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Archive for March, 2010

Wednesday, March 31st 2010

The Doctor Won’t See You

I’ve made a big deal about access to physicians of recent. A little bit of a whiny deal. But there’s more to physician access than merely reimbursement. The media has picked up, with some gusto, the story that a surge in the insured and a ‘shortage’ of primary care physicians in the United States may severely limit access to care.

Examples from the Associated Press,

Primary care physicians already are in short supply in parts of the country, and the landmark health overhaul that will bring them millions more newly insured patients in the next few years promises extra strain.

The new law goes beyond offering coverage to the uninsured, with steps to improve the quality of care for the average person and help keep us well instead of today’s seek-care-after-you’re-sick culture. To benefit, you’ll need a regular health provider.

And other media, tell us as much. Now in general the United States has fewer physicians per capita than other western nations. And there are no doubt huge regional differences in physician supply. Parts of this country suffer from a severe deficiency in physicians in general, and primary care in particular.

But the fact is that, as much as we hear about the difficulty primary care has in attracting future physicians, the United States’ per capita primary care population compares pretty equatable to those of other nations. Other nations whose primary care delivery is generally considered more impressive.

Compare the primary care population to that of Australia and New Zealand or to the United Kingdom. Sure we trail two of the three, but not on the order of magnitudes.

Again, the anecdotes will be out there. No doubt incorporating a huge new patient population into the mess but a crisis is more difficult to believe.

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Sunday, March 28th 2010

Let A Children Hospital Rise

I call home one of the largest cities in the country without a freestanding, full service children’s hospital. In the state of Texas my home is the only ‘major’ metropolitan area without such an institution.

The benefits of freestanding children’s hospitals and the problems pediatric care in my hometown faces should seem cognizant to even the layperson. While children’s hospitals certainly have higher charges they provide value for such, providing better care from everything in trauma to acute asthma exacerbation. The lack of a freestanding children’s hospital means tertiary pediatric care is fragmented. Pediatric services at hospitals around the city see fewer of each case of pediatric illness. Volume, as has long been shown, means quality. Concentrating tertiary care also promises to promote recruitment of everything from pediatric subspecialists to pediatric nurses.


The Beautiful Dell Children’s Hospital An Hour North Of San Antonio

I’ve always had a place in my heart for pediatrics. It represents unique challenges and at times can be tragic and gut wrenching caring for the young and critically ill. It is also incredibly rewarding. Your patients share no responsibility for their conditions and the promise they hold when you help heal them is virtually limitless. But of course, as easy as it is for pols to talk about children’s issues, they lack a constituency and children’s healthcare doesn’t exactly have the political will as, say, care for those over 65 does.

So I’m happy to see the movement for a new children’s hospital in San Antonio. A public-private venture the hurdles it faces are more than political but the backing of prominent politicians like Nelson Wolff is a very positive turn for pediatrics in this town. Amongst others in town, the former Mayor and long term head of Bexar County seems to have thrown his full weight behind a freestanding children’s hospital. That can only be a good thing.

Supportive media coverage as well is a positive. The local newspaper has it here and here, saying,

Far from standing still, San Antonio is losing ground in pediatric care as other cities expand theirs, Austin moves closer to getting a medical school, and local military realignments reduce pediatric care resources.

In July, Texas Children’s Hospital bought full-page ads in the San Antonio Express-News promoting its services, evidence that this city is seen as a lucrative market for other cities’ children’s hospitals.

As has local television media. Hopefully that forecasts well for the future. San Antonio needs a children’s hospital.

Saturday, March 27th 2010

The Fall of Texas

Texas is an amazing part of this country. For reasons beyond scope here, it’s historical and cultural identity are uniquely ingrained and recognized; certainly more than those of any other state. That goes for California. People around the world can pick Texas from a map. They know who a Texan is, and despite the slight inaccuracy of the stereotype the fact it has circled the globe speaks for Texas’ position.

I have a fiancee who doesn’t quite understand my devotion to my state. Texans’ devotion to their state has its historical roots but in some ways Texas’ pride is merely circular, I’m proud that Texans have such pride in their state.

And I’m proud that Texas has exported its influence. From it’s rise in national politics just prior to and following World War II to the presidency of the second Bush it is hard to argue another states’ influence in Washington was greater in the past century.


Rise Of The Superstate

And then came the failure of oil money and what is viewed as the slow decline of the industry, the 2006 midterm elections, and then the election of Barack Obama. And suddenly Texas was dead; it’s influence in a likely perpetual decline.

The 28th state has loomed large over Washington for much of the past century — think the president, his father, Lyndon Johnson, Sam Rayburn, John Tower, Dick Armey and Tom DeLay.

Since at least the 1960s, Texans have been simultaneously admired and loathed by the rest of Washington. Their command, for the most part, has come on account of seniority. Their home districts were so safe that they were able to stay in Washington more or less all of the time and invest wholeheartedly in committee work.

