President Barack Obama will address a joint session of Congress on health care reform in prime time on Wednesday, Sept. 9.

Obama plans to give lawmakers a more specific prescription for health care legislation than he has in the past, aides said.

Presidential aides have promised Obama will take back the reins after allowing Congress to work its will on his idea, without one specific plan for Democratic lawmakers to defend back home. We’re entering a new season,” senior adviser David Axelrod said in an interview Tuesday. “It’s time to synthesize and harmonize these strands and get this done. We’re confident that we can do that. But obviously it is a different phase. We’re going to approach it in a different way. The president is going to be very active.”

Not exactly a return to form. This administration has never been terribly specific on health care. They’re ‘for a public option’, then a ‘public option isn’t a necessity for reform’. This effort at healthcare reform has been anything but fixed with a message. This wasn’t Edwards’ campaign, this wasn’t the Clinton’s first effort. And perhaps those examples gave him some reserve.

It isn’t like the House and Senate are currently being led by the likes of Sam Rayburn and Mike Mansfield. Strong leadership was probably in order on this issue from the White House. And while the President may be attempting to provide it now with this prime time address, it is very late. In purely political terms Obama’s wishy-washy wants and generally hands off approach has been catastrophic to the chances of ‘meaningful’ healthcare reform. The administration’s management of Congress to date has been something less than Johnson-esque.

What exactly have they screwed up however? What exactly is being discussed when we talk about healthcare reform efforts in Washington right now?

I thought it only fit that one of my first posts on Residency Notes be a primer on the current healthcare reform debate.

I’ve commented pretty extensively on healthcare policy in the past. Hopefully my previous posts from From Medskool will be up soon and so I don’t want to repost simply what I’ve said in the past. I don’t think I shy away from the nitty-gritty. I’m not a wonk but I’ve dug through the published comparative quality data, the cost breakdowns, the history of healthcare reform in this country, the proposals. I enjoy this stuff. My point is this post isn’t a rant on the subject, this isn’t (in entirety) an op-ed; I’m pretty well read on the subject and I want to break it down because when talking with people I sense a lot of confusion on what exactly is going on with reform and I imagine the immediate future will get even murkier in Washington.

Healthcare In America
I’ve commented ad nauseum on what the American healthcare system does and does not do well. I don’t want to spend too much time explaining what proponents of reform see as the problems with the American system but some basics need to be reiterated.

The United States spends a comparatively large amount on healthcare. As a percentage of gross domestic product healthcare spending tops that of any other western nation. The reasons for that are multietiological; don’t let anyone try to cite a sole source for the spending.

It’s true the United States system is especially inefficient but even removing all the bureaucratic waste would do little to make the United States’ spending more in line with the rest of the world.

It’s true the United States’ population is inherently less healthy, independent of access to care, than much of the rest of the western world which may drive up costs of care but that alone cannot explain our exorbitant costs; nor can it fully explain the fact that we utilize healthcare services at an increased rate compared to the rest of the world.

It’s true expectations of healthcare, especially at the end of life, are much higher in the United States than in other parts of the world; this likely drives up healthcare utilization with marginal benefits and thus helps drives cost. Again, this solely cannot explain the United States healthcare spending; nor can it fully explain the fact that we utilize healthcare services at an increased rate compared to the rest of the world.

It’s also true that we utilize healthcare services at an increased rate and that each of these services, which we use more than the rest of the world, actually cost more in the United States as well. Hospitals and physicians and pharmacutical companies and others involved as providers are incentivized in a fee-for-service system, with little to no true oversight, to perform procedures, to do tests, to prescribe drugs. Variations in healthcare spending by region clearly show that utilization is associated with the amount of care available in an area. The more cardiac surgeons in an area and the more hospital beds in an area, the more CABGs are done. Trouble is the outcomes aren’t better. The implications are staggering. Things are done to patients that are questionably necessary. Healthcare providers (hospitals, physicians, pharmacutical companies, medical device manufacturers) create their own demand in America like nowhere else in the world. Remember that phrase – healthcare providers create their own demand. It is an important part of why healthcare costs are so high in America and you should not let anyone you’re having a conversation on healthcare policy with walk away without understanding that and the implications of such.

There are some things the United States does very well. Doing healthcare cheaply, triaging care solely to those who actually need it are not some of them. Neither is primary care or public health.

On virtually every global public health measure the United States trails. Things like life expectancy and infant mortality. It is true these are self reported statistics with some variations in how they’re recorded. For instance back in the 1960s and 1970s the Soviet Union and its member states were notorious for keeping newborns who were stillborn or who didn’t meet certain weight requirements at birth off of their infant mortality record sheets and inflating their numbers. As well, it’s true that in general the United States is an unhealthy population. It is an obese, genetically heterogeneous population with some unique problems. Although these factors contribute they can hardly explain in full our poor performance on these public health metrics.

The United States has a system that does not focus on primary care, does not focus on the management of chronic illnesses, does not focus on public health. The ratio of primary care providers to specialists in the United States is the lowest of any western country. We have virtually no triage system, anyone who can afford it can bypass a primary care doctor and go straight to a specialist. While this may initially seem like an enticing prospect, it actually contributes to the overutilization of healthcare that we talked about above.

Instead of primary care the United States focuses on acute, procedure oriented treatments for the long term consequences of poorly controlled chronic illnesses.

That fact is confounded by the rationing of access to care in the United States. However many un- and under-insured the United States hosts, and I admit there are major issues in the methodologies used to count those individuals, the United States has an access to care issue largely centered on the fact we have a significant population who cannot afford healthcare. We should not pretend that emergency rooms and indigent care services make up a safety net for those without insurance.

It’s true the United States does an okay job at providing acute services to everyone, including those who cannot afford them. If you have a heart attack you’ll get the ACLS and the cath that may save your life no matter your ability to pay. If you have a head bleed you’ll get that decompressive crani that may save your life no matter your ability to pay. But these services do little to affect the global outcome metrics (like life expectancy) that the United States performs so woeful on. The fact is these patients had a heart attack or a stroke because their underlying chronic risk factors for such, like their hypertension, weren’t treated.

The truth is that virtually all major studies show that a lack of insurance is a barrier to access to care and that decreased access to care means worse outcomes for virtually all chronic diseases. And it is those chronic diseases which influence these outcome measurements by which healthcare systems are judged.

Patients with long term uninsured status present with later stages of cancer and do worse, are less likely to have their diabetes or hypertension or hyperlipidemia under control, are more likely to suffer a stroke, are more likely to be hospitalized with complications of chronic conditions.

There is almost no argument on the matter. The United States has an access to care issue associated with individuals who cannot afford healthcare; and those with ‘poor’ access to care are worse off, health wise, than those who have ‘good’ access to care. End of story.

No wonder so many are focused on reforming healthcare in America. Next in this brief series: What Makes Meaningful Rerom?