But [when President Obama is inaugurated], Texas becomes — please don’t throw things — just another state.

Such declarations are a little premature.

No, Texas’ congressional delegation carries no standing committee chairmanships. Not surprising considering recent redistricting, turnover amongst the States’ 12 Democratic congressmen and only a single truly rising star amongst them in the form of Edwards.

“Chet is a good guy and will have a lot of influence,” Frost said. “But the reality is that Texas doesn’t have anywhere near the kind of clout that it used to have.”

Nor do Texas’ current two Senators inspire the cult of personality and the projection of influence that the Lone Star state has often sent to Washington. All a bummer. But the future is not bleak. In the current political environment Texas is showing its state politics have cultivated galvanizing figures who are now becoming more and more prominent on the national stage. A recent Texas Monthly piece asked ‘Why Not President Perry?”

Throughout his career, Perry has always benefited from an uncanny knack for being in the right place at the right time, and once again, his luck seems to be working. The Republican field for 2012 is not deep. Who among the contenders has a better conservative record? Who better expresses the anger of the average Republican voter? Who has a more robust fundraising base? Of the governors commonly mentioned—Tim Pawlenty, of Minnesota; Haley Barbour, of Mississippi; Bobby Jindal, of Louisiana; Mitch Daniels, of Indiana—whose state has weathered the recession more successfully?

Perry has been so often viewed as a caricature that many Texans have failed to recognize his talent. The fact is that no Republican has so ably surfed the wave of populist anger that has swept through the party in the past year.

And while I have mixed feelings about Rick Perry, why not another President from Texas? It certainly seems like Perry is setting himself up for a run at national office. And courting the conservative base across this country very nicely.

Texas’ play on the national stage is far from dead. Texas’ influence in Washington has dropped off, for a period, it remains however the nation’s second most populace state. And more importantly the nation’s fastest growing state. In Congress, the midterms which are sure to cost the Democrats something, promise to help Texas. And perhaps more importantly, so does the 2010 Census. It’s large Hispanic population, whose political souls remain surprisingly up in the air despite their ties to the Democratic party, makes it a state which cannot be ignored.

The state, with its low tax and low spend focus, has weathered the recession as well as any state in the country. Compare that to say, California, the bread basket of progressivism.

If California doesn’t want to be Texas, it must find a way to be a better California. The easy thing about being Texas is that the government has a great deal of control over the part of its package deal that attracts consumer-voters—it must merely keep taxes low. California, on the other hand, must deliver on the high benefits promised in its sales pitch. It won’t be enough for its state and local governments to spend a lot of money; they have to spend it efficiently and effectively.

The optimistic assessment is that things are going to get worse in California before they get better. The pessimistic assessment is that they’re going to get worse before they get much worse.

States that have grown accustomed to thinking of the engine that drives their economies as an inexhaustible resource—whether it’s Michigan and the auto industry, New York and Wall Street, or California and the vision of the sunlit good life that used to attract new residents—find it tough to compete again for what they thought would be theirs forever, and to plan budgets for lean years that turn into lean decades. Instead, they invest their hopes in a deus ex machina that will rescue them from the hard choices they dread.

The failure of progressive economic policy and entitlement programs, in examples like California, only bolster Texas’ example. Despite lacking current representatives in leadership positions, Texas policies are poised to become entrenched as the soul of the GOP. If liberal economic policies continue to fail on main street it isn’t hard imagining Texas, and a new generation of good ol’ boy Texas pols, taking back the flag of influence as reactionary voters look for examples of the antithesis of current policy.

No matter how well the reactionary voter manifests in the coming midterms or in 2012, it is hard to imagine Texas out in the political wilderness for a generation. The fall of Texas has been grossly exaggerated.

Wednesday, March 24th 2010

So We’ve Reformed Health Care?

I’ve repeated myself a lot over the years on reform. The frequency of me going in circles has increased as passage of reform neared. That’s boring. As all encompassing as health care reform has loomed I clearly am not in the loop enough, not able to blog enough to comment on the minutiae. My general thoughts are well layed out, and I need to stop repeating them ad nauseum.

Consider this a last all encompassing post. One intended to look at the arguments for why reform was necessary, what the current reform entails, what the current reform proposes to cost, how the current reform will fund itself, how the current reform succeeds and how it fails.

Reform Is Necessary
Or so the argument goes.

I don’t support reform, not reform that requires the further redistribution of wealth. I have sideline relativistic moral arguments for such. But arguments that either reform isn’t necessary or that progressive/redistributive reforms cannot improve the population’s access to care in all the quantifiable ways, well, I don’t buy them.

Now let me concede and give those who disagree with me their due that: 1) measuring ‘health’ is an incredibly difficult thing and 2) the United States’ failings in terms of health (if we grant they even exist) are multietiological.

Things like our genetic heterogeneity, our economic inequality (independent of how that effects access to care), even the way we measure health outcomes and a multitude of other factors play into why the United States appears to trail many of its western counterparts in measurements such as life expectancy, infant mortality, hospitalization rates for chronic conditions, etc.

Granting all those, it must also be granted that in this country insurance status effects access to care and that access to care effects overall health. Arguments that we enjoy an established safety net and that our health care resources are distributed with some sort of uniformity so that all have some sort of baseline, appropriate access to care are beyond the pale. They’re ridiculous. It is a settled issue that your insurance status, as an independent factor, influences your health. It effects lifetime mortality (pdf), it effects baseline functional measurements, it effects the stage at which cancer is found, it effects mortality related to a whole host of chronic diseases such as heart disease. Without a doubt lack of long term health insurance is an independent culprit behind excess deaths in this country.

I refuse to even have a further discussion on whether, in our current financing system, insurance effects access and thus health. It is settled.

We can debate the economics of the un- and under-insured and the census of such people, but the lay down is, whatever the measurements and whatever the causes, that the problem is real and far from insignificant.

Reform is necessary if your goal is to improve the ‘health’ of this country because one of the key components of improving such is improving access to care.

And so we get the motivation behind an effort like the Patient Protection and Affordable Care Act.

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Saturday, March 20th 2010

A Welcome Back With Good News

Intermittent, spotty posting is no way to run a blog. It has been a month since I posted anything; probably explains my Google Analytic numbers of recent. Luckily, I return with pretty incredible news.

Most incredibly, I’m engaged to a beautiful and wonderful girl. Off the market ladies, I apologize. I don’t know how I convinced her to marry me but she’s so far above and beyond what I deserve that I can’t ever imagine coming off this high.

In addition, about a year ago this time I did an interview with a Wall Street Journal blogger during which I was meandering and only at times coherent. I excuse myself for that, I had recently learned that I did not match after participating in the National Residency Matching Program. The interview was on the process of medical students become residents and physicians in the match and, in my case, the scramble.

I’ve spent nearly nine months serving in a general surgery preliminary residency spot and going through the residency match once again. This time with much better results. I’m going to be a neurosurgeon. Sure the path forward is rough and lengthy, but I’ve cleared a major hurdle.


The Sex Appeal Isn’t That He’s A Neurosurgeon, It’s That Hair

Anyway, I’m back to posting and I hope readers will return to reading.

Saturday, March 20th 2010

Why The Whip Counts & The Bill Don’t Matter

It has become a fun past time to try to predict the future of the insurance reform bill. As I write the contract is dipping a bit on Intrade, Slate is confident, Firedoglake’s whip count has it as iffy, and The Hill’s whip count is promising.

As fun as all this is I am now of the opinion of Yglesias,

[T]here’s some critical mass of votes you need, short of a majority, at which point you start the doomsday countdown. Now that the count is underway, you can’t change the bill. So there’s no point in holding out for changing. And you “scale the bill down” or “start over” either. You have a victory, or you have a humiliating defeat. And everyone’s in the same boat. At that point, the votes will materialize.

Book this one, the House will pass the Senate’s bill tomorrow.

I’ve made my lack of faith in the Democratic caucus obvious. But when due give them some credit. Pelosi will come up with the votes and give nothing further away for such.

Pelosi told reporters there will be “no separate vote” on abortion or any other measure.

And Rep. Jan Schakowsky (D-IL), a leading pro-choice progressive, said they’re moving ahead without him. “There’s not going to be any deal made with Mr. Stupak…there’s been no deal whatsoever. He’s been told that his language is not going to be added to the legislation,” she told me this morning.

“We think we have the votes regardless, and we’re going to be moving forward,” Schakowsky said. “Yes. We do think we have the votes without him.”

Things have fallen into place from the CBO scoring (here’s the full CBO report),

According to reports, CBO estimates that the combined package will cost $940 billion over the first 10 years and reduce the deficit by $130 billion during that period. In the second 10 years, 2020 to 2029, it will reduce the deficit by $1.2 trillion. The legislation will cover 32 million Americans, or 95 percent of the legal population.

To last minute stake holder support. To the abandonment of Stupak.

My pessimism on any sort of reform was ill placed. That’s not to give the Democratic leadership a full pat on the back. The reform they’ve mustered can hardly even be called such with a straight face. I continue to contend it’s long term prospects for expanding access to care enough to, say, do things like effect our broad health care metrics are dismal. My pessimism on this issue may however be tapered by the idea of this bill as a ‘building block’. It remains however that the progressive caucus has conceded the vast majority of semblance of cost control, and thus long term expansion of access to care, in this bill. The liberal Firedoglake bemoans the same and has a great table looking at what is promised with insurance reform and the realities of it.

The fact the democrats have struggled to pass even this bill is something less than impressive. But to be fair I didn’t even give them that much credit.